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75,027
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|
23454
|
Discharge summary
|
report
|
Admission Date: [**2175-10-7**] Discharge Date: [**2175-10-10**]
Date of Birth: [**2127-2-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8263**]
Chief Complaint:
Epigastric pain and vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
48M with PMHx EtOH abuse, chronic pancreatitis and IDDM2 p/w 5
days of worsening bilateral upper abdominal pain radiating to
the back, decreased PO intake and NBNB vomiting. He states he
started drinking again 2 weeks ago after 3 months of sobriety,
approximately [**1-17**] drinks/day, last drink on day of admission.
States he has not been taking his insulin as prescribed, denies
fevers, chills, cough, rigors, dysuria, diarrhea. Endorses abd
pain. He denies any ingestions.
.
In the ED, triage VS were:
T 98.4 HR 115 BP 129/83 RR 18 O2 Sat 100% RA
Labs were notable for lactate 3.2, pH 7.21, AG 37, BG 264, trop
<0.01, Lipase 15. Delta/delta was 2.3. UA with 1000 glucose and
150 ketones. CXR without acute cardiopulmonary process, UA
negative for infection. EKG was NSR with normal intervals. He
received 4L NS, 10U Regular Insulin and was started on an
Insulin gtt. Also received 2mg Ativan IV. No cultures drawn.
On arrival to the MICU, initial VS were:
T 98 HR 88 BP 120/70 RR 22 O2 Sat 96% RA
Pt continued to endorse abd pain and thirst, otherwise no
complaints.
Past Medical History:
Anxiety
DM II on insulin
Alcohol abuse
Hypertension
Hyperlipidemia
Acute-on-Chronic pancreatitis
Social History:
He lives at home with his wife, daughter, and three grand
children. Reports cigarette use 15 years ago (about [**2-17**]
cigarettes per day). Denies drug use. Drinks 1 pint of brandy
every 1-2 days.
Family History:
Reports hypertension and anxiety in multiple family members.
Physical Exam:
ADMISSION EXAM:
T 98 HR 88 BP 120/70 RR 22 O2 Sat 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, no
tongue fasciculations
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, mild TTP in the epigastrium, non-distended, bowel
sounds present, no organomegaly
[**Month/Day (3) **]: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A/Ox3, CNII-XII intact, no asterexis or tremor, no tongue
fasiculations
DISCHARGE EXAM:
98.6 137/76 78 18 100%RA, Evening BS-170
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, no
tongue fasciculations
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
[**Month/Day (3) **]: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A/Ox3, CNII-XII intact, no asterexis or tremor, no tongue
fasiculations
Pertinent Results:
ADMISSION LABS
[**2175-10-6**] 05:32PM BLOOD Neuts-77* Bands-0 Lymphs-16* Monos-7
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2175-10-6**] 05:32PM BLOOD WBC-5.9 RBC-5.13 Hgb-14.4 Hct-46.4
MCV-91# MCH-28.1 MCHC-31.1 RDW-14.2 Plt Ct-422
[**2175-10-6**] 05:32PM BLOOD Glucose-264* UreaN-20 Creat-1.4* Na-132*
K-4.8 Cl-89* HCO3-11* AnGap-37*
[**2175-10-6**] 05:32PM BLOOD ALT-43* AST-53* AlkPhos-151* TotBili-0.4
[**2175-10-6**] 05:32PM BLOOD Lipase-15
[**2175-10-6**] 05:32PM BLOOD cTropnT-<0.01
[**2175-10-7**] 02:46AM BLOOD cTropnT-<0.01
[**2175-10-6**] 05:32PM BLOOD Albumin-5.6* Calcium-11.2* Phos-2.4*#
Mg-2.3
[**2175-10-6**] 05:32PM BLOOD Osmolal-311*
[**2175-10-6**] 09:12PM BLOOD Type-ART pO2-100 pCO2-30* pH-7.21*
calTCO2-13* Base XS--14
[**2175-10-7**] 03:04AM BLOOD Type-ART pO2-103 pCO2-30* pH-7.27*
calTCO2-14* Base XS--11
Intubat-NOT INTUBA
[**2175-10-6**] 07:51PM BLOOD Lactate-3.2*
[**2175-10-6**] 05:30PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2175-10-6**] 05:30PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
CXR [**2175-10-6**]
No acute cardiopulmonary process or evidence of displaced rib
fracture.
DISCHARGE LABS:
CBC: 4.8/ 10.4/32.3/275
CHEM-7: 132/4.1/97/28/4/0.9/384
FINGER STICK GLUCOSE PRIOR TO DISCHARGE: 190
Brief Hospital Course:
48 y/o man with DKA and contraction alkalosis admitted to the
MICU
.
# DKA: Likely [**2-16**] insulin non-compliance. Trop <0.01, CXR clear,
UA negative. Only localizing source is vomiting; lipase is 15.
LFTs are slightly elevated, though this is baseline and were wnl
prior to discharge. Patient was initially treated with IVF,
insulin drip in the medical ICU but as his gap closed, he was
transitioned to subq insulin and PO food which was well
tolerated. He was transferred to the regular internal medicine
floor in stable condition. [**Last Name (un) **] Diabetes Center was consulted
for DM management. His home Lantus dose was increased from 24
to 30, Humalog with meals increased from 8 with meals to 10 with
meals, and Insulin SCC was continued. He was discharged with a
blood sugar of 190 and will have close follow-up with [**Last Name (un) **] for
diabetes management. He is [**Last Name (un) 1988**] to see Dr. [**First Name8 (NamePattern2) 32440**] [**Name (STitle) **] on
[**10-11**] at 9:30am at [**Last Name (un) **].
.
# Metabolic Alkalosis: Delta/delta on admission is >2,
indicating there is also an underlying metabolic alkalosis. Most
likely contraction alkalosis in the setting of vomiting. This
resolved with treatment of his DKA as well as keeping him NPO
and slowly advance his diet as tolerated. His vomiting ceased
and he was able to tolerate a full diet by day of discharge. In
addition, both the DKA and metabolic alkalosis were resolved
prior to discharge.
.
# EtOH Abuse: Last drink the day of admission, no e/o withdrawl
at this time, got 2mg IV Ativan in the ED. He was maintained on
CIWA for which he did not require doses of Diazepam. SW was
consulted but patient denied needing their services. He reports
that he has several mentors in his church who have been through
similar situations and he would rather go to them for
encouragement and advice. In addition, he has tried AA in the
past but is not currently actively attending meetings. He has
set short-term goals of remaining sober as he his looking
forward to a church retreat to NC and does not want to ruin his
family's time together by drinking.
.
# [**Last Name (un) **]: pre-renal failure in the setting of hypovolemia with Cr
1.4 and elevated lactate to 3.4. This was treat with IVF which
improved his renal function to baseline and Cr was 0.9 and
lactate was 1.1 prior to discharge. His home lisinopril for
hypertension was held in the setting of [**Last Name (un) **] but was restarted
once Cr improved to baseline.
.
TRANSITIONAL ISSUES:
- Patient would like to be seen at [**Last Name (un) **] for future management
of DM, has f/u [**10-11**]
- Hospital f/u at [**Company 191**] [**Company 1988**] for [**10-19**], rec continued alcohol
cessation counseling and reassessment of any social work needs
for support to help maintain sobriety at this time
Medications on Admission:
. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO every
twelve (12) hours.
4. Lantus 100 unit/mL Solution Sig: Twenty Four (24) units
Subcutaneous at bedtime.
5. Humalog 100 unit/mL Solution Sig: as directed by sliding
scale units Subcutaneous four times a day: please take as
directed by sliding scale .
6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Gabapentin 300 mg PO Q12H
5. Lisinopril 20 mg PO DAILY
please hold for sbp<90
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Thiamine 100 mg PO DAILY
9. Glargine 30 Units Breakfast
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis
Alcohol Abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital feeling weak and nauseous. you were
found to have diabetic ketoacidosis. You were treated in the ICU
with IV fluid and insulin. Your condition improved rapidly and
you were transferred to a regular hospital floor.
This episode happened because you were not taking your insulin
as directed. This is extremely dangerous and can be fatal. You
must take your insulin as directed by your physicians. If you
ever feel your blood sugar is low, check it and consume a food
high in sugar content ie [**Location (un) 2452**] juice or a piece of candy.
You mentioned you likely have not been eating enough because of
your high alcohol intake. You alcoholism is a dangerous habit
that you must quit. Alcoholism is dangerous for all patients,
especially those with diabetes. You have met with one of our
experts in addiciton counseling, [**First Name8 (NamePattern2) 2411**] [**Last Name (NamePattern1) 2412**], for tips on how
to quit. We are excited that you are motivated to stop drinking.
This is very important to your health.
Please see changes made to your insulin regimen below:
Glargine 30 units per day
Humalog (Aspart) 10 units with meals three times per day
Please see your follow-up appoinments listed below.
It was a pleasure taking care of you, Mr [**Known lastname 60118**].
Followup Instructions:
Name: Dr. [**First Name8 (NamePattern2) 32440**] [**Name (STitle) **]
Location: [**Hospital **] CLINIC
Address: ONE [**Last Name (un) **] PLACE, SECOND FL, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 9670**]
Appointment: Wednesday [**2175-10-11**] 9:30am
*This is a follow up appointment for your hospitalization. You
will reconnect with your primary endocrinologist after this
visit.
Department: [**Hospital3 249**]
When: THURSDAY [**2175-10-19**] at 10:10 AM
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Central [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor
in follow up.
|
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55,672
| 116,183
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35017
|
Discharge summary
|
report
|
Admission Date: [**2170-2-8**] Discharge Date: [**2170-2-16**]
Date of Birth: [**2111-10-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Tetracycline / Sulfa (Sulfonamide Antibiotics) /
Morphine / Codeine
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Cervical malacia, with shortness of breath.
Major Surgical or Invasive Procedure:
[**2170-2-8**]: Cervical tracheal resection and reconstruction
and bronchoscopy with bronchoalveolar lavage.
History of Present Illness:
The patient is a 58-year-old woman who has had a tracheostomy.
She also developed severe diffuse tracheobronchomalacia which
was treated with the right thoracotomy and posterior splinting
of her thoracic airways. After this procedure, she was noted to
have persistent and worsening cervical
tracheomalacia and some minor narrowing at the site of the
previous stoma. She was admitted following tracheal resection
and reconstruction.
Past Medical History:
# tracheobronchial malacia s/p tracheoplasty [**2169-6-13**]
# tracheostomy
# Cervical malacia
# obesity
# GERD
# avascular necrosis of the L hip s/p L hip replacement in [**2161**]
# alcohol abuse
# RUE DVT in [**2167-10-14**]
# Tracheostomy and PEG placement [**2169-3-13**]
# COPD
# granulomas in L lung
# s/p TAH
# s/p appendectomy
Social History:
Ms. [**Known lastname 42611**] had been a regional manager at insurance company.
She lives with her boyfriend of 14 years. Patient has history of
significant alcoholism. Former smoker
Family History:
Noncontributory
Physical Exam:
VS: T: 98.7 HR: 81-82 SR BP: 102-118/64 Sats: 95% 2L nasal
cannula. Room air 86-88%
BS: 126-170
Gen: pleasant in NAD
Neck: cervical incision with slight erythema, slight swelling
without drainage.
Lungs: decreased breath sounds bilateral with faint bibasilar
crackles. no wheezes
CV: RRR S1, S2, no MRG or JVD
Abd: soft, NT, ND, PEG site clean no erythema or discharge
Ext: warm without edema
Neuro: awake, alert oriented
Pertinent Results:
CXR:
[**2170-2-15**]: Calcified left basal granuloma. Status post old left
ribs fracture. Bilateral areas of atelectasis that are basically
unchanged. No newly appeared focal parenchymal opacities. No
larger pleural effusions. No evidence of pulmonary edema.
[**2170-2-12**]: Right hemidiaphragm is chronically elevated
substantially. Persistent obscuration of the left diaphragmatic
contour indicates combination of small pleural effusion and
worsening left lower lobe atelectasis, now probably collapsed.
Upper lungs are grossly clear. Heart size normal.
[**2170-2-10**]: Lung volumes remain very low, and there is greater
consolidation at both lung bases, particularly the right since
[**2-9**], most likely atelectasis. Small left pleural
effusion has increased. Heart is top normal size, unchanged. I
see no endotracheal tube. There is no pneumothorax.
[**2170-2-14**] WBC-5.9 RBC-3.17* Hgb-8.4* Hct-25.9 Plt Ct-209
[**2170-2-13**] WBC-6.8 RBC-3.29* Hgb-8.5* Hct-26.8 Plt Ct-181
[**2170-2-8**] WBC-9.2 RBC-3.71* Hgb-9.2* Hct-28.9 Plt Ct-231
[**2170-2-7**] WBC-8.2 RBC-4.43 Hgb-11.4* Hct-35.1 Plt Ct-214
[**2170-2-14**] Glucose-117* UreaN-14 Creat-0.7 Na-145 K-4.4 Cl-101
HCO3-38
[**2170-2-11**] Glucose-123* UreaN-14 Creat-0.8 Na-146* K-4.1 Cl-107
HCO3-35
[**2170-2-8**] Glucose-137* UreaN-14 Creat-0.8 Na-148* K-3.5 Cl-111*
HCO3-27
[**2170-2-14**] Calcium-8.8 Phos-3.7 Mg-2.3
Micros: [**2170-2-8**] MRSA SCREEN Source: Nasal swab. No MRSA
isolated.
Brief Hospital Course:
Ms. [**Known firstname **] [**Known lastname 42611**] was taken to the operating room by Dr.
[**Last Name (STitle) **] on [**2170-2-8**] for a cervical tracheal resection and
reconstruction and bronchoscopy with bronchoalveolar lavage for
cervical malacia and guard suture placement. She transferred to
the ICU intubated monitored overnight.
Neuro/Pain: Initial pain management was achieved with IV
Dilaudid and propofol while intubated. This was later
transitioned to Roxicet via PEG with good control. The patient
remained neurologically per her baseline: intact but with some
memory loss. She is compulsive with taking off oxygen and
getting out of bed. She was kept under fall precautions. Her
home Seroquel of 150 mg po daily was divided to 50 mg per NGT
TID, with good effect.
Pulmonary: She was extubated on POD1. Heliox and BiPAP for
hypercarbia during POD's [**1-15**]. With Aggressive pulmonary toilet,
mucolytics nebs and incentive spirometry her oxygenation
improved. Supplemental oxygen was titrated to 2 L nasal cannula
with saturation of 97%. Titrate oxygen to maintain oxygen
saturations > 92%. Room air oxygen saturation 86-88%.
Serial Chest X-ray's (see above report)
Bronchoscopy, flexible [**2170-2-14**] showed intact cervical
anastomosis, with abnormal bronchial mucosa in the cervical
anastomosis, and abnormal bronchial mucosa in the proximal and
mid trachea. Her guard suture was removed.
CV: The patient was tachycardic initially which improved with
home diltiazem, switched to 60 mg po qid for PEG tube. She
remained hemodynamically stable throughout in sinus rhythm 80's,
blood pressure 100-120's.
GI/Nutrition: Tube feeds were resume via PEG POD1. Strict NPO
for known aspiration. She was evaluated by the registered
dietician with tube feed recommendations of replete with fiber
at 70 ml/hour.
Renal/GU: Foley removed [**2170-2-12**]. She voided well thereafter.
Electrolytes were monitored and treated as needed. Hypernatremia
peak NA 148 discharge 145, normalized with free water and
Aldactone.
Heme: No blood transfusions. Stable anemia.
ID: She remained afebrile, with stable WBC counts. CBC trends
were watched throughout her stay.
Endocrine: Fingerstick blood sugars < 200.
Drains: JP removed [**2170-2-12**].
Prophylaxis: SQ heparin and SCD's were instituted to prevent
VTE.
Disposition: Physical therapy deemed the patient appropriate for
rehabilitation. She continued to make steady progress and was
discharged to [**Hospital1 41724**] in [**Location (un) 701**] on [**2170-2-16**]. She will
follow-up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] as an outpatient.
Medications on Admission:
1. diltiazem HCl 120 mg Capsule, Sustained Release [**Last Name (STitle) **]: One (1)
Capsule, Sustained Release PO BID (2 times a day).
2. Nexium 40 mg Capsule, Delayed Release(E.C.) [**Last Name (STitle) **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. quetiapine 150 mg Tablet Sustained Release 24 hr [**Last Name (STitle) **]: One (1)
Tablet Sustained Release 24 hr PO once a day.
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
5. multivitamin Capsule [**Last Name (STitle) **]: One (1) Capsule PO once a day.
6. home oxygen
40% humidified oxygen continuous via trach collar.
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) ml PO BID (2
times a day) as needed for constipation.
2. heparin (porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) ml
Injection TID (3 times a day): SQ for VTE prophylaxis.
3. oxycodone-acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs
PO Q6H (every 6 hours) as needed for pain.
4. acetylcysteine 20 % (200 mg/mL) Solution [**Last Name (STitle) **]: Three (3) ML
Miscellaneous every twelve (12) hours as needed for thick
secretions: mix with albuterol to prevent bronchospasm.
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheeze.
6. diltiazem HCl 60 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4
times a day): give crushed via PEG.
7. Seroquel 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times a
day: crushed via peg.
8. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day: crush, give via peg.
9. lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO BID (2
times a day): hold for loose stools.
10. guaifenesin 600 mg Tablet Sustained Release [**Last Name (STitle) **]: One (1)
Tablet Sustained Release PO twice a day.
11. tiotropium bromide 18 mcg Capsule, w/Inhalation Device [**Last Name (STitle) **]:
One (1) Inhalation once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Cervical malacia s/p tracheal resection and reconstruction
[**2170-2-8**]
TBM s/p right tracheoplasty [**2169-7-7**]
GERD
Esophageal dysmotility with aspiration
Tracheostomy and PEG placement [**2169-3-13**]
COPD
Granulomas in L lung
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office at [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, cough or chest pain
-Cervical incision develops drainage or increased redness.
Pulmonary: aggressive pulmonary toilet with mucolytic nebs
Oxygen titrate to maintain oxygen saturations > 93%
Humidified oxygen to help keep secreations loose
Diet: Strict NPO secondary to aspiration
Followup Instructions:
Appointments Location: [**Hospital Ward Name 517**] [**Hospital Ward Name 121**] Building [**Hospital1 **] I
West [**Hospital 7755**] Clinic
Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2170-3-6**] 11:00 [**Hospital Ward Name 121**] Building [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) 479**]
[**Hospital 7755**] Clinic
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2170-3-6**]
11:30
Provider: [**Name10 (NameIs) 5073**] INTAKE,ONE [**Name10 (NameIs) 5073**] ROOMS/BAYS Date/Time:[**2170-3-6**] 1:00
Hold Tube feedings midnight the night before her appointment for
Flexible Bronchoscopy
Completed by:[**2170-2-20**]
|
[
"V44.1",
"V12.51",
"276.0",
"278.00",
"518.89",
"V43.64",
"519.19",
"496",
"412",
"293.0",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.6",
"31.79",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
8483, 8555
|
3507, 6155
|
391, 502
|
8833, 8833
|
2023, 3484
|
9468, 10263
|
1543, 1560
|
6944, 8460
|
8576, 8812
|
6181, 6921
|
9018, 9445
|
1575, 2004
|
308, 353
|
530, 964
|
8848, 8994
|
986, 1324
|
1340, 1527
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,192
| 168,214
|
29611
|
Discharge summary
|
report
|
Admission Date: [**2155-3-8**] Discharge Date: [**2155-3-14**]
Date of Birth: [**2103-5-19**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Infection on buttocks
Major Surgical or Invasive Procedure:
[**3-9**] Exam under anesthesia, debridement of necrotis, soft tissue
infection
History of Present Illness:
Ms. [**Known lastname 70979**] is a 51 year old female who was transferred from an
OSH to [**Hospital1 18**]-ED on [**3-8**] for further management of a right
buttock wound. She was febrile, hypotensive; an incision and
drainage was attempted at the OSH with foul necrotic tissue
removed, intravenous broad spectrum antibiotics were
administered and she was admitted to the surgical service for
further management.
Past Medical History:
Past Medical History:
Scoliosis
Hypercholestremia
Past Surgical History:
L4-L5 fusion
Social History:
Works as a technologist, occasional alcohol, +smoking history of
[**2-11**] ppd x 35 years.
Family History:
Non-contributory
Physical Exam:
Upon admission:
103.9 86 86/74 16 98% room air
Gen: Female in no active distress
Head/Eyes: Sclera anicteric, pupils equal and reactive to light,
oropharnyx clear
Chest: Crackles at bases bilaterally
CV: Tachycardic, regular, normal S1 S2, no murmurs
Abd: Soft, non-tender, non-distended, +bowel sounds, no
hepatosplenomegaly
GU: No costo-vetebral tenderness, large necrotic incised lesion
along right buttock medial crease, +brown, serous drainage
MSK: No spinal tenderness
Skin: No rashes
Heme: No edema, 2+ pulses of lower extremities bilaterally
Pertinent Results:
Operative Note:
Necrotizing fasciitis of the right
buttock region.
OPERATION: Extensive debridement.
Admission labs:
[**2155-3-8**] 06:50PM BLOOD WBC-25.0* RBC-3.75* Hgb-12.3 Hct-35.7*
MCV-95 MCH-32.7* MCHC-34.4 RDW-13.4 Plt Ct-204
[**2155-3-8**] 06:50PM BLOOD Neuts-94* Bands-0 Lymphs-2* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2155-3-8**] 06:50PM BLOOD PT-14.7* PTT-23.9 INR(PT)-1.3*
[**2155-3-8**] 06:50PM BLOOD Glucose-85 UreaN-23* Creat-1.1 Na-136
K-4.0 Cl-105 HCO3-21* AnGap-14
[**2155-3-8**] 06:50PM BLOOD ALT-17 AST-16 LD(LDH)-211 CK(CPK)-168*
AlkPhos-111 TotBili-0.7
[**2155-3-8**] 11:24PM BLOOD Calcium-7.1* Phos-3.0 Mg-1.7
[**2155-3-8**] 06:50PM BLOOD Lactate-1.3
Discharge labs:
[**2155-3-12**] 04:39AM BLOOD WBC-14.0* RBC-2.87* Hgb-9.1* Hct-27.2*
MCV-95 MCH-31.6 MCHC-33.4 RDW-13.7 Plt Ct-254
[**2155-3-12**] 04:39AM BLOOD Plt Ct-254
[**2155-3-12**] 04:39AM BLOOD Glucose-88 UreaN-7 Creat-0.7 Na-138
K-3.2* Cl-102 HCO3-30 AnGap-9
[**2155-3-12**] 04:39AM BLOOD Calcium-7.7* Phos-4.4 Mg-1.8
[**2155-3-8**] 6:50 pm BLOOD CULTURE
**FINAL REPORT [**2155-3-14**]**
AEROBIC BOTTLE (Final [**2155-3-14**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2155-3-14**]): NO GROWTH.
[**2155-3-8**] 10:30 pm TISSUE EXCISED NECROTIC TISSUE.
GRAM STAIN (Final [**2155-3-9**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Preliminary):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
GRAM POSITIVE RODS. MODERATE GROWTH. UNABLE TO
IDENTIFY FURTHER.
ENTEROCOCCUS SP.. SPARSE GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
ANAEROBIC CULTURE (Final [**2155-3-13**]):
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum. None isolated.
Brief Hospital Course:
Ms. [**Known lastname 70979**] was taken to the operating room for treatment of
necrotizing fasciitis of the right buttock region, she underwent
an extensive debridement without complication.
Neuro: Alert and oriented, pain well controlled on PCA, changed
to Percocet with good control.
Chest: Extubated without difficulty, oxygenating well on room
air
CV: Hypotension treated with Levophed, weaned off without
difficulty, remained normotensive.
GI: Tolerating regular diet at time of discharge, +flatus, and
+bowel movements
GU: Foley removed, voided without difficulty
ID: Remained afebrile post-operatively, tissue culture with
mixed bacteria (gram positive rods, sparse Enterococcus, sparse
corynebacterium, sparse gram negative rods; final sensitivities
pending at time of discharge, blood cultures without bacteria,
intravenous antibiotics changed to oral Clindamycin and Levaquin
for an additional two weeks. Admission white blood cell count
25k, decreased to 14K at time of discharge.
Skin: Right buttock with improved erythema and induration, wet
to dry dressing with packing continued twice a day with overall
improvement in her wound.
Heme: Hemodynamically stable
She was discharged home in good condition on [**3-14**] with visiting
nurse services for continued assessment of her wound and
dressing changes. She was provided a two week prescription for
Levaquin, Clindamycin, and Percocet. She was to follow-up with
Dr. [**Last Name (STitle) **] in [**2-11**] weeks.
Medications on Admission:
Lipitor
Discharge Medications:
1. 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*
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
3. Clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO Q6H
(every 6 hours) for 2 weeks.
Disp:*168 Capsule(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Take while on pain medication
Hold for loose stool.
Disp:*60 Capsule(s)* Refills:*0*
5. Compazine 5 mg Tablet Sig: 1-2 Tablets PO every eight (8)
hours as needed for nausea.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] vna
Discharge Diagnosis:
Necrotic fasciitis
Discharge Condition:
Stable
Discharge Instructions:
Notify MD or return to the emergency department if you
experience:
*Increased or persistent pain not relieved by pain medication
*Fever > 101.5 or chills
*If right buttock develops increased redness, hardness, foul
odor, or change in character of drainage
*Nausea, vomiting, or diarrhea that persists longer than 24
hours
*Inability to pass gas, stool, or urine
*Shortness of breath or chest pain
*Any other symptoms concerning to you
You may shower, old dressing and packing should be removed prior
to your shower and replaced after your shower
No driving, operating machinery, or alcohol use while on pain
medication
You may take over the counter stool softners (Colace) if you
experience constipation while on pain medication
Please take your antibiotics as directed, do not skip any doses\
Be sure to take antibiotics with food to prevent nausea
You may continue your home medication of:
Lipitor
You should continue to eat small frequent meals throughout the
day
You should drink fluids throughout the day, minimum of 10
glasses
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in [**2-11**] weeks, call [**Telephone/Fax (1) 9**]
for an appointment
Completed by:[**2155-3-14**]
|
[
"995.92",
"272.0",
"728.86",
"737.30",
"V45.4",
"682.5",
"041.04",
"305.1",
"785.52",
"038.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.22",
"86.09",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
6452, 6507
|
4204, 5694
|
332, 414
|
6570, 6579
|
1704, 1809
|
7666, 7813
|
1095, 1113
|
5752, 6429
|
6528, 6549
|
5720, 5729
|
6603, 7643
|
2411, 4181
|
956, 970
|
1128, 1130
|
271, 294
|
442, 858
|
1826, 2394
|
1145, 1685
|
903, 932
|
986, 1079
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,429
| 198,594
|
40886
|
Discharge summary
|
report
|
Admission Date: [**2197-3-29**] Discharge Date: [**2197-4-5**]
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2197-3-31**]
Laparoscopic cholecystectomy
History of Present Illness:
89 yo woman who presented to [**Hospital3 635**] hospital with abdominal
pain. She reports 3-4 days of epigastric pain, nonradiating,
with some 3 episodes of bilious emesis. Has only been able to
take water and pepsi for 3 days prior to adimssion. Has never
had similar symptoms. Abd seems swollen to her. Denies
diarrhea or urinary symptoms. All other ROS negative.
CT and labs at OSH revealed pancreatitis. Given zosyn and
levofloxacin. She was transferred to [**Hospital1 18**] for ongoing care.
In [**Hospital1 18**], bp 90-108/82, hr 118, T 97.8, RR 18, 98% RA. Her CT
scan was uploaded into PACS. Surgery was consulted, who
recommended supportive care and admission to medicine. Her
lipase was 290 and WBC = 21.3 with 6 bands. Ultrasound was
performed which showed "sludge balls" but no GB wall edema. She
was given IVF, morphine, zofran and ativan.
Past Medical History:
PMH
HTN
PSH
S/P Hysterectomy
Social History:
Former smoker, quit 20 years ago, 30 pk year history. Drinks 1
shot per day, 3-4 times per week (brandy). She lives with her
husband in [**Hospital3 **], 2 adult children live near by. Contact is
daughter, [**Name (NI) **], [**Telephone/Fax (1) 89290**]. [**Name2 (NI) 4906**] with dementia.
Family History:
Denies family history of gastrointestinal disorders and cancers.
Denies family history of other cancers.
Physical Exam:
T: 97.9 P: 88-110 BP: 140/80 RR: 16 O2sat: 96%RA
General: awake, alert, uncomfortable
HEENT: NCAT, EOMI, anicteric. MM are dry.
Heart: rapid rate, irregular, NMRG
Lungs: CTAB no crackles. intermittant tachypnea - ? due to pain
Back: no CVAT
Abdomen: obese, soft, distended / tympanic to percussion.
Tender in epigastrium with palpation, no guarding, + rebound.
Neuro: 5/5 strength x 4. Oriented x3, easily able to relate
medical history in detail.
Extremities: WWP, no edema or cyanosis.
Skin: + psoriasis over elbows
Pyschiatric: calm, appropriate affect
Pertinent Results:
[**2197-3-29**] 12:21AM LACTATE-1.4
[**2197-3-29**] 12:11AM GLUCOSE-122* UREA N-31* CREAT-1.0 SODIUM-133
POTASSIUM-3.3 CHLORIDE-94* TOTAL CO2-31 ANION GAP-11
[**2197-3-29**] 12:11AM ALT(SGPT)-33 AST(SGOT)-70* ALK PHOS-84 TOT
BILI-1.2
[**2197-3-29**] 12:11AM LIPASE-290*
[**2197-3-29**] 12:11AM ALBUMIN-3.7
[**2197-3-29**] 12:11AM WBC-21.3* RBC-4.64 HGB-13.9 HCT-39.9 MCV-86
MCH-30.0 MCHC-34.9 RDW-13.6
[**2197-3-29**] 12:11AM NEUTS-85* BANDS-6* LYMPHS-3* MONOS-4 EOS-0
BASOS-0 ATYPS-1* METAS-1* MYELOS-0
[**2197-3-29**] 12:11AM PLT COUNT-273
RUQ US:
gallbladder appears distended with billiary sludge and possibly
sludge balls vs. nonshadowing gallstones. no gallbladder wall
edema. negative son[**Name (NI) 493**] [**Name2 (NI) **] sign.
CT abdomen/pelvis:
1. blurring of pancreatic margins with surrounding
peripancreatic
stranding extending into the anterior renal fascia with no
definite areas of hypoenhancement to suggest necrosis, no
definite e/o pseudoaneurysms. findings concerning for
uncomplicated pancreatitis.
2. distended gallbladder with billiary sludge and minimal
surrounding stranding which may be extension of inflammation
from
pancreatitis.
3. right small pleural effusion and right atelectasis vs pna.
4. ascites.
5. mildly thickened limbs of bilateral adrenals.
6. 21 x 24 mm rounded structure in the left paraortic region may
represent small focal fluid collection vs lymph node.
7. diverticulosis.
Brief Hospital Course:
Mrs [**Known lastname **] is a healthy 89 yo woman admitted with acute
pancreatitis.
1. Acute Pancreatitis, likely secondary to gallstones / sludge.
She was treated supportively with bowel rest, iv fluids and iv
narcotic analgesia with rapid improvement in her symptoms. She
was evaluated by surgery, and taken for a laproscopic
cholecystectomy on [**2197-3-31**] which she tolerated well. She
maintained stable hemodynamics in the PACU and her pain was well
controlled. Following transfer to the Surgical floor she
developed rapid atrial fibrillation. Her rate was difficult to
control with IV Lopressor and she was transferred to the ICU for
further management.
**ICU COURSE***
# Tachycardia: Most likely atrial flutter on EKG. Given IV
Lopressor and diltiazem on floor wo effect. No significant
cardiac history. On transfer to the ICU she was given 15mg IV
dilt and started on a drip at 5mg/hr with rapid conversion to
normal sinus rhythm: SBP 130s, HR 60s. EKG checked and at NSR.
She was started on po diltiazem 30mg QID and dilt drip was
discontinued wo difficulty. Her hemodynamics were monitored and
her lisinopril was not restarted after BP noted to be stable on
diltiazem alone. She remained in NSR in the 70's throughout the
rest of her recovery. Her PCP will follow her after discharge
and decide whether Diltiazem alone is sufficient for BP control.
She was continued on baby aspirin.
# SOB: Likely related to diminished forward flow secondary to
rapid atrial rate and poor filling. Chest xray noted to have
bibasilar atelectasis with small pleural effusions. She was
encouraged to increase her use of the incentive spirometer. Her
symptoms resolved after converting to normal sinus rhythm.
Following transfer back to the Surgical floor she began to make
good progress. Her diet was gradually advanced and she
tolerated it well. She did have some problems with constipation
which is a longstanding problem for her but with stool softeners
and suppositories she improved. Her rhythm remained sinus and
her blood pressure was 130/70 on Diltiazem 30 mg QID.
The Physical Therapy service evaluated Mrs. [**Known lastname **] to assure that
she was safe ambulating on her own. She did well with a rolling
walker and will continue to use it at home. Her abdominal port
sites were dry and she was improving daily. She was discharged
home on [**2197-4-5**] with VNA services.
Medications on Admission:
Lisinopril 10mg QD
Aspirin 81mg QD
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. 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*
4. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for Pain.
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1376**] vna and hospice service
Discharge Diagnosis:
Gallstone pancreatitis.
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
* You were admitted to the hospital with abdominal pain from
gallstone pancreatitis.
* Your gallbladder was removed on [**2197-3-31**].
* After the surgery you developed atrial fibrillation which is
an irregular heart rate and rhythm which required an ICU stay
for special IV medication.
* Currently your heart rate and rhythm is normal with some new
medication which you will continue to take at home. Your
primary care doctor will decide the length of treatment.
* You are being discharged home with VNA services and the
following instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications except Lisinopril
and take any new meds as ordered.
Activity:
No heavy lifting of items [**9-30**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**1-19**] weeks.
Call Dr. [**Last Name (STitle) 9449**] for a follow up appointmment in [**1-19**] weeks.
Completed by:[**2197-4-5**]
|
[
"427.32",
"584.9",
"427.31",
"401.9",
"275.3",
"997.1",
"276.8",
"577.0",
"511.9",
"574.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.23"
] |
icd9pcs
|
[
[
[]
]
] |
6840, 6915
|
3731, 6128
|
231, 278
|
7003, 7003
|
2266, 3708
|
9322, 9549
|
1560, 1668
|
6214, 6817
|
6936, 6982
|
6154, 6191
|
7186, 8952
|
1683, 2247
|
177, 193
|
8964, 9299
|
306, 1179
|
7018, 7162
|
1201, 1232
|
1248, 1544
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,734
| 182,609
|
17196
|
Discharge summary
|
report
|
Admission Date: [**2159-9-14**] Discharge Date: [**2159-9-19**]
Date of Birth: [**2088-6-6**] Sex: F
Service: THORACIC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old
female, with Stage IIIB lung cancer (nonsmall cell) with
positive left supraclavicular lymph node, who has finished
her chemotherapy and radiation therapy, last dose on [**2159-8-3**]. She presented to the thoracic surgery office for
restaging cervical mediastinoscopy with biopsy and left
scalene fat pad excisional biopsy, and a flexible
bronchoscopy on [**2159-8-24**]. She underwent that
procedure without any complications, and all of the biopsy
samples, including lymph nodes and scalene fat pad, came back
without any evidence of malignancy. The patient was
scheduled for left upper lobe lobectomy, radical lymph node
dissection, and intercostal muscle flap, and presented to the
OR on [**2159-9-14**].
PAST MEDICAL HISTORY:
1. As noted above, with an admission to the ICU on [**7-21**]
for respiratory difficulty.
2. The patient also has a history of deep venous thrombosis
approximately two years ago.
3. A history of small bowel obstruction with exploratory
laparotomy x 2.
4. Peptic ulcer disease with positive H. pylori specimen.
MEDICATIONS PRIOR TO ADMISSION:
1. Prednisone 20 mg po qd.
2. Prilosec 40 mg po qd.
ALLERGIES: She has no allergies to medications.
SOCIAL HISTORY: She is a retired employee of the [**Company 22916**]
Corporation, and is an ex-smoker.
FAMILY HISTORY: Significant for lung cancer in her brother
who was a smoker and had died in his 70s. One of her sisters
has breast cancer. Her father died at age 74 with an unknown
cause. Her mother died in childbirth.
PHYSICAL EXAM ON ADMISSION: She was afebrile at 98.1, pulse
rate 72, blood pressure 140/61, satting well at 97% on room
air. The patient was alert and oriented x 3.
CARDIOVASCULAR EXAM: Within normal limits, rate and rhythm
regular, S1, S2.
RESPIRATORY EXAM: Clear to auscultation bilaterally.
HEAD, EYES, EARS, NOSE AND THROAT: There were no cervical
lymph nodes palpable on exam.
ABDOMINAL EXAM: With bowel sounds, soft, nontender,
nondistended.
EXTREMITIES: There was no edema or cyanosis.
HOSPITAL COURSE: The patient presented to the operating room
on [**2159-9-14**] for left upper lobe lobectomy, radical
lymph node dissection, and intercostal muscle flap and
underwent those procedures without any complications with Dr.
[**Last Name (STitle) 952**]. Please see the operative report for further details.
Postoperatively, the patient was transferred immediately to
CSIU for further observation and was monitored there. The
patient did very well postoperatively, and her pain was well
controlled with an epidural catheter running dilaudid and
bupivacaine. She was covered with perioperative IV cefazolin
and was started on IV hydrocortisone at a tapered dose, with
plans to discharge her on the same dose that she was taking
at home prior to surgery.
By postoperative day #2, she was transferred to the floor and
continued to do well. Her chest tube output was monitored,
and by postoperative day #3 her chest tube was readied to be
DC'd. Her chest tubes came out. She was converted from
epidural catheter for pain control to PO percocet. The Foley
catheter was removed, as well. The patient continued on IV
hydrocortisone tapering doses until postoperative day #5.
The patient is discharged on prednisone 20 mg po qd.
I have personally spoken with Dr. [**Last Name (STitle) **], the patient's
oncologist, regarding her prednisolone dose and a regimen has
been made with Dr. [**Last Name (STitle) **] in her follow-up care, and Dr.
[**Last Name (STitle) **] will personally supervise the tapering dose of her
prednisone.
CONDITION ON DISCHARGE: Stable.
STATUS: Discharge to home.
DISCHARGE DIAGNOSIS: Stage IIIB nonsmall cell lung cancer,
status post radiation therapy and chemotherapy, now status
post left upper lobe lobectomy and radical lymph node
resection.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg po qd.
2. Percocet 5/325 mg 1-2 tablets po q 4-6 h prn pain.
3. Colace 100 mg po tid while on percocet.
4. Ambien 5 mg po q hs prn insomnia.
5. Dulcolax 10 mg po qd prn constipation.
6. Prednisone 20 mg po qd for 2 weeks with follow-up with Dr.
[**Last Name (STitle) **] for tapering.
7. Tylenol 325-650 mg po q 4-6 h prn pain--maximum Tylenol
dose is 4 gm/24 h including Tylenol and percocet.
8. Albuterol inhaler 1-2 puffs inhaled q 4 h prn.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 45150**]
MEDQUIST36
D: [**2159-9-19**] 10:30
T: [**2159-9-19**] 10:32
JOB#: [**Job Number 48221**]
cc:[**Last Name (NamePattern1) 48222**]
|
[
"533.90",
"162.3",
"515",
"196.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.3",
"40.3"
] |
icd9pcs
|
[
[
[]
]
] |
1510, 1731
|
4036, 4819
|
3850, 4013
|
2236, 3765
|
1285, 1388
|
177, 920
|
1746, 2218
|
942, 1253
|
1405, 1493
|
3790, 3828
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,054
| 107,394
|
40560+58387
|
Discharge summary
|
report+addendum
|
Admission Date: [**2162-4-8**] Discharge Date: [**2162-4-28**]
Date of Birth: [**2121-12-30**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
[**9-27**] headache
Major Surgical or Invasive Procedure:
[**2162-4-8**]: Left [**Month/Day/Year 5041**] placement
[**2162-4-8**]: Diagnostic Cerebral Angiogram
[**2162-4-9**]: Craniotomy & Mass Resection. Placement of Right [**Month/Day/Year 5041**]
History of Present Illness:
40 yo F awoke from sleep with severe sudden onset headache
followed by emesis. Per her husband she was confused and
screaming in pain. She currently complains of headache,
although confused and unable to obtain other history.
Past Medical History:
None
Social History:
Married, two children, smokes cigarettes and has ETOH
occasionally
Family History:
NC
Physical Exam:
Hunt and [**Doctor Last Name 9381**]: 3 [**Doctor Last Name **]: 4 GCS E: 3 V: 4 Motor 6
O: T: BP: 109/61 HR: 94 R 20 O2Sats 98%
Gen: WD/WN, lethargic.
HEENT: Pupils: 3->2mm bilat EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Lethargic, awakens to voice.
Orientation: Oriented to person, hospital.
Speech slurred with slowed response.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Not cooperating with formal motor exam, but moves all
extremities symmetrically.
Toes downgoing bilaterally
Pertinent Results:
Cerebral Angiogram:
[**2162-4-8**] Extensive subarachnoid and intraventricular hemorrhage.
Given the predominant location of intracranial hemorrhage in the
cistern of lamina terminalis, the likely potential source of
bleeding is considered anterior communicating artery. However,
no discrete aneurysm formation
[**2162-4-8**] CT Brain - Interval placement of ventricular drain with
slight decrease in ventricular size.
[**2162-4-8**] MRI Brain w/w/o contrast - Abnormal enhancement is seen
in the suprasellar region surrounding the hemorrhage extending
to the sellar region suspicious for a suprasellar mass. Given
the location, there is suspicion for craniopharyngioma. However,
the tumor characteristics are somewhat altered secondary to
hemorrhage and compression.
[**2162-4-9**] - No change in the ventricular or suprasellar
hemorrhage. As noted on the prior study, the suprasellar clot
demonstrates peripheral enhancement which is unchanged.
[**2162-4-9**] CT brain - Postoperative changes related to right
ventriculostomy catheter placement with fluid and air along its
course. Right lateral ventricular blood clot has been evacuated.
The left ventriculostomy catheter is in unchanged position. The
left lateral ventricle is diminished in size compared to
[**2162-4-8**] exam. Heterogeneous suprasellar hemorrhagic mass is
stable in appearance.
[**2162-4-10**] MRI brain - Status post resection of the suprasellar
mass. Blood products are seen with post-surgical changes in the
region. Some residual enhancement is identified surrounding the
blood clot since the previous study. No acute infarcts are seen.
Some restricted diffusion at the margin of surgical cavity
appears to be related to patient's surgical procedure.
[**4-15**] CT brain - stable position of [**Month/Year (2) 5041**] drains bilaterally. No
evidence of hydrocephalus. stable suprasellar hemorrhage
[**4-15**] CT brain - s/p [**Month/Year (2) **] removal. No evidence fo acute
hemorrhage or hydrocephalus
[**4-18**] CTA Chest- Thrombus is present in the left lower lobe
segmental pulmonary arteries. There is no significant evidence
of right heart strain, however, the RV/LV ratio is difficult to
assess as the left ventricle is predominantly in systole during
the examination.
[**4-18**] CT Head- Post-operative changes following right craniotomy
for resection of suprasellar mass. Overlying subgaleal fluid
collection is noted, possibly increased from prior studies.
Hematoma within the suprasellar cistern decreased in size and
conspicuity, compatible with expected evolution of blood
products. No new hemorrhage, edema, or mass effect. No
hydrocephalus.
[**4-19**] LENI's- No evidence of residual DVT in either lower
extremity.
[**4-20**] CT Head: 1. Interval enlargement of the subgaleal fluid
collection overlying the right frontal craniotomy. 2. No
evidence of interval change in the intracranial compartment. No
hydrocephalus.
[**4-22**] CT Head: Stable ventricular size. Decrease in subgaleal
collection as 60cc was reportedly aspirated.
[**4-23**] CT head: slight reaccumulation of subgaleal collection.
stable ventricular size
Brief Hospital Course:
Ms. [**Known lastname 15852**] was intubated in the emergency room for Left frontal
[**Known lastname 5041**] placement. She was taken to angiogram the following day to
evaluate for an underlying vascular lesion. She was started on
Dilantin for seizure prophylaxis.
Angiogram was negative for an AVM or aneurysm. An MRI of the
brain with contrast revealed a small enhancing lesion above the
pituitary gland. During her post angio course patient had
diabetes insipidus on [**2162-4-8**]. Her sodium rapidly increased
from 141 to 157. Her sodium elevated to 162. PT was given
DDAVP and endocrine was consulted for further management. She
continued to have increase urine output, but improved with
DDAVP.
Patient remained intubated and was taken to the operating room
on [**4-9**] for Right frontal craniotomy resection of sella/supra
sellar mass and right [**Month/Year (2) 5041**] placement. Please review dictated
operative report for details. Postoperatively she was started
on Dexamethasone for cerebral edema. She remained intubated
post-op and was transferred to the neuro ICU for further
management. She had a post operative head CT and MRI which
showed partial resection of sellar mass and post operative
changes. There was no evidence infarct or acute hemorrhages.
She was extubated without incident and continued to be monitored
with prn DDAVP for high urine output and elevated Serum Na.
Bilateral [**Month/Year (2) 5041**] wean was begun on [**4-12**]. Pt tolerated it without
elevation of ICPs or increased headache. On 4.26 her [**Month/Year (2) 5041**]'s were
rasied to 20cm of H2O and she toelrated it well until the
mornign of 4.27 when she was ntoed to have leakage around the
[**Month/Year (2) 5041**] site on the right side. A stitch was placed and no further
leakage was noted. A NCHCT was obtained to assess for
hydrocephalus which showed stable ventricular size. Following
this her [**Month/Year (2) 5041**]'s were clamped. She was transitioned to Oral DDAVP
per Endocrine team. Dexamethasone was slowly tapered every
other day to 2mg [**Hospital1 **] .
On [**4-15**] a repeat Head CT showed stable size of lateral
ventricles without evidence of HCP. Thus [**Name2 (NI) 5041**]'s were removed in
routine fashion without incident. Another repeat head CT
deomonstrated no acute hemorrhage or hydrocephalus. She was
transferred to SDU in stable condition for frequent neuro checks
and for monitor UO. Overnight, sodium decreased to 132 and
given concern for SIADH patient was fluid restricted. Endocrine
rec: qid serum sodiums.
On [**4-18**] the patient was neurologically stable but she was
tachycardic to the 140's. This was discussed with endocrine and
IVF bolus was recommended. She was also febrile to 102.1 so a
fever work up was sent. Her u/a was significant for infection so
she was started on a course of cipro and her foley was changed.
She then began putting out excessive amounts of urine and
continued to be tachycardic so a CTA chest was performed which
was positive for PE. At this time she was transferred to the
ICU. Na was noticed to be elevated so she was given a 1L fluid
bolus.
On [**4-19**] she was neurologically stable. LENI's were ordered were
negative for DVT. General Surgery was consulted for IVC Filter
placement.
Repeat Na was trending up (157) so she was started on IVF per
endocrine recs.
On [**4-20**] her serum Na continued to trend up to 160 and her urine
output increased to greater than 300cc/hr for 2 hours. She
responded to an oral dose of DDAVP and her urine output dropped
off. She continued to receive IVF and her Serum Na started to
downtrend. Serum Na, OSM, Urine Na Osm and spec gravity were
followed closely for DDAVP dosing. She underwent placement of a
rightside PICC line. She also underwent placement of an IVC
filter with General Surgery.
On the evening of [**4-19**] it was noted that she had an enlarging
subgaleal collection under the right craniotomy site and so a
head CT was performed that demonstrated communication with the
ventricular system. A followup head CT was obtained on the
morning of [**4-21**] that showed enlargement of the subgaleal
collection. On the evening of [**4-21**] an Left Frontal [**Date Range 5041**] was
attempted but was not successful, likely due to small
ventricular size. Subsequently the subgaleal fluid collection
was aspirated at the bedside, 60cc withdrawn and a headwrap was
placed. Repeat head CT on [**4-22**] demonstrated no increase in
ventricular size but did show residual fluid collection. She
was then followed with serial head CTs. On 5.6 she was deemed
fit for transfer to the SDU. HEr subgaleal collection had
slightly reaccumulated and her neuro status was stable so the
collection was not drained. Also her nutritional intake was
questionable so calorie counts were initiated. She remained
stable in the SDU on [**4-24**] and [**4-25**] and her neuro exam was improved
as well. Her subgaleal collection remained stable if not
slightly decreased without headwrap. Endocrinology continued to
follow and recommended changing her evening dosing of DDAVP to
0.1 and increase her encourages fluid intake to 2 liters daily
in an attempt to wean her off of IV fluids
On the morning of [**4-26**] her mental status continued to improve
however she self-removed her PICC line in the morning. She was
not receiving any medication intravenously and as such the PICC
was not replaced.
Her serum Na continued to improve and the salt tabs were stopped
and fluid restriction was lifted however on [**4-27**] her serum Na
droppped to 131. She was placed on a 1.5 L fluid restriction
and her AM dose of desmopressin was held on [**4-28**]. Her Na
improved to 133 in the morning of [**4-28**]. Her Na needs to be
closely followed over the next several days to ensure that it
normalizes.
At the time of discharge she is tolerating a regular diet,
ambulating with close assist, afebrile with stable vital signs.
Medications on Admission:
none
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever.
2. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
3. insulin regular human 100 unit/mL Solution Sig: Two (2)
Injection ASDIR (AS DIRECTED).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
7. acetaminophen-codeine 120-12 mg/5 mL Elixir Sig: 12.5-25 MLs
PO Q4H (every 4 hours) as needed for headache or pain.
8. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
12. desmopressin 0.1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. desmopressin 0.1 mg Tablet Sig: half Tablet PO BREAKFAST
(Breakfast).
14. dextrose 50% in water (D50W) Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Suprasellar mass
Intraventricular hemorrhage
Obstructive hydrocephalus
diabetes insipidus
hyponatremia
SIADH
Pulmonary Embolus
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - always.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
General Instructions
?????? 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 and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? 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.
?????? 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, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 2 weeks.
??????You will need a CT scan of the brain without contrast.
- Followup with Endocrinology Dr. [**Last Name (STitle) **] on [**2162-5-11**] at 11:20.
[**Telephone/Fax (1) 1803**].
-You will need frequent Daily Na checks. Please have them faxed
to Dr.[**Name (NI) 56952**] office.
Completed by:[**2162-4-28**] Name: [**Known lastname 10167**],[**Known firstname **] Unit No: [**Numeric Identifier 14104**]
Admission Date: [**2162-4-8**] Discharge Date: [**2162-4-28**]
Date of Birth: [**2121-12-30**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 599**]
Addendum:
New recs per Endo. Please see below.
Brief Hospital Course:
Endocrinology chose to stop all DDAVP on [**4-28**]. They request an
Endocrinology consult at [**Hospital3 **] with the Staff
Endocrinologist for dosing of DDAVP (desmopressin) and close
monitoring of serum Na. SHe will need a Serum Na check on [**4-28**]
PM and also Daily for appropriate DDAVP dosing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**]
Completed by:[**2162-4-28**]
|
[
"253.5",
"415.11",
"E878.8",
"348.9",
"331.4",
"599.0",
"430",
"239.6",
"253.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"38.97",
"38.7",
"83.95",
"93.59",
"38.91",
"01.59",
"02.2",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
15844, 16051
|
15514, 15821
|
328, 523
|
12861, 12908
|
2097, 4832
|
14594, 15491
|
910, 914
|
11267, 12597
|
12711, 12840
|
11238, 11244
|
13036, 14571
|
929, 1281
|
269, 290
|
552, 782
|
1422, 2078
|
5160, 5233
|
12923, 13012
|
804, 810
|
826, 894
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,174
| 121,908
|
27276
|
Discharge summary
|
report
|
Admission Date: [**2184-6-14**] Discharge Date: [**2184-6-22**]
Date of Birth: [**2126-10-18**] Sex: F
Service: MEDICINE
Allergies:
Clindamycin / Erythromycin Base / Amoxicillin / Keflex /
Wellbutrin
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
tylenol OD
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
History of Present Illness:
57 y/o F with h/o breast CA, DM I, polyendocrine deficiency type
I including Addison's disease, hypoparathyroidism, premature
ovarian failure, depression sent to ED from [**Hospital3 537**] after
found unresponsive after ?overdosing on tylenol with codeine
(was found with open bottle Tylenol #3, note asking for
transport to [**Hospital1 2025**] per EMS report). On field, pupils were sluggish
2-3 mm but responsive, HR 100, RR 4, no audible BP, pt pale,
cool and diaphoretic. Given 1 mg IV narcan in field x 2 with no
good effect, vomited several times. In ED, on arrival T 96.8, BP
172/76, HR 103, RR 16, Sat 92% on unclear amount of oxygen. SBP
shortly therafter dropped to 58/46, started on dopamine
peripherally at 8 cc/hr and also given 10 mg IV decadron,
Anzemet IV, 500 mg Levofloxacin IV x 1, 500 mg IV flagyl x 1,
8250 mg IV NAC. In ED, RR improved and was given narcan x 2 with
good effect. Tylenol level 206 and lac 7.0. Pt was admitted to
[**Hospital Unit Name 153**] for further management. Of note, pt was DNR/DNI per report
from brother and [**Hospital3 **] supervisor which pt apparently
put in the last two weeks.
.
On arrival to [**Hospital Unit Name 153**], on dopamine at 10 mcg/min which was
increased to 20 mcg since SBP still in 90s. Pt was awake and
alert on arrival and told us that she "did not expect to wake
up" and took 80 pills of Tylenol with codeine.
Past Medical History:
1) Polyendocrine deficiency syndrome Type I which is comprised
of the following:
a) Hypoparathyroidism, dxed [**2132**]
b) Addison's disease, dxed [**2138**]
c) Premature ovarian failure, dxed [**2145**]
d) Alopecia areata and totalis, dxed [**2148**]
e) mucocutaneous candidiasis
f) Diabetes type I
2) colonic dysfunction alternating with diarrhea and
constipation
3) ?unstable serum calcium since [**2166**]
4) Generalized osteoarthritis
5) depression requiring ECT therapy in the past
6) bilateral Neuropathy of lower extremities
7) Bilateral cataracts
8) PVD
9) Spontaneous dislocation of left hip in [**2181**]
10) GERD
11) Low grade anemia
12) Elevated liver enzymes
13) h/o amputation of right 2nd toe secondary to osteomyelitis
in [**2172**]
14) h/o hemorrhoidectomy in [**2174**]
15) h/o left hip joint replacement in [**2175**]
16) h/o total hysterectomy in [**2176**]
17) h/o breast CA s/p mastectomies
PCP at [**Name9 (PRE) 2025**] [**Telephone/Fax (1) 66889**] Dr. [**Last Name (STitle) 66890**]. Has been hospitalized at [**Hospital1 2025**]
and [**Hospital1 756**] numerous times.
Social History:
lives in [**Hospital3 **]
Family History:
father with history of liver cancer at a late age
Physical Exam:
T 98.0 BP 68/42 (off dopamine), 99/56, HR 96 RR 15 Sat 97%2L NC
Gen: somnolent, poor eye contact but oriented
[**Name (NI) 4459**]: pupils 3-4 mm and sluggishly reactive, EOMI, alopecia, no
scleral icterus, MM moderately dry
Neck: supple, NT, no supraclavicular LAD
CV:tachy, reg rhythm, no m/r/g, +bilateral mastectomy scars
Pulm: R basilar crackles
Abd: s/nt/nd +BS, no hepatomegaly
Ext: trace edema, no cyanosis, nails with bandages and no
nailbed on most nails
Neuro: CN 2-12 intact, tongue midline, no asterixis, brisk
reflexes 3+symmetric throughout, strength 4+/5 equal throughout,
sensation light touch intact, toes upgoing bilaterally, no
clonus; spells world backwards and days of week backwards,
oriented x 3
Rectal per ED exam: guiac negative
Pertinent Results:
Admission Labs:
[**2184-6-14**] 10:10AM PT-12.0 PTT-22.8 INR(PT)-1.0
[**2184-6-14**] 10:10AM PLT COUNT-622*
[**2184-6-14**] 10:10AM HYPOCHROM-OCCASIONAL ANISOCYT-OCCASIONAL
POIKILOCY-1+ MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL
POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL
BURR-OCCASIONAL HOW-JOL-OCCASIONAL ACANTHOCY-OCCASIONAL
[**2184-6-14**] 10:10AM NEUTS-70 BANDS-1 LYMPHS-28 MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2184-6-14**] 10:10AM WBC-13.8* RBC-4.31 HGB-12.0 HCT-37.3 MCV-87
MCH-27.9 MCHC-32.2 RDW-19.5*
[**2184-6-14**] 10:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-206.5*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2184-6-14**] 10:10AM ALBUMIN-3.9 CALCIUM-8.4 PHOSPHATE-13.7*
MAGNESIUM-2.5
[**2184-6-14**] 10:10AM CK-MB-5
[**2184-6-14**] 10:10AM cTropnT-0.03*
[**2184-6-14**] 10:10AM LIPASE-31
[**2184-6-14**] 10:10AM ALT(SGPT)-35 AST(SGOT)-46* CK(CPK)-126 ALK
PHOS-107 AMYLASE-156* TOT BILI-0.2
[**2184-6-14**] 10:10AM GLUCOSE-353* UREA N-24* CREAT-2.7* SODIUM-141
POTASSIUM-4.9 CHLORIDE-94* TOTAL CO2-24 ANION GAP-28*
[**2184-6-14**] 10:19AM LACTATE-7.0*
[**2184-6-14**] 10:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2184-6-14**] 10:35AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2184-6-14**] 10:35AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2184-6-14**] 10:35AM URINE HOURS-RANDOM
[**2184-6-14**] 03:20PM PT-12.8 PTT-27.4 INR(PT)-1.1
[**2184-6-14**] 05:40PM URINE EOS-NEGATIVE
[**2184-6-14**] 05:40PM URINE OSMOLAL-398
[**2184-6-14**] 05:40PM URINE HOURS-RANDOM CREAT-62 SODIUM-105
[**2184-6-14**] 08:15PM freeCa-1.00*
[**2184-6-14**] 08:15PM TYPE-ART PO2-69* PCO2-79* PH-7.08* TOTAL
CO2-25 BASE XS--8
[**2184-6-14**] 11:59PM ACETMNPHN-12.6
[**2184-6-14**] 11:59PM ALBUMIN-3.1*
.
CT Abd and Pelvis:
1. No evidence of intra-abdominal or significant groin hematoma
on either side.
2. Markedly distended gallbladder, which could be seen in a
fasting state.
3. Nonspecific thickening of the cecum, with small amount of
stranding and fluid in the right pararenal fascia and right
pericolic gutter.
4. Stranding and fluid around the presacral space and about the
rectum, also nonspecific.
5. Right hip effusion.
.
CXR [**6-15**]:
INDICATION: Repositioning of right subclavian line.
.
A right subclavian catheter has been withdrawn several
centimeters, and now terminates within the lower superior vena
cava. There is no pneumothorax. There is new opacity in the
left retrocardiac region, likely atelectasis, although
aspiration is an additional consideration. There is otherwise
no substantial change from a recent radiograph of a few hours
earlier.
.
Non-Contrast Head CT, [**6-14**]:
FINDINGS: Very unusual widely disseminated curvilinear shaped
calcifications are seen within the subcortical white matter of
both cerebral hemispheres. Additionally, somewhat conglomerate
punctate calcifications are noted within the lentiform nuclei,
with faint calcifications seen in both dentate nuclei. There is
no sign for an intracranial hemorrhage, mass effect, or
hydrocephalus, minor or major vascular territorial infarction.
No overt extracranial abnormalities are seen.
.
CONCLUSION: Unusual, presumably dystrophic calcifications
within the brain as noted above. Either a degenerative disorder
or metabolic abnormality involving calcium and phosphorus could
be considered. Too more comprehensively exclude metastatic
neoplastic disease not large enough to produce either edema or
mass effect, a followup contrast-enhanced MR study has been
suggested, via transmission of this recommendation to the ED
dashboard.
.
EKG:NSR at 88 bpm, nl axis, QTC 378, nl intervals, no ST changes
Brief Hospital Course:
57 y/o F with multiple medical problems including polyendocrine
deficiency comprised of adrenal insufficiency, DM, premature
ovarian failure, hypoparathyroidism, addison's disease and also
breast CA and depression who presented s/p tylenol with codeine
overdose and hypotension.
.
[**Hospital Unit Name 153**] course:
- received 48 hrs IV N-Ac
- intubated for resp acidosis (pH 7.08 -> 7.15, pCO2 79 -> 61)
on [**6-15**] -> extubated on [**6-17**] without incident
- stress dose steroids administered given hx Addisons -> weaned
to home dose steroids
- hypotensive and requiring pressors initially, weaned off [**6-17**],
blood pressures stable after weaning.
- Levo/Flagyl started for asp PNA on [**6-15**]
- Insulin gtt -> to Glargine and RISS on [**6-17**] -> developed AG ->
gtt restarted -> transitioned back to Glargine and RISS on [**6-18**]
.
# Tylenol Toxicity - Hepatology and toxicology consulted,
received 48 hrs IV N-Ac. LFTs trended down after peak AST 118,
ALT 63 on [**6-14**], peak INR 1.3 on [**6-15**]
.
# Depression/[**Name (NI) **] - Pt is followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at
[**Hospital1 2025**], as well as a psychopharmacologist. SW is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Followed by Psychiatry here, who felt pt would require inpatient
psych admit once medically stable.
- held effexor, neurontin, remeron, ritalin, and Namenda per
psych recs
- started low dose Haldol after an episode of ?paranoia in the
ICU
- denied active SI in the hospital - continued 1:1 sitter and
suicide precautions.
.
# Hypotension: resolved on the floor, though to be
multifactorial, secondary to med effect from codeine, worsening
of known adrenal insufficiency with stress, and underlying
infection.
- Continued home dose steroids
- Continued Levo for asp PNA for a 7 day course, received her
last dose on [**2184-6-21**]
.
# ARF: resolved with IVF, likely pre-renal
.
# Breast Cancer: Continued with Arimidex. No active issues.
.
# Hypocalcemia: baseline calcium per PCP is [**Name Initial (PRE) **] 8. Continued
calcium carbonate and calcitriol.
.
# DM I: Pt. was initially managed with Lantus at home dose (26 U
QHS) + Humalog sliding scale on the floor, with some elevated
blood sugars initially during the transition from the Insulin
gtt which normalized overnight from [**Date range (1) 51037**]. Pt. carb counts
at home and has a sliding scale she uses -> asked to continue
with this. She was noted however to have low AM sugars (35-40s)
with this regimen, so her PM humalog was stopped, she was
administered a standard sliding scale, and her Lantus was
decreased to 23 U. AM FS improved with this intervention to
80s.
.
# Polyendocrine deficiency: See above (DM, hypocalcemia,
Addisons) Continued Rx of DM, Addisons (steroids), and
hypocalcemia (Calcium and calcitriol).
.
# Candidiasis - on qmonth diflucan
.
# Diarrhea- Likely antibiotic related, C diff negative on [**6-20**]
# Ppx: PPI, Hep sq, suicide precautions, sitter
.
# Pt. signed DNR/DNI form at [**Hospital3 537**] recently, but given
that she was actively suicidal Psych felt that this should not
be honored at present. Pt. consented to intubation in ICU.
.
# Communication: with brother and sister in law regarding
medical issues ONLY. Mother does NOT know that this was a
suicide attempt. PCP notified and has seen pt. HCP [**Name (NI) **] [**Name (NI) 9063**]
[**Telephone/Fax (1) 66891**]. [**Hospital3 537**] SW [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Director Dr. [**Last Name (STitle) 1007**],
assistant with ADLs Ray Seller. [**Hospital3 537**] Number
[**Telephone/Fax (1) 5260**] PCP at [**Name9 (PRE) 2025**]: Dr. [**Last Name (STitle) 66892**] [**Telephone/Fax (1) 66889**]
Medications on Admission:
1) Os-Cal 500 mg qid
2) ASA 81 mg PO daily
3) Calcitriol 0.5 mcg PO daily
4) Chlorothiazide 500 mg PO daily
5) Neurontin 300 mg PO qid
6) Effexor XR 300 mg PO daily
7) Mag oxide 400 mg PO BID
8) Prednisone 5 mg PO daily in am, 2.5 mg PO daily 3 pm
9) Florinef 0.1 mg PO daily
10) Nexium 20 mg PO daily
11) Ritalin 15 mg [**Hospital1 **] Mon -Fri
12) Diflucan 100 mg PO 1 tab daily for 1st week each month
13) Colace 1 tab PO tid
14) MVI 1 tab PO daily
15) Lipitor 20 mg PO daily
16) Remeron 45 mg PO qhs
17) Ativan 1 mg PO qhs and prn
18) Namenda 20 mg PO daily
19) Extra strength tylenol 1-2 tabs prn
20) Motrin 1-2 tabs prn
21) MOM prn
22) Lactulose 60-120 cc prn
23) Lantus insulin 26 units QHS, Humalog SI at meals and HS
24) Fosamax 70 mg PO qwk
25) Arimidex
Discharge Medications:
1. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTHUR (every
Thursday).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Chlorothiazide 250 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
9. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO Q 3PM ().
10. Nexium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO three
times a day.
12. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
13. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
14. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
16. Lantus 100 unit/mL Solution Sig: Twenty Three (23) units
Subcutaneous at bedtime.
17. Humalog
Please check FS before meals and bedtime - use attached sliding
scale
18. Os-Cal 500 mg Tablet Sig: One (1) Tablet PO four times a
day.
19. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) mg
Injection [**Hospital1 **] (2 times a day).
20. Mag-Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a day.
21. Klor-Con 20 mEq Packet Sig: One (1) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Location (un) 86**]
Discharge Diagnosis:
primary diagnosis:
tylenol overdose
depression
Secondary diagnosis:
1) Polyendocrine deficiency syndrome Type I which is comprised
of the following:
a) Hypoparathyroidism, dxed [**2132**]
b) Addison's disease, dxed [**2138**]
c) Premature ovarian failure, dxed [**2145**]
d) Alopecia areata and totalis, dxed [**2148**]
e) mucocutaneous candidiasis
f) Diabetes type I
2) colonic dysfunction alternating with diarrhea and
constipation
3) ?unstable serum calcium since [**2166**]
4) Generalized osteoarthritis
5) depression requiring ECT therapy in the past
6) bilateral Neuropathy of lower extremities
7) Bilateral cataracts
8) PVD
9) Spontaneous dislocation of left hip in [**2181**]
10) GERD
11) Low grade anemia
12) Elevated liver enzymes
13) h/o amputation of right 2nd toe secondary to osteomyelitis
in [**2172**]
14) h/o hemorrhoidectomy in [**2174**]
15) h/o left hip joint replacement in [**2175**]
16) h/o total hysterectomy in [**2176**]
17) h/o breast CA s/p mastectomies
Discharge Condition:
good
Discharge Instructions:
Please continue your home medications. Call your doctor
immediately if you have thoughts of hurting yourself or others.
Followup Instructions:
Please make an appointment to see your PCP at [**Name9 (PRE) 2025**] [**Telephone/Fax (1) 66889**]
Dr. [**Last Name (STitle) 66890**] in the next 2 weeks.
The CT of your head here showed some unusual calcifications that
are likely related to your fluctuating calcium levels; however,
a MRI of the brain is recommended to further evaluate. You
should discuss this with your PCP at [**Name9 (PRE) 2025**].
Completed by:[**2184-6-22**]
|
[
"250.71",
"733.00",
"255.4",
"250.61",
"530.81",
"584.9",
"E849.8",
"965.09",
"518.81",
"357.2",
"V10.3",
"311",
"443.81",
"486",
"965.4",
"E950.0",
"458.29",
"276.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13835, 13905
|
7638, 11415
|
339, 379
|
14932, 14939
|
3814, 3814
|
15107, 15544
|
2972, 3023
|
12230, 13812
|
13926, 13926
|
11441, 12207
|
14963, 15084
|
3038, 3795
|
289, 301
|
407, 1793
|
13995, 14911
|
3831, 7615
|
13945, 13974
|
1815, 2913
|
2929, 2956
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,458
| 125,338
|
24612
|
Discharge summary
|
report
|
Admission Date: [**2176-12-22**] Discharge Date: [**2176-12-27**]
Date of Birth: [**2140-12-16**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 1491**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
TIPS procedure
History of Present Illness:
36 yo male w/ h/o Hep C, cirrhosis, ETOH/IVDU who presents to ED
after being discharged from [**Hospital1 18**] three days ago w/ uncontrolled
abdominal pain. Patient planned to undergo TIPS placement
tomorrow with O/N stay, however had increasing abdominal pain at
home. Denies N/V/diarrhea, no F/C, no CP or SOB. Patient had
been taking tramadol and oxycodone w/out relief. States pain is
typical of what he experiences w/ increased ascites. Underwent
dx paracentesis in ED.
Past Medical History:
1. Alcoholic cirrhosis, complicated by grade I varices. Prior
episode of SBP, on abx prophylaxis.
2. Hepatitis C diagnosed at OSH, no viral load available.
3. Proteinuria and hematuria, ? IgA nephropathy
4. Thrombocytopenia [**12-26**] splenic sequestration
5. History of IVDU, last [**2158**]
6. Recent pneumonia.
Social History:
He lives with his wife and 3 young kids. No EtOH X 6 months.
Ex-IVDU, stopped in [**2158**]. Continues to smoke a few cigarettes
daily. + prison, served 3 years for armed robbery 15 years ago.
Family History:
Father with DM type 2, mother with bipolar disorder. He has 4
siblings who are alive. History of EtOH and narcotic abuse.
Physical Exam:
vitals:98.6/ hr 97/ bp 127/98/ 100% on RA
GEN: awake, alert, ambulating, eating, NAD
HEENT: pinpoint pupils, symmetric, anicteric, clear OP
NECK: no JVD, no LAD
CARDIAC:nml s1/s2, no murmurs, full distal pulses
LUNGS: clear B/L, no accessory muscle use
ABDOMEN: distended, tight, tender on LQ>RQ (around tap), + fluid
wave, hyperactive bs
EXT: + pitting edema B/L up to knees, symmetric. Warm, full
pulses
NEURO:CN II-XII intact, no focal deficits. No asterixis. Muscle
strength 5/5 and symmetric in all 4 extremities
Pertinent Results:
[**2175-12-18**]: Abdominal CT
IMPRESSION:
1. No evidence of renal stones.
2. Cirrhotic liver with splenomegaly and ascites, as seen
previously.
.
CXR [**12-22**]: FINDINGS: The heart, mediastinal hilar contours are
within normal limits. The lungs are clear without effusion,
consolidation or pneumothorax. The osseous structures are within
normal limits.
IMPRESSION: No acute cardiopulmonary abnormality.
.
[**2176-12-24**] U/S: IMPRESSION:
TIPS catheter with wall-to-wall flow and normal flow velocities.
Study is slightly technically limited, however, and short-term
follow-up examination is recommended.
.
[**2176-12-22**] 02:45PM BLOOD WBC-4.5 RBC-3.73* Hgb-12.4* Hct-33.8*
MCV-91 MCH-33.4* MCHC-36.8* RDW-14.1 Plt Ct-51*
[**2176-12-24**] 06:01AM BLOOD WBC-7.8 RBC-3.37* Hgb-10.4* Hct-28.9*
MCV-86 MCH-31.0 MCHC-36.1* RDW-14.4 Plt Ct-53*
[**2176-12-27**] 01:00PM BLOOD WBC-5.2 RBC-3.29* Hgb-10.3* Hct-29.0*
MCV-88 MCH-31.3 MCHC-35.5* RDW-14.8 Plt Ct-65*
[**2176-12-22**] 02:45PM BLOOD Neuts-70.4* Lymphs-21.1 Monos-4.2 Eos-3.8
Baso-0.5
[**2176-12-22**] 02:45PM BLOOD PT-13.8* PTT-33.5 INR(PT)-1.2*
[**2176-12-25**] 08:30AM BLOOD PT-15.6* PTT-34.0 INR(PT)-1.4*
[**2176-12-22**] 02:45PM BLOOD Glucose-95 UreaN-20 Creat-1.6* Na-142
K-4.0 Cl-108 HCO3-27 AnGap-11
[**2176-12-27**] 01:00PM BLOOD Glucose-99 UreaN-18 Creat-1.5* Na-137
K-3.7 Cl-104 HCO3-26 AnGap-11
[**2176-12-22**] 02:45PM BLOOD ALT-30 AST-59* AlkPhos-170*
[**2176-12-26**] 10:55AM BLOOD ALT-85* AST-147* LD(LDH)-182 AlkPhos-259*
TotBili-5.4*
[**2176-12-22**] 02:45PM BLOOD Albumin-2.5* Calcium-8.7 Phos-2.9 Mg-1.8
Brief Hospital Course:
Pt was admitted for TIPS procedure for difficult to control
ascites. He was admitted early for pain control requiring IV
dilaudid. Pt's TIPS procedure was technically difficult and he
was noted to have a hard resistant liver, although following
TIPS subsequent studies showed good reversal of flow and
appropriate decrease in portal pressure. During the procedure
he had ascites fluid removed. He went to MICU initially for
observation and pain control, initially on dilaudid drip. Then
transferred to floor, transitioned to PO pain meds. HCT
decreased slightly initially after procedure to 29 from 32, but
remained stable.
.
# Liver - cirrhosis with hx etoh abuse, hep C s/p sucessful TIPS
procedure, U/S with appropriate flows after procedure. Off
nadolol after TIPS.
- continued lactulose prophylactically, no sx of encephalopathy
- decreased ascites, not on diuretics [**12-26**] renal insufficiency
- prior to discharge repeat u/s showed no ascitic fluid that
could be marked for removal
.
# Renal - workup previously thought to be related IgA
nephropathy also with hematuria and proteinuria, noted to have
very dark urine, which is chronic. U/A with significant RBCs,
no hemosiderin.
.
# FEN - low sodium diet, monitor fluid status
.
# CODE- full
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): titrate to [**1-25**] bowel movements daily.
Disp:*[**2170**] ML(s)* Refills:*2*
3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain.
Disp:*60 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Glycerin (Adult) 3 g Suppository Sig: One (1) suppository
Rectal once a day as needed for constipation: if constipated on
colace, senna, and lactulose.
Disp:*15 suppositories* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Cirrhosis
Portal Hypertension
Discharge Condition:
stable, pain well controlled on oral regimen, tolerating PO,
adequate bowel regimen
Discharge Instructions:
Please follow-up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**]. Take your
medications as prescribed. Call your doctor or report to the
hospital if you develop any fever, chills, increasing confusion,
yellowing of the skin, or if you develop any other concerning
symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 275**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2177-1-2**] 4:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2177-1-15**] 11:45
Completed by:[**2177-1-6**]
|
[
"583.9",
"284.8",
"571.2",
"303.90",
"070.70",
"572.3",
"456.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"39.1",
"38.93",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
6007, 6013
|
3659, 4920
|
287, 304
|
6087, 6173
|
2055, 3636
|
6525, 6855
|
1377, 1501
|
4943, 5984
|
6034, 6066
|
6197, 6502
|
1516, 2036
|
233, 249
|
332, 810
|
832, 1149
|
1165, 1361
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,918
| 152,345
|
23691
|
Discharge summary
|
report
|
Admission Date: [**2140-10-25**] Discharge Date: [**2140-11-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
mental status change, s/p fall
Major Surgical or Invasive Procedure:
blood transfusion
nasogastric tube
peripherally inserted central catheter
History of Present Illness:
87 year old, Cantonese-only speaking female with CAD and
cardiomyopathy who intially presented to her PCP [**Last Name (NamePattern4) **] [**2140-10-24**] for
a routine physical, found to have sodium 119, admitted here on
[**10-25**], hospital course complicated by worsening mental status,
discovered C4 fx and sub-dural hematomas and now with melena.
.
The patient's daughter, (pt's primary caregiver at home), notes
the pt has been progressively confused for the past ~2 months.
She used to be able to walk with a cane but for the week prior
to admission, was more "wobbly" and had fallen and struck her
mouth on the ground 1 week ago because she lost her balance
while walking to the bathroom without LOC.
.
During [**Hospital **] hospital stay, there was initial concern for cauda
equina syndrome as she had urinary retention and decreased
rectal tone with some decreased strength. Neuro and NeuroSurgery
was consulted and had multiple imaging studies including
ultimately an MRI spine showing C4 fracture, (she is in
C-collar) and no evidence of cauda equina. Head CT also showed
sub-dural hematomas. Patient was noted to be hyponatremic on
admission c/w SIADH on admission, possibly due to
hygroma/subdural bleed, started on fluid restriction and NS, and
repeat urine lytes with UNa < 10 consistent with pre-renal
etiology. Sodium has been trending up and on day of transfer to
MICU was 129.
.
Late on [**10-27**], pt noted to have melenic stool. Previously she
had been guaiac negative. NG lavage performed and ?very small
amount of clot that cleared quickly. Hct on [**10-25**] 24 --> 18 on
[**10-27**] at 11p.m. She was transfused 4 units and Hct increased to
39.7 (?real). 2 - 20 gauge iv placed, protonix [**Hospital1 **] started and
GI consulted. No urgent need for EGD especially given pt's C4 fx
and in a C-collar. Pt HD stable throughout although now unable
to state her name which she was able to do on admission.
Neurosurgery was to be contact[**Name (NI) **] about this issue and whether
contraindicated to remove collar. On [**10-27**], BUN increased from
26 to 51, creatinine from 0.6 to 0.8 and renal was consulted
given SIADH, worsening mental status and concern that she may be
becoming uremic. In retrospect, the BUN rise may have been due
to GI Bleed.
.
In MICU, the patient's GI bleeding resolved and her mental
status improved. Her hyponatremia was improving on fluid
restriction. Given that her mental status was improving, she was
transferred to [**Hospital1 1516**] service for continuing care.
Past Medical History:
1. Angina - unknown specifics of history.
2. HTN - for 10 years
3. Cataracts bilaterally: Had operation on left eye 30 years
ago. Has had gradual deterioration in vision. Is currently
unable to read.
4. Heart murmur - unknown specifics
5. Depression
6. Hypercholesterolemia
Social History:
Lives in [**Location 3786**], MA with her daughter who is her primary
caregiver. Denies ever using alcohol, tobacco or drugs.
Family History:
Non contributory
Physical Exam:
Vitals: 98.0 72 142/43 15 100% 2L NC
General: alert, NAD, breathing comfortably
HEENT: NC/AT, PERRL, not cooperative with extraocular movements,
anicteric, MM moist
Neck: +hard collar, unable to assess JVP
Pulmonary: CTAB
CV: RRR, s1s2 normal, 3/6 SEM throughout precordium
Abdomen: bowel sounds present, soft, NT/ND
Extremities: warm, no edema, 2+ DP pulses b/l
Skin: warm, no rashes
Neuro: alert, CN II-XII intact, moves all extremities, speech
soft but clear, poor concentration, [**4-20**] grip strength
bilaterally, raises both legs off the bed independently,
+moderate dysmetria, [**Doctor First Name **] intact, gait narrow based and
moderately unsteady, able to walk a few steps with assistance
Pertinent Results:
Hematology:
[**2140-10-24**] 10:56AM BLOOD WBC-6.4 RBC-3.48* Hgb-11.1* Hct-31.8*
MCV-92 MCH-31.9 MCHC-34.9 RDW-14.6 Plt Ct-242
[**2140-11-3**] 06:10AM BLOOD WBC-6.5 RBC-4.17* Hgb-13.4 Hct-36.8
MCV-88 MCH-32.1* MCHC-36.3* RDW-16.8* Plt Ct-111*
[**2140-10-24**] 10:56AM BLOOD Plt Ct-242
[**2140-11-3**] 06:10AM BLOOD Plt Ct-111*
[**2140-10-25**] 12:30PM BLOOD PT-11.5 PTT-26.4 INR(PT)-1.0
.
Chemistry:
[**2140-10-24**] 10:56AM BLOOD UreaN-13 Creat-0.8 Na-119* K-4.0 Cl-85*
HCO3-21* AnGap-17
[**2140-11-3**] 06:10AM BLOOD Glucose-115* UreaN-12 Creat-0.7 Na-133
K-4.1 Cl-98 HCO3-27 AnGap-12
[**2140-10-25**] 12:30PM BLOOD CK(CPK)-206*
[**2140-10-31**] 06:00AM BLOOD ALT-13 AST-16 AlkPhos-51 TotBili-1.5
[**2140-10-25**] 12:30PM BLOOD Lipase-41
[**2140-10-25**] 12:30PM BLOOD CK-MB-5
[**2140-10-25**] 12:30PM BLOOD cTropnT-LESS THAN
[**2140-10-31**] 06:00AM BLOOD Albumin-2.7* Calcium-7.8* Phos-2.9 Mg-1.6
[**2140-10-24**] 10:56AM BLOOD Cholest-151
[**2140-10-25**] 12:30PM BLOOD calTIBC-212* VitB12-554 Ferritn-392*
TRF-163*
[**2140-10-27**] 12:40PM BLOOD Folate-4.8
[**2140-10-24**] 10:56AM BLOOD Triglyc-91 HDL-77 CHOL/HD-2.0 LDLcalc-56
[**2140-10-31**] 08:46PM BLOOD Ammonia-10*
[**2140-10-31**] 08:46PM BLOOD Osmolal-285
[**2140-10-25**] 12:30PM BLOOD TSH-0.91
[**2140-10-26**] 12:01PM BLOOD Cortsol-11.8
.
Urine:
[**2140-10-24**] 10:56AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2140-10-24**] 10:56AM URINE RBC-0 WBC-0 BACTERIA-OCC YEAST-NONE
EPI-1
.
CXR: Lungs clear. Heart size normal.
.
Non contrast Head CT [**10-26**]: Small left greater than right
subdural hygroma versus chronic hematoma. There are prominent
prefrontal extra-axial spaces with no evidence of collections.
There perceived slight
hyperattenuation is felt to be due to beam hardening artifact.
There is no mass effect. There is mild generalized brain
atrophy.
.
CT C-spine [**10-26**]:
1. Acute versus chronic right-based retropulsed C3-C4 disc
and/or hematoma with cord compression. A chronic disc herniation
is most likely, however (see above report).
2. Minimally displaced fractures through the right transverse
process extending through the vertebral foramen at C4. MR C
spine is recommended.
.
MR C/T spine [**10-27**]:
1. Mild canal stenosis at C3-4 associated with posterior disc
bulge, but no signal abnormality in the cord to suggest
significant compression. The disc bulge is most likely due to
degenerative change, with no signal abnormalities at C3-4 disc
identified or any adjacent osseous structures.
2. T2 hyperintense focus adjacent to the right side of the
spine, at the T11 level, of unclear significance. Correlation
with clinical factors is recommended, as the appearance could
suggest subtle presence of fluid.
3. Known fractures involving the right vertebral artery foramen
of C4 not well demonstrated on this study, probably because of
technical factors.
.
MR L spine :
1) No evidence of significant compression of the conus,
although multilevel degenerative changes are present, including
mild spinal stenosis, and left-sided mild neural foraminal
narrowing at L3-L4 and L4-L5. This appearance is consistent with
degenerative changes.
2) Questionable presacral fluid or edema, based on mildly
increased signal on T2-weighted imaging.
.
MRA Neck [**10-27**]: IMPRESSION: No evidence of acute injury,
including at the site of clinical concern involving vertebral
foraminal fractures of C4. Bilateral carotid stenoses, and a
probable short narrowing of the left vertebra at C4-C5 with
slight post-stenotic dilatation.
.
CXR [**10-28**]: A thin bore nasogastric tube ends in the mid stomach.
Lungs clear. Heart size normal. Thoracic aorta tortuous and
calcified but not dilated. No pleural abnormality or evidence of
central adenopathy.
.
TTE [**10-28**]: The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are moderately thickened.
There is mild to moderate aortic valve stenosis. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**1-18**]+) mitral regurgitation
is seen. The left ventricular inflow pattern suggests impaired
relaxation. There is a trivial/physiologic pericardial effusion.
.
CT head ([**2140-11-2**]): No acute intracranial hemorrhage or mass
effect. Prominent prefrontal extraaxial spaces, unchanged,
without evidence of focal collection.
.
Brief Hospital Course:
87F presents after 2 months of worsening mental status,
decreased ambulation, fall, hyponatremia [**2-18**] SIADH, C4 fracture.
While inpatient, she developed a significant upper GI bleed
requiring a brief stay in the ICU. Her hematocrit improved and
stabilized s/p blood transfusion. Her mental status returned to
baseline with correction of her hyponatremia and she was
discharged to rehab in good condition.
.
# Acute blood loss anemia: The patient developed melanotic
stools while an inpatient and her hematocrit decreased acutely
to 18. She was transferred to the MICU for stabilization and
monitoring. Her Hct normalized s/p 4 units pRBC transfusion and
remained stable for 5 days prior to discharge. GI was consulted
and recommened EGD/colonoscopy, however given her C4 fracture
and C-collar and the fact that her Hct had stabilized, the risks
of spinal injury were deemed to outweigh the benefits of EGD at
this time. She will require EDG/colonoscopy in [**6-23**] weeks when
her cervical collar is cleared by Neurosurgery. She was
continued on PPI [**Hospital1 **]. Her aspirin was held given GI bleed.
.
# Hyponatremia: Her admission serum sodium was 117. She was
initially given IV NS and put on a 500cc fluid restriction with
improvement. IVFs were discontinued and her fluid restriction
was relaxed to 1500cc at discharge. Her serum sodium increased
into the 130's and her mental status improved. Her hyponatremia
was thought to be [**2-18**] SIADH, possibly from subdural
hygroma/hematomas.
.
# Altered mental status / dementia: She likely presented with
acute delerium on basline dementia. Toxic-metabolic vs
neurologic from ?chronic subdural likely [**2-18**] brain atrophy and
recent fall. Other possibilities considered included infectious
etiology, however there no localizing features. Head CT revealed
likely old subdural. U/A and culture were negative. LFTs,
ammonia, and vitamin B12 were normal. RPR was non-reactive. Two
days prior to admission, the patient became agitated and pulled
out her PICC line. She was given 0.5mg ativan IV and became
somnolent for approximately 12 hours. A repeat head CT was
performed which revealed no acute hemorrhage or mass effect. Per
her daughter, the patient was at baseline mentation prior to
discharge. - ammonia and LFTs normal
.
# Lower extremity weakness: Per daughter, the patient could walk
with a cane until 2 weeks prior to admission. Motor exam appears
intact, and patient was able to walk with PT yesterday. CT head
negative. Deconditioning likely is a large factor. She will
benefit from long term rehabilitation.
.
# C4 fracture: Neurosurgery consulted for C4 fracture noted on
C-spine imaging performed for evaluation of possible cauda
equina syndrome as initial concern for urinary retention. The
recommend continuing hard C-collar for 8 weeks. She should f/u
with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 1669**]) in clinic in 8 weeks for
evaluation.
.
# Urinary retention: Concern for urinary retention and possible
cauda equina syndrome at presentation. Spine imaging revealed no
acute cord compression or cauda equina, although there was mild
chronic cord compression. Her foley was d/c'd and she passed a
voiding trial. She was voiding independently at discharge.
.
# Anemia: Her Hct in [**4-/2139**] was 36.9. GI bleed as above during
this admission. Iron studies were consistent with ACD; B12 and
folate were normal. Her Hct stabilized s/p blood transfusion.
She will need EGD/colonoscopy when C-collar is cleared by
Neurosurgery.
.
# Subdural hematoma: Appears chronic on head CT, likely [**2-18**]
recent fall reported per family in patient with brain atrophy.
Her mental status cleared and her neuro examination was
nonfocal. Repeat head CT revealed the subdurals were stable.
.
# Heart failure: EF 37% in '[**31**], but EF>55% now with only mild
LVH. She may have diastolic dysfunction. She was not volume
overloaded on exam and maintained a good SaO2. No active issues.
.
# HTN: BPs elevated during admission, and her ACEi was
uptitrated. In addition, she was started on metoprolol which she
tolerated well. Intermittently she was noted to have SBP in the
190's but was asymptomatic, likely [**2-18**] occasional anxiety.
.
# Thrombocytopenia: Likely [**2-18**] GIB, held all heparin products.
She will need repeat platelet count at her PCP visit next week
to evaluate.
.
# s/p Fall: The day of discharge, the patient had a witnessed
fall. She got out of bed and was walking to the commode when she
was witnessed by a nursing aide to slowly lower herself to the
ground. There was no head trauma. Via translator, the patient
denied any pain. Neurological exam was intact and unchanged from
prior. No tenderness to palpation. She appeared to be mentating
at baseline.
.
Medications on Admission:
1. Lisinopril 10 mg Qday
2. metoprolol XL 50 mg Qday
3. Atorvastatin 20 mg Qday
4. Fluoxetine 20 mg Qday
5. Aspirin 325 mg Qday
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
1. Traumatic Subdural Hemotoma.
2. Delirium.
3. Upper GI Bleed.
4. Blood Loss Anemia.
5. Hyponatremia.
6. C4 Cervical Neck Fracture.
7. Urinary Retention.
8. Thrombocytopenia NOS.
Secondary:
1. Hypertension.
2. Coronary Disease NOS.
3. Hypercholesterolemia.
4. Mild AI, Moderate MR.
5. Depression.
6. Bilateral Cataracts.
7. Dementia.
Discharge Condition:
good
Discharge Instructions:
Please take all medications as prescribed.
.
New medications: metoprolol, lansoprazole, cholecalciferol
Changed medications: lisinopril
Discontinued medications: aspirin
.
Call your doctor or return to the ED immediately if you
experience worsening chest pain, shortness of breath, nausea,
vomiting, sweating, fevers, chills, bleeding, confusion,
headaches, weakness, numbness, or other concerning symptoms.
Followup Instructions:
Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **], at [**Telephone/Fax (1) 8236**] for a
follow-up appointment next week.
|
[
"287.5",
"788.20",
"E928.9",
"428.0",
"806.00",
"293.0",
"719.7",
"852.21",
"578.1",
"401.9",
"V15.88",
"285.29",
"253.6",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
14286, 14358
|
8884, 13651
|
292, 368
|
14747, 14754
|
4135, 8861
|
15210, 15388
|
3379, 3397
|
13829, 14263
|
14379, 14726
|
13677, 13806
|
14778, 15187
|
3412, 4116
|
222, 254
|
396, 2923
|
2945, 3220
|
3236, 3363
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,991
| 111,425
|
9733
|
Discharge summary
|
report
|
Admission Date: [**2194-7-28**] Discharge Date: [**2194-8-11**]
Date of Birth: [**2153-3-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Aspirin / Sulfa (Sulfonamides) / Tetracyclines / Lopid / Demerol
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
+ ETT / Chest discomfort
Major Surgical or Invasive Procedure:
[**2194-7-28**] CABG x2
History of Present Illness:
41-year-old patient with prior percutaneous coronary
intervention and stenting of the right coronary artery presented
with symptoms of further ischemia
and was investigated and was found to have a lesion in the left
anterior descending artery as well as in-the-stent stenosis and
disease in the posterior descending artery distal to the stents.
She was electively admitted for
coronary artery bypass grafting.
Past Medical History:
1. Hypercholesterolemia.
2. Obesity.
3. Hypertension.
4. Tobacco history.
5. Coronary artery disease: [**2192-7-6**] non-ST-elevation
myocardial infarction, 100% RCA, three stents, 50% mid LAD.
[**2193-1-6**] instent restenosis status post
brachytherapy.
6. GERD.
7. Asthma.
8. Sciatica.
9. Degenerative joint disease.
10. Glomerulosclerosis.
Social History:
Patient is on disability; lives at home with her 8 y.o.
daughter. Sister and mother live nearby, but not in same house.
Family History:
Mother had heart valves replaced
Physical Exam:
GEN: WDWN in no acute distress
HEENT: NCAT, PERRL, EOMI, OP benign
NECK: Supple no JVD, no bruit
LUNGS: Clear
HEART: RRR, Nl S1-S2
ABD: Obese, benign
EXT: no edema, 2+ pulses, no varicosities.
Pertinent Results:
[**2194-8-9**] 06:10AM BLOOD WBC-16.8* RBC-4.09* Hgb-12.5 Hct-37.5
MCV-92 MCH-30.6 MCHC-33.4 RDW-13.4 Plt Ct-520*
[**2194-8-9**] 06:10AM BLOOD Plt Ct-520*
[**2194-8-11**] 02:19PM BLOOD Glucose-101 UreaN-27* Creat-1.3* Na-136
K-4.3 Cl-98 HCO3-23 AnGap-19
[**2194-8-4**] 03:01AM BLOOD ALT-29 AST-40 LD(LDH)-447* AlkPhos-136*
Amylase-18
CXR [**2194-7-28**]
There is mild postoperative widening of the superior
mediastinum. Heart size is normal. A pleural tube overlies
region of previous nodule in the left lower lung. There is no
pneumothorax or pleural effusion. ET tube, right jugular
introducer, and nasogastric tube are in standard placements. The
tip of the endotracheal tube is probably less than 2 cm from
either the carina or the underside of the clavicles, with the
chin extended. Withdrawal of the tube by approximately 15 mm
would put it in optimal placement.
CXR [**2194-8-6**]
Nasogastric tube should be advanced at least 6 cm to move all
the side ports into the stomach. ET tube is in standard
placement. Moderate enlargement of the postoperative cardiac
silhouette is stable and unremarkable. There is no pleural
abnormality. Pulmonary edema has resolved since [**8-4**]. No
pleural abnormality.
ECHO [**2194-7-31**]
1. The left atrium is mildly dilated.
2. 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
difficult to assess but is probably normal (LVEF>55%).
3. There is no pericardial effusion.
4. Compared with the findings of the prior study of [**2194-7-10**],
there has been no significant change.
[**2194-7-28**] EKG
Normal sinus rhythm, without diagnostic abnormality
Brief Hospital Course:
Ms. [**Known lastname 32857**] was electively admitted to the [**Hospital1 18**] on [**2194-7-28**]
for surgical management of her coronary artery disease. She was
taken directly to the operating room where she underwent
coronary artery bypass grafting to two vessels. Postoperatively
she was taken to the cardiac surgical intensive care unit for
monitoring. On postoperative day one, Ms. [**Known lastname 32857**] [**Last Name (Titles) 5058**]
neurologically intact and was extubated. The pulmonology service
was consulted for hypoxia. An echo was obtained which ruled out
tamponade. Subcutaneous heparin was started for pulmonary
embolism prophylaxis. As no ventilatory problems were
identified, other findings were consistent with pulmonary edema
and diuresis was optimized. She continued to be hypoxic and
BIPAP was started. She was transfused with red blood cells for
postoperative anemia. On postoperative day three, Ms. [**Known lastname 32857**]
was reintubated for respiratory failure. A bronchoscopy was
performed which showed normal airways and a bronchoalveolar
lavage was sent for culture. Vancomycin and Zosyn were started
given her fevers and she was pan cultured. A blood cultured
revealed coagulase negative staph in one bottle and she
clinically improved on antibiotics. Ms. [**Known lastname 32857**] slowly weaned
from the ventilator and was again extubated on postoperative day
ten. Diuresis was continued. On postoperative day eleven, Ms.
[**Known lastname 32857**] was transferred to the step down unit for further
recovery. The physical therapy service was consulted for
assistance with her postoperative strength and mobility. Her
drains and pacing wires were removed per protocol. Ms. [**Known lastname 32857**]
made slow but steady progress and was discharged home on
postoperative day fourteen. She will follow-up with Dr. [**Last Name (Prefixes) **] her cardiologist and her primary care physician as an
outpatient.
Medications on Admission:
Prilosec
Lopressor
Urecholine
Plavix
Tricor
Flexeril
Aspirin
Wellbutrin
Trazadone
Colace
Zyrtec
Vicodin
Diovan
Singulair
Prozac
Zetia
Gabapentin
Guaifenex
Ativan
Crestor
Senekot
Compazine
Metformin
Actos
Zocor
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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 months.
Disp:*30 Tablet(s)* Refills:*2*
4. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
5. Lansoprazole Oral
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed for pain for 30 doses.
Disp:*30 Tablet(s)* Refills:*0*
7. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
9. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours) as needed.
11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
13. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 701**] VNA
Discharge Diagnosis:
CAD
HTN
Hypercholesterolemia
Asthma
Diabetes Melitus type II
DJD
GERD
Obesity
Fibromyalgia
s/p TAH
s/p Appendectomy
s/p cholecystectomy
s/p lysis of adhesions
Respiratry Failure
Bacteremia
Pneumonia
Discharge Condition:
Stable
Discharge Instructions:
Shower daily, wash incision with mild soap and water and pat
dry. No lotions, creams, powders, or baths. No lifting more than
10 pounds or driving until folloup with surgeon.
Call with temperature more than 101.4, redness or drainage from
incision, or weight gain more than 2 pounds in one day or five
in one week.
Shower daily, wash incision with mild soap and water and pat
dry. No lotions, creams, powders, or baths. No lifting more than
10 pounds or driving until folloup with surgeon.
Call with temperature more than 101.4, redness or drainage from
incision, or weight gain more than 2 pounds in one day or five
in one week.
Followup Instructions:
Provider: [**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 29557**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3183**] Call to schedule
appointment should be in 1 week
Completed by:[**2194-8-12**]
|
[
"272.0",
"518.5",
"285.9",
"250.00",
"401.9",
"997.3",
"493.90",
"507.0",
"996.72",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"33.24",
"96.6",
"36.15",
"36.11",
"96.04",
"99.04",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7088, 7146
|
3362, 5309
|
356, 382
|
7388, 7397
|
1605, 3339
|
8075, 8418
|
1343, 1377
|
5570, 7065
|
7167, 7367
|
5335, 5547
|
7421, 8052
|
1392, 1586
|
292, 318
|
410, 822
|
844, 1189
|
1205, 1327
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,018
| 146,036
|
50206
|
Discharge summary
|
report
|
Admission Date: [**2196-10-23**] Discharge Date: [**2196-10-30**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Altered Mental Status.
Failure to Thrive.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85yo M with history of CAD, DM, PVD, dementia referred by PCP to
the [**Name9 (PRE) **] with altered mental status and failure to thrive.
The patient had a left AKA two months ago and has been
reportedly "not the same" since this operation. Per his wife, he
was depressed and "didn't speak much" prior to the operation,
but since the surgery has been increasingly confused. He was
discharged to home from the Rehab approximately 1.5 weeks ago
and over this time has had worsening mental status, primarily
moaning and saying "help me". His wife does note some confusion
at Rehab as well. He has had decreased po intake over this time
and has not taken solids or fluids for several days. His nursing
aid reports that over the past two days, he has been slumping to
the side in his wheelchair and had a recent fall from his
wheelchair and hit his head last Monday, [**10-17**]. No reported loss
of consciousness. His wife reports that he has had a 10-pound
weight-loss over the past two months. His wife and home health
aide deny that he has had cough, SOB, CP, diarrhea, melena,
BRBPR. The history was obtained primarily from ED records and
speaking with his wife and family members.
The pt was brought in by his wife on [**2196-10-23**] as he had
been losing weight and he had not eaten since d/c from Rehab.
ED course: the patient was noted to be moaning. Temp 99.8, BP
144/72 with HR 76. A UA was positive and he was started on
Levofloxacin and flagyl. GI was contact[**Name (NI) **] for guiaiac positive
stool and anemia. NG lavage in ED was negative for blood.
Cardiology was contact[**Name (NI) **] for troponin of 0.14. Head CT negative
for acute bleed. He received 2L NS and 1U PRBC and was
transferred to the MICU.
Past Medical History:
1. CV:
---CAD: last Stress Echo ([**3-4**]): No EKG changes or angina. No 2D
echocardiographic evidence of inducible ischemia to achieved
workload. Non-diagnostic study - target HR was not achieved.
---CHF: Probable diastolic dysfunction, Echo ([**5-6**]): EF 60%, E/A
ratio: 0.53, moderate symmetric left ventricular hypertrophy,
left ventricular inflow pattern suggests impaired relaxation, 1+
AR, 2+ MR
[**Name13 (STitle) 104730**]: Bradycardia s/p pacemaker placement
---PVD: Peripheral vascular disease s/p angioplasty of left
common femoral artery with a Dacron patch angioplasty and
thrombectomy [**2196-8-9**], s/p Left AKA for acute left leg ischemia
[**2196-8-12**]
2. HTN
3. DM
4. GIB
5. Dementia
6. COPD
7. CRF
8. OA
9. Gout
10. OSA
Social History:
Patient lives with is wife in [**Name (NI) **]. Previously worked with
antiques. Wife denies that he drinks or does illicit drugs. Quit
smoking 40 yrs ago.
Family History:
NC
Physical Exam:
Vitals: T 95.8, Tmax: 97, BP: 158/68, HR: 70, RR: 21, 96% 2L
NC
Gen: ill-appearing elderly man. Asleep, difficult to arouse
with verbal stimuli but arousable by physical stimuli. Pt
continuously moaning once awake and answers questions with
grunts. NAD
HEENT: NCAT, PEERL, difficult to assess EOM as pt would not
cooperate with exam, dry mucous membranes
Neck: supple, no LAD, no JVD
Lung: CTA bilaterally but difficult to assess due to lack of
cooperation and grunting.
CV: RRR, nml S1, S2, no m/r/g appreciated but again difficult to
appreciate due to grunting.
Abd: soft NT, ND, BS+, no rebound or guarding.
Rectal: not performed as pt was not cooperating.
Ext: ecchymoses on right heel, s/p left AKA, no edema
Neuro: difficult to assess due to lack of cooperation, slurred
speech and groaning/mumbling
Pertinent Results:
[**2196-10-23**] 03:20PM
WBC-19.2*# HGB-8.6* HCT-25.4* MCV-96 PLT COUNT-140*#
PT-13.1 PTT-21.8* INR(PT)-1.2
NEUTS-79* BANDS-3 LYMPHS-10* MONOS-3 EOS-4 BASOS-0 ATYPS-0
METAS-1* MYELOS-0
LACTATE-3.9*
SODIUM-139 POTASSIUM-3.8 CHLORIDE-91* TOTAL CO2-23 UREA N-179*
CREAT-7.6*#
GLUCOSE-233* ANION GAP-24*
ALT(SGPT)-47* AST(SGOT)-50* ALK PHOS-122* AMYLASE-106* LIPASE-14
CK(CPK)-444* CK-MB-5 cTropnT-0.14*
CHOLEST-151 TRIGLYCER-383* HDL CHOL-14 CHOL/HDL-10.8
LDL(CALC)-60
VIT B12-1629* FOLATE-GREATER TH
TSH-0.69
URINE RBC-[**5-13**]* WBC-[**10-23**]* BACTERIA-MANY YEAST-NONE EPI-0-2
URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD
EKG ([**2196-10-23**]): Ventricular paced at 71 bpm
CXR ([**2196-10-23**]): Small left pleural effusion. No evidence of
pneumonia.
CXR ([**2196-10-26**]): Probable aspiration pneumonia in the left lower
lobe and right lower lobe.
Head CT ([**2196-10-23**]): no hemorrhage or mass effect
Abd CT ([**2196-10-23**]): bibasilar atelectasis, 2.8cm hyperdense left
renal cyst (recomended US or MRI), non-obstructing
bowel-containing left inguinal hernia
Echo ([**5-6**]): EF 60%, E/A ratio: 0.53, moderate symmetric left
ventricular hypertrophy, left ventricular inflow pattern
suggests impaired relaxation, 1+ AR, 2+ MR
Colonoscopy ([**4-3**]): Lipoma in the ileocecal valve.
Diverticulosis of the ascending colon, sigmoid colon and
descending colon.
Brief Hospital Course:
85M with history of CAD, DM, PVD, and dementia who was referred
by PCP to the [**Name9 (PRE) **] for altered mental status and failure to thrive
[**2196-10-23**]. Patient initially admitted to MICU with AMS, renal
failure, GI bleed and troponin leak and found to have Klebsiella
UTI and thought to be in urosepsis. Patient later transferred
to the floor [**10-25**] where he had been stable until [**10-26**], when he
had an episode of hematemesis post attempted NGT placement and
was transferred back to the MICU for closer monitoring. Patient
transferred back to the floor [**10-27**] with stable HCT after blood
transfusions and no further upper airway bleeding.
1. Altered mental status: Pt continued to moan and mumble
incoherently, which according to his wife and caretaker had been
going on for at least 1.5 weeks, and possibly during his stay at
Rehab prior to that. This appears to be a somewhat subacute
process superimposed on chronic deficits, likely delirium
superimposed on underlying depression and dementia. Delirium was
thought to be likely related to urosepsis and uremia. TSH,
Vitamin B12 normal. Mental status did not improve much during
hospital stay and eventually declined [**2196-10-29**] with diminshed
response to painful stimuli.
2. Urosepsis: Pt with Klebsiella UTI and was hemodynamically
stable throughout hospital course. Patient initially afebrile
but later began to spike fevers despite continued antibiotic
therapy (renally-dosed Levofloxacin) for his UTI while on the
floor.
3. Renal failure: Acute on chronic renal failure. Baseline
creatinine appears to be around 2.5, 7.9 at peak. Acute on
chronic renal failure of mixed etiology- likely a prerenal
component given decreased po intake over the last several weeks
and GIB, as well as ATN in setting of known UTI/Pyelnephritis,
given muddy brown casts and FENa of 4% on admission. Creatinine
improved minimally after fluid hydration and blood products on
admission. Renal US showed no hydronephrosis and simple cyst
left kidney. Renal service was following and initiated HD
[**10-26**].
4. GIB: The pt was found to have BRBPR at time of admission
along with a Hct of 25.4. NG lavage in ED was negative
suggesting lower GI bleed. The pt was transfused 2units of
PRBC. The pt had not been tachycardic (although V-paced) or
hypotensive in the MICU. After receiving 3 units of PRBC's over
24 hrs, pt's hematocrit was 34.5. A colonoscopy was deferred
and the pt was managed conservatively. Pt was manually
disimpacted and stool contained BRB as well as old blood. The
stool was very thick but not well-formed and quite dark. Pt was
to undergo flex sig once determined to be stable.
5. Hematemesis: Most likely related to trauma of the upper
airway from the NGT in the setting of coagulopathy (INR 1.9)
causing bleeding [**2196-10-26**]. The patient had epistaxis, which is
also c/w trauma. He was likely swallowing blood from his
oropharynx and vomited it (500cc Bright red blood with large
clots +400cc of suctioned blood). ENT and GI both thought that
presentation was consistent with NGT trauma and recommended
afrin spray and ice packs to head and neck. Bleeding has now
resolved after 2uFFP and treatment with afrin.He remained
hemodynamically stable but was transferred to the MICU for
closer monitoring given his history of GI bleed. He remained
hemodynamically stable but received 2U PRBC when his Hct was
found to have 35.8 to 26.4. He was transferred back to the floor
on [**10-27**].
6. Coagulopathy: Unclear etiology of coagulopathy- LFTs slightly
elevated on admission, but have returned to within normal
limits. Could also be related to malnutrition. DIC is also a
possibility given urosepsis on admission, but PT and PTT are wnl
and DIC labs were not consistent with DIC.
7. Hypoxia: Pt developed a new oxygen requirement during
hospitalization post NGT attempt. CXR with possible aspiration
PNA in LLL and RLL. More likely to be apiration pneumonitis.
Given the development of low grade fevers, Flagyl was started to
cover anaerobes as patient was already getting gram positive
coverage with Levopfloxacin (for UTI).
8. Troponin elevation: Troponin elevated on admission (CK and
CK-MB flat with troponin of 0.14) in setting of dehydration and
acute renal failure, now trending down.Unclear significance in
setting of creatinine clearance of ~8. EKG is now V-paced so
difficult to assess for acute ST changes. Pt complains of pain,
but cannot communicate where his pain is. This was thought to be
demand ischemia in the setting of anemia and dehydration from
decreased po's. Plavix was held but beta blocker and ASA was
restarted on hospital day2.
6. Hypernatremia: Sodium was trending up during hospital stay
and patient appeared hypovolemic. Patient given IVF/free water
with improvement of serum sodium.
7. LFT elevations: New elevation in ALT, AST and alk phos on
admission. Unclear etiology as abdominal CT did not reveal any
abnormalities. LFTs have since trended down to normal.
Hepatitis serologies were pending.
8. DM: Fingersticks QID with gentle insulin sliding scale, given
renal failure.
9. Gout: Continue allopurinol, but renally dose at 100mg Q48hrs
10. Communication: Wife and daughter (HCP [**Name (NI) **] [**Name (NI) 104731**]
[**Telephone/Fax (1) 104732**]).
11. Patient initally full code, but family later found
documentation dated [**2193**] which indicated that the patient did
not want heroic efforts and/or artificial means to keep him
alive. Code status was later changed to DNR/DNI to reflect
patient's wishes. With deterioration of [**Hospital 228**] medical
condition despite continued therapy, family later decided to
make the patient comfort measures only. Patient expired
[**2196-10-30**].
Medications on Admission:
MEDICATIONS AT HOME:
1. Plavix 75mg once daily
2. Isosorbide Mononitrate 30mg once daily
3. Hctz 25 mg once daily
4. Sodium Bicarbonate 650mg 3 tab daily
5. Zoloft
6. Allopurinol 100mg daily
7. ASA 81mg once daily
.
.
MEDICATIONS AT TIME OF TRANSFER:
1. Allopurinol 100 mg NG every other day
2. Aspirin 325 mg NG daily
3. Hydromorphone 1 mg IV x 1
4. Metoprolol 12.5 mg PO BID
5. Pantoprazole 40 mg IV Q12H
6. Piperacillin-Tazobactam Na 2.25 gm IV Q8H
.
.
ALLERGIES: NKDA
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary arrest
Urosepsis
Acute renal failure
GIB
CAD
DM
PVD
Dementia
Discharge Condition:
expired
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"578.9",
"038.49",
"396.3",
"250.00",
"496",
"443.9",
"398.91",
"V49.76",
"276.51",
"274.9",
"584.9",
"410.71",
"507.0",
"585.9",
"V45.01",
"599.0",
"995.92",
"290.0",
"403.91",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"99.07",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11636, 11645
|
5344, 6023
|
305, 311
|
11766, 11870
|
3875, 5321
|
3025, 3029
|
11666, 11745
|
11126, 11126
|
11147, 11613
|
3044, 3856
|
224, 267
|
339, 2067
|
6038, 11100
|
2089, 2836
|
2852, 3009
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,390
| 116,799
|
50332
|
Discharge summary
|
report
|
Admission Date: [**2170-8-1**] Discharge Date: [**2170-8-14**]
Date of Birth: [**2125-3-16**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p 18 ft fall
Major Surgical or Invasive Procedure:
Splenectomy
VATS procedure with empyema tube placement
History of Present Illness:
45 year-old gentleman s/p fall approx 18 ft onto a large post
which snapped in half who broke several left sided ribs and also
ruptured his spleen. +EtOH He was transported to [**Hospital1 18**] where he
was takne to the operating and underwent a splenectomy.
Social History:
+EtOH
Family History:
Noncontributory
Pertinent Results:
[**2170-8-1**] 11:58PM GLUCOSE-159* LACTATE-2.4* NA+-137 K+-4.6
CL--105
[**2170-8-1**] 03:22AM GLUCOSE-116* UREA N-19 CREAT-0.9 SODIUM-138
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-20* ANION GAP-17
[**2170-8-1**] 03:22AM CALCIUM-7.9* PHOSPHATE-3.3 MAGNESIUM-2.1
[**2170-8-1**] 03:22AM WBC-10.8 RBC-4.19* HGB-14.0 HCT-40.4 MCV-97
MCH-33.5* MCHC-34.7 RDW-13.2
[**2170-8-1**] 03:22AM PLT COUNT-230
[**2170-8-1**] 12:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
CT CHEST W/CONTRAST
IMPRESSION:
1. Resolving contusion in right apex and basal segment of right
lower lobe.
2. Interval resolution of loculated effusion in left apex
anteriorly.
3. Chest tube in situ with left pleural effusion noted.
4. The patient is status post splenectomy.
5. Multiple rib fractures on the left.
6. Small fluid collection in intercostal muscles on the left
side at the site of a rib fracture.
CT HEAD W/O CONTRAST
IMPRESSION: No intracranial hemorrhage or fracture.
CT C-SPINE W/O CONTRAST
IMPRESSION:
1. No acute alignment abnormality or fracture.
2. Partial demonstration of patient's left pneumothorax.
Brief Hospital Course:
He was admitted to the Trauma service. Once stabilized in the
trauma bay he was taken to the operating room for an exploratory
laparotomy and splenectomy. There were no intraoperative
complications. He remained in the Trauma ICU for several days
for close monitoring given his injuries. He was noted to have
dyspnea and increased oxygen requirements; chest imaging
revealed a loculated left sided effusion. Thoracic surgery was
consulted and he was taken to the operating room on [**8-6**] for left
VATS decortication.
Cultures of the pleural fluid and of his chest wound were sent
which revealed a staphylococcal infection. It was recommended by
Infectious Disease that he be treated with a 6 week course of
Nafcillin. A PICC line was placed and plans were made or
discharge home with IV antibiotics.
He was given the appropriate vaccinations due to the splenectomy
prior to his discharge. Follow up is needed in both Trauma and
Thoracic clinic.
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
5. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) GM
Intravenous Q6H (every 6 hours) for 6 weeks.
Disp:*qs GM* Refills:*0*
6. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Ten (10) ML
Injection DAILY (Daily): Flush PICC line before and after use
and PRN.
Disp:*qs ML(s)* Refills:*2*
7. Central line dressing kit
Change PICC line dressing as directed
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
s/p 18 ft fall
Left pneumothorax
Multiple left sided rib fractures
Grade III splenic laceration
Wound staphylococcal infection
Discharge Condition:
Stable
Discharge Instructions:
You will need to continue with the IV antibiotics for a total of
6 weeks.
Return to the Emergency room if you develop any fevers, chills,
shortness of breath, chest discomfort, redness or thick drainage
from PICC lie site, abdominal pain, nausea, vomiting, diarrhea
and/or any other symptoms that are concerning to you.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in 1 week; call [**Telephone/Fax (1) 600**] for an
appointment.
Follow up in [**Hospital 16814**] clinic in [**2-6**] weeks, call [**Telephone/Fax (1) 170**]
for an appointment.
Completed by:[**2170-8-14**]
|
[
"518.5",
"868.01",
"865.03",
"790.7",
"305.00",
"511.1",
"293.0",
"807.04",
"753.3",
"041.11",
"E882",
"482.41",
"862.29",
"510.9",
"860.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.51",
"96.71",
"96.6",
"41.5",
"38.93",
"99.04",
"96.04",
"33.24",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
3711, 3763
|
1908, 2861
|
328, 385
|
3934, 3943
|
749, 1885
|
4312, 4567
|
713, 730
|
2884, 3688
|
3784, 3913
|
3967, 4289
|
274, 290
|
413, 674
|
690, 697
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,998
| 169,488
|
38999
|
Discharge summary
|
report
|
Admission Date: [**2181-6-3**] Discharge Date: [**2181-6-14**]
Date of Birth: [**2142-7-9**] Sex: F
Service: NEUROSURGERY
Allergies:
Lactose
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
neck pain
Major Surgical or Invasive Procedure:
C5 corpectomy and fusion
History of Present Illness:
38yo woman reportedly dove into the shallow end of a pool
striking top of her head. Per report she required assistance
getting out of the pool and wasn't moving lower
extremities.Placed in c-spine precautions by EMS. At OSH she was
quadraplegic and intubated for airway protection (secondary to
vomiting).
Imaging at OSH revealed C5 on C6 subluxation therefore
transferred to the [**Hospital1 18**]. Neurosurgery consultation requested
for evaluation.
Past Medical History:
unknown
Social History:
married, 2 kids, non-smoker
Family History:
non- contributory
Physical Exam:
O: T: 33.6 BP: 102/67 HR:50 R 14 O2Sats 100%
Gen: intubated. eyes open to voice. attends examiner.
HEENT: Pupils: 2-2.5mm PERRL EOMs intact
Neck: Hard Collar on
Abd: Soft, NT
Extrem: Warm and well-perfused.
Neuro:
Mental status: arouses to voice. attends examiner.
Orientation:unable to assess
Motor:
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
R 5 4+ 0 0 0 0 0 0 0 0 0
L 5 4+ 0 0 0 0 0 0 0 0 0
Sensation: Intact to light touch to forearms bilaterally. No
sensation to hands or below clavicle.
Reflexes: T Br Pa Ac
Right 0 0 0 0
Left 0 0 0 0
Propioception not intact
Toes downgoing bilaterally
no Hoffmans appreciated
no clonus
Exam upon discharge:
deltoid/biceps 5, triceps [**Last Name (LF) 32190**], [**First Name3 (LF) **] 0/5
anterior cerv incision well healed
EXAM UPON DISCHARGE ************
Pertinent Results:
MR CERVICAL SPINE W/O CONTRAST [**2181-6-3**]
Spinal cord contusion with hemorrhage, diffusion abnormalities,
swelling, and edema.
Retropulsion of the fractured C5 vertebral body as well as
epidural hematoma contribute to spinal cord compromise.
Findings indicate disruption of the posterior ligamentous
complex at C3-4 with widening of the space between the lamina at
this level. There is possible disruption of the posterior
ligamentous complex as well at C4-5 and C5-6. Increased fluid
in the facet joints suggest disruption of the joint capsules
bilaterally at C5-6.
There is avulsion of the anterior longitudinal ligament from the
anterior
inferior margin of C5. Retropulsion of the C5 vertebral body and
an epidural hematoma contribute to spinal canal narrowing.
cervicaL mri [**2181-6-5**]: Apparent decompression of the spinal
canal status post C5 corpectomy and C4-C6 anterior fusion.
However, due to severe spinal cord swelling, there remains only
a small amount of CSF surrounding the cord at the level of C5
andC6. The craniocaudad extent of cord edema has increased.
Hemorrhagic contusion is again noted within the cord at C5.
[**6-6**] Chest CT: 1. No evidence of PE or aortic dissection.
2. Bilateral pleural effusions with collapse of the right lower
lobe.
3. Obstruction of the right main stem bronchus may represent
mucus plug or
secretions - bronchoscopy is recommended.
4. Left pneumothorax without evidence of tension.
[**6-9**] CXR: Right base opacity -- review of a CT scan from [**2181-6-6**]
suggests that this represents collapse of the right lower lobe.
[**6-11**] CXR: FINDINGS: In comparison with the study of [**6-9**], there is
persistent opacification at the right base with obscuration of
the hemidiaphragm and preservation of the right heart border,
consistent with the CT diagnosis of right lower lobe collapse.
Left lung is clear. Central catheter remains in place.
[**6-11**] LENI's: mobile thrombus in right common femoral vein.
[**6-13**] CXR: Comparison is made with a prior study performed a day
earlier.
Cardiomediastinal contours are normal. Right lower lobe collapse
is
persistent. Moderate pleural effusion is unchanged. The lungs
are otherwise
clear. There is no evidence of pneumothorax. Left subclavian
catheter
remains in place.
[**6-13**] CT sinuses:1. Trace aerosolized secretions and mucosal
thickening in the sphenoid air cells, which could be related to
prior intubation.
2. Other paranasal sinuses are clear without fluid or mucosal
thickening.
[**2181-6-13**] 06:40 COMPLETE BLOOD COUNT
White Blood Cells 7.5 4.0 - 11.0 K/uL
Red Blood Cells 3.31* 4.2 - 5.4 m/uL
Hemoglobin 10.0* 12.0 - 16.0 g/dL
Hematocrit 29.8* 36 - 48 %
MCV 90 82 - 98 fL
MCH 30.2 27 - 32 pg
MCHC 33.5 31 - 35 %
RDW 13.7 10.5 - 15.5 %
Neutrophils 78.1* 50 - 70 %
Lymphocytes 15.0* 18 - 42 %
Monocytes 5.8 2 - 11 %
Eosinophils 0.9 0 - 4 %
Basophils 0.3 0 - 2 %
Platelet Count 148* 150 - 440 K/uL
[**2181-6-14**] 06:30 BASIC COAGULATION
PT 25.2* 10.4 - 13.4 sec
INR(PT) 2.4* 0.9 - 1.1
[**2181-6-9**] 7:33 am
URINE CULTURE (Final [**2181-6-14**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
TETRACYCLINE ( >=16 MCG/ML ).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ <=2 S <=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 <=16 S
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ 2 S
All other blood cultures and central line tip no growth to date
([**2181-6-14**])
Brief Hospital Course:
She was admitted and taken to the OR for a C5 corpectomy and
fusion on [**6-3**]. Post operatively, MAP>70 was acheived with
pressors to ensure cord perfusion. She remained intubated
overnight and was extubated on [**6-3**] and on the morning of [**6-4**]
was on face tent, awake and alert, interactive and appropriate.
Her exam showed sensation was intact above the xiphoid and motor
function in proximal(deltoid/bicep)was full with some movement
in triceps. Incision was clean dry and intact with steris.
She was maintained in hard cervical collar. She had some
respiratory increased effort due to decreased ability to clear
secretions but had bronchoscopy [**6-6**] to clear mucus plug and has
continued with face mask and nebulizer treatment as needed. She
has worked with PT and OT and maintained good spirits with
frequent visits from supportive family. She had video swallow
performed and passed thin liquids and regular solids without
difficulty. [**6-7**] Midodrine discontinued due to stable SBP. She
had IVC filter placed [**6-8**] and was transferred to floor.
Overnight she developed a fever to 101.6. fever work up was
sent. CXR revealed persistent RLL collapse but patient
asymptomatic and this was stable on multiple follow up xrays.
Blood cultures= NGTD. U/A revealed a UTI and patient was placed
on Bactrim for positive e coli which showed good sensitivity on
cultures - this should remain through [**2181-6-19**] for full
treatment.Her foley was removed and she has been getting
straight cathed q6hours. LENI's positive for mobile DVT in R
commmon femoral vein. She was started on heparin drip bridging
to coumadin. Her INR became therapeutic [**2181-6-13**] and heparin was
stopped, she will need titration on her coumadin dose to remain
in [**1-10**] range for INR. Her central line was removed with tip
sent for culture as well as peripheral blood cultures. All are
no growth to date. She has been afebrile since early AM [**2181-6-13**].
she remains on IV fluids as she had some hypotension with PT
but has been stable past few days. This could also be weaned in
rehab. Her exam on discharge shows [**4-11**] motors in deltoid/biceps
with 2-3/5 in triceps and some wrist movement. No motor function
in lower extremities.
Medications on Admission:
none
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**12-9**] Inhalation Q4H (every 4 hours) as needed
for sob, wheezes.
4. Ipratropium Bromide 0.02 % Solution Sig: [**12-9**] Inhalation Q4H
(every 4 hours) as needed for shortness of breath or wheezing.
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for no BM>24hr.
9. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for eye irritation.
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain fever.
11. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for nonproductive cough.
12. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 10 days: last day [**6-19**].
13. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO QOD (): next
due [**2181-6-15**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
C5-6 Subluxation, C5 vert body/lamina fracture
UTI
Femoral DVT
fevers
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:
?????? Do not smoke
?????? Keep wound clean / Do not immerse incision of 2 weeks
but may bathe area.
?????? You have steri-strips in place. They will fall off on
their own or have then taken off [**2181-6-23**]
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
?????? Limit your use of stairs to 2-3 times per day
?????? Have your incision checked daily for signs of infection
?????? You are required to wear cervical collar at all times.
?????? You may shower briefly without the collar.
?????? Take pain medication as instructed/needed.
?????? Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc. for 3 months to promote
fusion.
Followup Instructions:
YOUR SUTURES ARE UNDER THE SKIN YOU WILL NOT NEED TO BE SEEN
UNTIL THE FOLLOW UP APPOINTMENT
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED XRAYS PRIOR TO YOUR APPOINTMENT
Completed by:[**2181-6-14**]
|
[
"780.60",
"453.41",
"E883.0",
"806.09",
"599.0",
"997.79",
"344.03",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.05",
"38.7",
"80.99",
"81.62",
"96.6",
"38.93",
"81.02"
] |
icd9pcs
|
[
[
[]
]
] |
9765, 9835
|
6052, 8307
|
280, 307
|
9948, 9948
|
1889, 6029
|
10923, 11215
|
883, 902
|
8362, 9742
|
9856, 9927
|
8333, 8339
|
10123, 10900
|
917, 1142
|
231, 242
|
335, 789
|
9963, 10099
|
811, 821
|
837, 867
|
1718, 1870
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,908
| 157,713
|
48130
|
Discharge summary
|
report
|
Admission Date: [**2104-4-10**] Discharge Date: [**2104-4-15**]
Service:
NOTE: Day of discharge to be decided; possibly [**2104-4-15**].
CHIEF COMPLAINT: Melena.
HISTORY OF PRESENT ILLNESS: The patient is an 88-year-old
female with a history coronary artery disease and previous
colonoscopy in [**2101**] with multiple polyps presenting with
melena and hematemesis.
The patient presented to the Emergency Department for
evaluation of lower back and leg pain. While there, she
developed melena and hematemesis. The patient was recently
treated for a zoster infection with Motrin times two weeks
per Emergency Department documentation.
Currently, she denies any fevers, chills, chest pain,
shortness of breath, or abdominal pain. She reports diarrhea
today times five times. She had not looked at her previous
stools.
The patient was hemodynamically stable in the Emergency
Department. In the Emergency Department, a nasogastric tube
was placed and lavage did not clear with 2 liters of lavage.
She received Kayexalate for a potassium of 6, calcium,
insulin, and D-50. Her electrocardiogram also showed peaked
T waves consistent with hyperkalemia.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post coronary artery
bypass graft in [**2097**] with saphenous vein graft to the first
obtuse marginal, saphenous vein graft to posterior descending
artery, and saphenous vein graft to the left anterior
descending artery. She is status post multiple percutaneous
transluminal coronary angioplasties with brachy therapy.
2. Gastroesophageal reflux disease.
3. Depression.
4. Degenerative joint disease.
5. Irritable bowel syndrome.
6. B12 deficiency (pernicious anemia).
7. Chronic renal insufficiency (with a baseline creatinine
of 1.2).
8. Anemia (with a baseline hematocrit of 26 to 32).
9. Recent urinary tract infections.
10. Status post total abdominal hysterectomy and small-bowel
obstruction.
11. A 2-D echocardiogram in [**2102-9-26**] showing an
ejection fraction of greater than 70%, moderate left
ventricular hypertrophy, normal right wall motion, 1+ aortic
insufficiency, and 1+ mitral regurgitation, and diastolic
dysfunction.
12. History of Kaposi sarcoma resected in [**2103-5-27**].
ALLERGIES: BACTRIM, CIPROFLOXACIN, and AMPICILLIN.
MEDICATIONS ON ADMISSION:
1. Lisinopril 10 mg by mouth once per day.
2. Lipitor 20 mg by mouth once per day.
3. Imdur 45 mg by mouth once per day.
4. Metoprolol 50 mg by mouth twice per day.
5. Plavix 75 mg by mouth once per day.
6. Aspirin 325 mg by mouth once per day.
7. Prilosec 20 mg by mouth once per day.
8. Remeron 30 mg by mouth at hour of sleep.
9. Ferrous sulfate 325 mg by mouth once per day.
10. BuSpar 5 mg by mouth twice per day.
FAMILY HISTORY: Sister with heart disease.
SOCIAL HISTORY: Lives at the [**Hospital3 537**]. She denies
tobacco or alcohol use. She is a widow.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 98.7
degrees Fahrenheit, her blood pressure was 136/70, her pulse
was 90, her respiratory rate was 16, and she was saturating
98% on room air. In general, the patient is an elderly
female in no apparent distress. She appeared pale and
fatigued. Head, eyes, ears, nose, and throat examination the
oropharynx was clear. The mucous membranes were dry.
Nasogastric tube with blood. The neck was supple. The lungs
were clear to auscultation bilaterally. Heart was regular in
rate and rhythm plus a 2/6 systolic ejection murmur at the
right upper sternal border. The abdomen was soft, nontender,
and nondistended. There were good bowel sounds.
Maroon-tinged stool. Guaiac-positive. No melena.
Extremities revealed needed. Multiple bruise-like lesions
with central hardness on arms and legs. No evidence of
rashes. Neurologically, cranial nerves II through XII were
intact. She followed commands.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 5.8 (with a differential of 76% neutrophils,
21% lymphocytes, 2% monocytes, and 1% eosinophils), her
hematocrit was 27.4 (down from 30 on admission to the
Emergency Department), and her platelets were 127. Her INR
was 1.1, her partial thromboplastin time was 24.9.
Chemistry-7 revealed her sodium was 137, potassium was 6
(repeat 4.9), chloride was 108, bicarbonate was 20, blood
urea nitrogen was 51, creatinine was 1.2, and her blood
glucose was 115. Urinalysis was straw colored, specific
gravity of 0.018, trace leukocyte esterase, pH of 5.
PERTINENT RADIOLOGY/IMAGING: An electrocardiogram showed a
normal sinus rhythm at 79 beats per minute, and primary
atrioventricular block. Q wave in II, III, and F. Normal
axis. Peaked T waves in precordium.
ASSESSMENT: The patient is an 88-year-old female with a
gastrointestinal bleed after taking nonsteroidal
antiinflammatory drugs for the last two weeks for left leg
pain.
BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. GASTROINTESTINAL BLEED ISSUES: The patient had an
initial esophagogastroduodenoscopy on [**4-11**] which showed a
big clot adherent to a large-sized hiatal hernia. The clot
was too large to safely irrigate off. Underneath the clot
could have been an ulcer erosion or [**Doctor First Name **]-[**Doctor Last Name **] tear. In
the stomach, there was diffuse atrophy of the mucosa with no
bleeding noted; compatible with chronic atrophic gastritis.
There was no bleeding in the duodenum.
The patient was kept on strict nothing by mouth and
intravenous fluids, and her hematocrit levels were followed
to keep her hematocrit above 30. Her hematocrit dropped
initially from 30.3 to 27.4 and then to 22.6. She was
transfused 2 units of packed red blood cells, and her
hematocrit has been stable since, ranging from 30 to 32, with
no further episodes of bleeding since [**4-12**]. She has
remained on a proton pump inhibitor (Protonix) twice per day.
A repeat esophagogastroduodenoscopy performed on [**4-14**]
showed still adherent clot about 8 cm in length and 2 cm in
width, adherent to a 2-cm length mucosa within the large
hiatal hernia. There were no signs of active bleeding.
Electrocautery was applied to the base of the clot in an
attempt to dislodge it from the esophageal mucosa and for
hemostasis; however, despite the clot still remained adherent
to the esophageal mucosa. It appeared that there may be an
ulceration and mucous in the area of the esophagus to which
the clot was adherent. Otherwise, the stomach and the
duodenum were normal on the repeat
esophagogastroduodenoscopy.
The patient was kept nothing by mouth for the remaining
portion of [**Last Name (LF) 766**], [**4-14**], and was continued on intravenous
fluids. Since her hematocrit remained stable on the
following day ([**4-15**]), she was started on clear liquids in
the morning, and diet may be advanced to soft solids until
her repeat upper endoscopy next week which has already been
scheduled.
Since her hematocrit has been stable for the last several
days, the patient is safe to be discharged to home or to
rehabilitation.
An upper endoscopy followup has been scheduled with Dr. [**Last Name (STitle) 21140**]
and Dr. [**Last Name (STitle) 2161**] at the Endoscopy Unit on the [**Location (un) 448**] of
[**Hospital Ward Name 1950**] One [**Hospital Ward Name 516**] Building on [**2104-5-8**] at 9:30
a.m. The patient should not have anything to eat after
midnight on [**2104-5-7**] and should not eat breakfast on the
morning of [**2104-5-8**] (on the morning of the
esophagogastroduodenoscopy).
Her aspirin and Plavix should be held considering her
gastrointestinal bleed, and restarting of these two
medications will be made after her repeat endoscopy on [**5-8**]. The patient should remain on Protonix 40 mg by mouth
twice per day until her repeat endoscopy, and she should
avoid nonsteroidal antiinflammatory drugs until her
procedure. The patient will also probably benefit from a
colonoscopy as an outpatient. Helicobacter pylori antibody
was still pending.
2. THROMBOCYTOPENIA ISSUES: Heparin-induced
thrombocytopenia antibody was positive, so the patient should
not receive any heparin. The patient has a history of a mild
pancytopenia in the past, and this issue was discussed
between the patient and Dr. [**Last Name (STitle) 410**] of Hematology/Oncology,
and it was decided that no bone marrow biopsy would be
performed. The patient should follow up as an outpatient
with her primary care physician to insure that she has a rise
in her platelets.
3. HYPERKALEMIA ISSUES: The patient had an initial
potassium value of 6 with peaked T waves on
electrocardiogram. This was thought to likely be due to
dehydration, and the blood sample was also moderately
hemolyzed. Otherwise, her potassium has remained stable.
4. CONGESTIVE HEART FAILURE ISSUES: The patient does have
an element of diastolic dysfunction, and so her fluid status
was carefully monitored a she was getting significant amounts
of fluids and packed red blood cells. She has maintained
stable oxygenation, and good oxygen saturations, as well as
good urine output.
5. COAGULOPATHY ISSUES: The patient developed an INR of
1.4; likely secondary to being nothing by mouth for many days
and deficiency in vitamin K. She has been given by mouth
vitamin K and should continue this for two more days. Her
INR will likely decrease when she receives adequate
nutrition.
6. CORONARY ARTERY DISEASE ISSUES: As mentioned above,
aspirin and Plavix were being held secondary to a large
gastrointestinal bleed. The patient should continue to hold
these two medications until her repeat endoscopy on [**5-8**];
at which time the decision as to whether to restart these
medications can be made. The patient has been restarted on
her beta blocker. She will continue with her statin, Imdur
beta blocker, and ACE inhibitor.
7. CHRONIC RENAL INSUFFICIENCY ISSUES: The patient's
creatinine is at baseline. Her blood urea nitrogen was
likely increased secondary to bleeding and has now returned
to [**Location 213**].
8. LEFT LEG PAIN ISSUES: The patient had a previous zoster
infection that was treated with Valtrex. On admission, she
had no evidence of a zoster infection with no rashes
apparent. The patient has multiple musculoskeletal
complaints that have been chronic. She was continued on her
Neurontin for neuropathic pain. The patient was also given
Tylenol for pain control. She does not have an active
zoster infection.
9. PSYCHIATRIC ISSUES: The patient was continued on her
BuSpar. She has multiple somatic complaints; likely anxiety
related.
10. ACIDOSIS/FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The
patient's acidosis was improving as her diarrhea improved.
It will likely continue to improve as she maintains a normal
diet and her diarrhea continues to decrease. She was
started on a clear diet on [**4-15**] following her
esophagogastroduodenoscopy since her hematocrit has been
stable.
11. PROPHYLAXIS ISSUES: The patient was maintained on
pneumatic boots and a proton pump inhibitor. The patient
should not receive any heparin secondary to positive
heparin-induced thrombocytopenia antibody.
12. ACCESS ISSUES: The patient has difficult access issues
and two peripheral intravenous lines through most of her
stay.
13. CODE STATUS ISSUES: The patient is a full code.
14. DISPOSITION ISSUES: At the time of this dictation, a
Physical Therapy consultation has recommended benefit from
rehabilitation for maximum safety. The patient is being
screened for rehabilitation at the time of this dictation.
DISCHARGE DIAGNOSES:
1. Gastrointestinal bleed.
2. Anemia.
3. Chronic renal insufficiency.
4. Coronary artery disease.
5. Anxiety/depression.
DISCHARGE STATUS: To rehabilitation.
CONDITION AT DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE:
1. Protonix 40 mg by mouth twice per day.
2. Metoprolol 25 mg by mouth twice per day.
3. Nystatin 5 mg by mouth four times per day as needed (for
thrush).
4. Gabapentin 300 mg by mouth twice per day.
5. Cepacol one lozenge by mouth as needed.
6. Oxycodone 2.5 mg to 5 mg by mouth q.4-6h. as needed.
7. Tylenol 1000 mg by mouth three times per day.
8. Ferrous sulfate 325 mg by mouth once per day.
9. BuSpar 5 mg by mouth twice per day.
10. Mirtazapine 30 mg by mouth at hour of sleep.
11. Isosorbide mononitrate extended release 45 mg by mouth
once per day.
12. Atorvastatin 20 mg by mouth once per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with her primary
care physician in one to two weeks.
2. The patient has a follow-up esophagogastroduodenoscopy
scheduled for [**5-8**] at 9:30 a.m. with Dr. [**Last Name (STitle) 21140**] and Dr.
[**Last Name (STitle) 2161**] at the Endoscopy Unit, [**Location (un) 448**] of [**Hospital Ward Name 1950**] One,
[**Hospital Ward Name 516**] Building. The patient should register in the
lobby of the [**Hospital Ward Name 1826**] Building at 8:30 a.m. and should not
have anything to eat after midnight on [**2104-5-7**]. She
should not eat breakfast on the morning of [**2104-5-8**].
3. Esophagogastroduodenoscopy reports have been sent with
the patient to rehabilitation, and the patient should bring
these papers with her to her esophagogastroduodenoscopy
appointment.
[**Doctor Last Name **],[**Name8 (MD) **] M.D. [**MD Number(1) 1019**]
Dictated By:[**Name8 (MD) 10397**]
MEDQUIST36
D: [**2104-4-15**] 13:01
T: [**2104-4-15**] 14:36
JOB#: [**Job Number 101481**]
|
[
"276.2",
"396.3",
"398.91",
"E935.9",
"281.0",
"287.5",
"530.21",
"276.5",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"42.33",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
2784, 2812
|
11589, 11765
|
11816, 12441
|
2329, 2767
|
12474, 13528
|
4935, 11568
|
11780, 11789
|
166, 175
|
204, 1170
|
1193, 2302
|
2829, 4901
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,581
| 198,067
|
54456
|
Discharge summary
|
report
|
Admission Date: [**2181-1-19**] Discharge Date: [**2181-1-29**]
Date of Birth: [**2131-7-26**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
fever, confusion and SOB
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
49M h/o COPD on home O2 (4L) and HIV (CD4 474 in [**2180-11-26**]) on
hospice care at home but continuing to receive aggressive
medical treatment who p/w with fever, SOB, and mental status
changes as well as decreased PO intake and decreased UOP.
Mother was unable to get hospice to respond to her calls from
home so felt desperate and brought him in. He wears home O2 and
received neb with EMS. FSBS-101 with EMS.
.
Mother noted that pt. was becoming confused starting on Tuesday.
He was not answering her questions appropriately, asking for
things she could not provide him, moving in and out of bed and
becoming more and more sleepy. He was c/o of nausea initially
and then mild intermittent abdominal pain. Since Tuesday he's
been having fevers to 100 at home (she says he usually runs a
baseline temp of 96) and has become progressively progressively
more confused, though she feels he is more alert today then
yest. Mother denies that pt has diarrhea (intermittnent issues
with constipation), headache, change in appetite, weakness, or
worsened SOB. Pt. reports always having intermittent cough, but
it has become more frequent and he is c/o of worsening SOB and
pleuritic CP. He uses 4-5L of oxygen at home at baseline and
yesterday has O2 sat at home was 98%. He has been compliant with
his medications except for missing one dose of his HIV meds in
the last week. However, she reports his vomiting issues this
week made it hard for him to take some of his meds. Apparently
taken off bactrim by his PCP either due to interaction w/
another med or
.
+ Hx cocaine use - mother doesn't think using now but says to
check just in case
.
In the ED, initial VS: 100.9 86 124/72 28 100%. On exam, pt.
was unable to communicate consistently with staff,
grunting/moaning and able to follow commands intermittently.
Neck was supple, poor air movement w/ rales. Labs were notable
for N 146, CO2 47, Cl 94 and Phos 0.8. HCT was 35, Neg UA and
ABG of pH-7.47/CO2-72/O2-44/HCO3-54 and repeat was 7.42/75/60/50
on 5L NC w/ lactate of 1.4. Utox + Cocaine. CT head showed
atrophy but no ICH or acute hypodensity to suggest encephalitis.
Multiple attempts were made at LP, however were unsuccessful.
Pt. received 2g CFTX/1g Vanco, but not Amp. or Acyclovir and 1L
NS. VS at time of transfer were 98.0F HR 101, RR 25, BP 119/63,
O2Sat: 98 3L NC. On the floor, pulled out his IV.
.
per neurology note in [**2180-10-26**], MS = "The patient is awake,
alert, oriented x 3, and provides a coherent history with
inconsistent details. Attention, formal memory testing, and fund
of knowledge are normal."
.
Currently, [**Age over 90 **]F 150/75 115 22 95% 4L NC. Pt. is confused, moving
in and out of the bed, answering questions incongruently to
examiner.
Past Medical History:
-HIV/AIDS - CD4 trending up recently (474 in [**November 2180**]) but has
been very low at times in the past, VL supressed recently. Has
had [**Year (2 digits) 1074**] gastritis, Type II HSV, disseminated toxo, thrush.
-Severe COPD on home oxygen: 4-5L NC. O2 sat 93% at baseline.
"Emphysema-asthma overlap syndrome" managed by pulmonology here
at [**Hospital1 18**]. Recent PFTs from [**10/2177**]: FEV1 is 0.89 liter (25% of
predicted). His FVC is 2.49 liters (3% of predicted). His
FEV1/FVC ratio is 48%. Patient uses wheelchair to get around due
to SOB from COPD.
- HIV polyneuropathy
- h/o c.diff colitis
- s/p G-tube. (currently takes 3 cans supplement / night through
g tube)
- dysthymia
- chronic pain: neuropathy, back pain
- L osteonecrosis of the shoulder
- shingles [**11-3**] (completed acyclovir course)
Surgeries:
- cataract surgery OD [**12-3**]
- R knee repair s/p fall
Social History:
Currently lives on home hospice with his mother, [**Name (NI) 5627**]. [**Name2 (NI) **]
visiting nurse 3x/week and hospice nurse at least once a week.
Although they have been on hospice for years, he still receives
aggressive medical care if ever ill. He was born in [**State 4565**],
has lived in [**State 35736**], SouthCarolina, [**State **], [**State 26110**], [**State 8449**],
[**State 3706**] and MA for past 31 years. Previously worked as a word
processing for archiectural firm. Denies any occupational
exposures. Sexual history is MSM. Continues to smoke marijuana
frequently until last few days when wasn't feeling well. Mother
says he has used cocaine in the past but to her knowledge is not
currenty using (although she asked us to check here at the
hospital). Has numerous chronic pain complaints and has been on
long-standing narcotics. No tobacco currently but smoked [**11-27**] ppd
x 14 years, quit [**12-2**]. No aminal/rural exposures. No recent
travel or known TB exposures.
Family History:
DM and heart dz in maternal aunt and MGM
CVA in maternal uncle
Mother with sarcoid.
Biological mother and adopted father, no known paternal [**Name (NI) 41900**].
Physical Exam:
ON ADMISSION:
VS - [**Age over 90 **]F 150/75 115 22 95% 4L NC.
GENERAL - Awake, eyes open, crawling out of bed. Looking around
the room, responding to his mother appropriately (lays down when
asked by her), but not to the examiner.
HEENT - sclerae anicteric, dMM
NECK - Supple
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - wheezes b/l on insp. and expiration. Crackles in left
lower field anteriorly. RR of mid 20s, pursing lips, but not
using accessory muscles.
ABDOMEN - scaphoid, diffusely TTP, G tube in place and c/d/i.
EXTREMITIES - warm, b/l foot edema, echymoses at L great toe, 2+
peripheral pulses
SKIN - macular rash, blanching, becoming confulent on anterior
chest.
LYMPH - no cervical, axillary, or inguinal LAD
.
NEURO - Awake, eyes open, crawling out of bed. Looking around
the room, responding to his mother appropriately (lays down when
asked by her), but not to the examiner. Names pen, glasses.
Inattentive. Akasthesia.
.
CN: VF intact to threat, EOMI, 4-2mm b/l, face symmetric, palate
symmetric and tongue midline.
.
UEs both antiresistance with normal tone. There is asterixis.
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/ normal tone, absent DTRs in [**Name2 (NI) 111454**] and toes are down.
Pertinent Results:
ADMISSION LABS:
[**2181-1-19**] 09:45PM GLUCOSE-92 UREA N-17 CREAT-0.7 SODIUM-146*
POTASSIUM-3.9 CHLORIDE-94* TOTAL CO2-47* ANION GAP-9
[**2181-1-19**] 09:45PM ALT(SGPT)-67* AST(SGOT)-37 LD(LDH)-129 ALK
PHOS-95 TOT BILI-0.5
[**2181-1-19**] 09:45PM ALBUMIN-4.4 CALCIUM-10.1 PHOSPHATE-0.8*#
MAGNESIUM-1.9
[**2181-1-19**] 09:45PM WBC-5.2 RBC-3.33* HGB-11.3* HCT-34.8*
MCV-105* MCH-33.9* MCHC-32.5 RDW-14.2
[**2181-1-19**] 09:45PM NEUTS-70.6* LYMPHS-21.1 MONOS-4.5 EOS-2.2
BASOS-1.6
[**2181-1-19**] 09:45PM PLT COUNT-158
[**2181-1-19**] 09:45PM PT-10.8 PTT-31.8 INR(PT)-1.0
[**2181-1-19**] 09:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2181-1-19**] 09:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
[**2181-1-19**] 09:45PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.017
[**2181-1-19**] 09:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2181-1-19**] 09:45PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2181-1-19**] 09:39PM TYPE-ART TEMP-36.7 PO2-44* PCO2-72* PH-7.47*
TOTAL CO2-54* BASE XS-23 INTUBATED-NOT INTUBA
[**2181-1-19**] 09:39PM LACTATE-1.4
.
OTHER PERTINENT LABS:
[**2181-1-20**] 09:05AM BLOOD WBC-5.1 Lymph-14* Abs [**Last Name (un) **]-714 CD3%-73
Abs CD3-523* CD4%-17 Abs CD4-118* CD8%-54 Abs CD8-388
CD4/CD8-0.3*
[**2181-1-24**] 05:54AM BLOOD calTIBC-216* VitB12-1356* Folate-12.5
Hapto-185 Ferritn-135 TRF-166*
[**2181-1-22**] 01:26AM BLOOD B-GLUCAN- Neg
[**2181-1-20**] 04:36AM URINE HISTOPLASMA ANTIGEN-Test
CSF:
[**2181-1-20**] 02:03PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-18* Polys-1
Lymphs-68 Monos-28 Atyps-3
[**2181-1-20**] 02:03PM CEREBROSPINAL FLUID (CSF) TotProt-33 Glucose-73
[**2181-1-20**] 02:24PM CEREBROSPINAL FLUID (CSF) MYCOPLASMA PNEUMONIAE
DNA, PCR-NEGATIVE
[**2181-1-20**] 09:10PM CEREBROSPINAL FLUID (CSF) CYTOMEGALOVIRUS -
PCR-NEGATIVE
[**2181-1-20**] 09:10PM CEREBROSPINAL FLUID (CSF) TOXOPLASMA GONDII BY
PCR-NEGATIVE
[**2181-1-20**] 09:10PM CEREBROSPINAL FLUID (CSF) [**Male First Name (un) 2326**] VIRUS (JCV) DNA
QUANTITATIVE PCR- 467 H
[**2181-1-20**] 09:10PM CEREBROSPINAL FLUID (CSF) EBV-PCR- NEGATIVE
[**2181-1-20**] 02:03PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-NEGATIVE
MICRO:
[**2181-1-23**] Rapid Respiratory Viral Screen & Culture NEGATIVE
[**2181-1-22**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; LEGIONELLA CULTURE-PRELIMINARY; Immunoflourescent
test for Pneumocystis jirovecii (carinii)-FINAL; FUNGAL
CULTURE-PRELIMINARY; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PENDING; VIRAL CULTURE: R/O CYTOMEGALOVIRUS-PRELIMINARY;
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD)-FINAL
[**2181-1-22**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
{CLOSTRIDIUM DIFFICILE}
[**2181-1-21**] [**Year (4 digits) **] GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA, GRAM NEGATIVE ROD
#2}
[**2181-1-21**] URINE CULTURE-NO GROWTH
[**2181-1-21**] BLOOD CULTURE-NO GROWTH
[**2181-1-21**] BLOOD CULTURE-NO GROWTH
[**2181-1-20**] SEROLOGY/BLOOD CRYPTOCOCCAL ANTIGEN- NEGATIVE
[**2181-1-20**] Mini-BAL GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; LEGIONELLA CULTURE-PRELIMINARY; POTASSIUM
HYDROXIDE PREPARATION-FINAL; Immunoflourescent test for
Pneumocystis jirovecii (carinii)-FINAL; FUNGAL
CULTURE-PRELIMINARY; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY; VIRAL CULTURE: R/O CYTOMEGALOVIRUS-FINAL;
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD)-FINAL
{POSITIVE FOR CYTOMEGALOVIRUS}
[**2181-1-20**] URINE Legionella Urinary Antigen -NEGATIVE
[**2181-1-20**] Immunology ([**Year (4 digits) 1074**]) [**Year (4 digits) 1074**] Viral Load-NEGATIVE
[**2181-1-20**] CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY; ACID FAST
CULTURE-PRELIMINARY; VIRAL CULTURE-PRELIMINARY
[**2181-1-20**] CSF;SPINAL FLUID CRYPTOCOCCAL ANTIGEN-NEGATIVE
[**2181-1-20**] [**Year (4 digits) **] GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY {NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA,
NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA, BETA STREPTOCOCCI,
NOT GROUP A}; Immunoflourescent test for Pneumocystis jirovecii
(carinii)-FINAL INPATIENT
[**2181-1-19**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST- NEGATIVE
[**2181-1-19**] BLOOD CULTURE-NEGATIVE
[**2181-1-19**] URINE CULTURE-NEGATIVE
[**2181-1-19**] BLOOD CULTURE-NEGATIVE
.
PATHOLOGY:
[**2181-1-20**] CSF CYTOLOGY: NEGATIVE FOR MALIGNANT CELLS.
[**2181-1-23**] PERIPHERAL BLOOD IMMUNOPHENOTYPING:
Non-specific T-cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by non-Hodgkin B-cell
lymphoma are not seen in specimen. 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.
.
.
STUDIES:
[**2181-1-19**] CT HEAD: 1. No acute intracranial process.2. Polypoid
bilateral mucosal disease.
.
[**2181-1-20**] EEG: This EEG gives evidence for diffuse severe
encephalopathic
abnormality with some interictal epileptiform potential
discharges
noted. The encephalopathic features may represent drug effect,
although
as was noted, the propofol was slowly reduced and did not show
significant improvement in the record, although the suppressive
bursts
appeared to be less prolonged as the record went on, which was
probably
at least contributed to by the presence of the propofol
initially. No
clear laterality or focality is noted. While there was some
sharp
transients asymmetries, there was no underlying background
rhythm
asymmetry to support a clear focal or lateralized structural
abnormality.
.
[**2181-1-20**] CXR: The lungs are hyperinflated, consistent with COPD.
Heart size is at the upper limits of normal. There are increased
markings in both lung apices, more pronounced than on [**2180-6-28**],
which could reflect either early upper zone redistribution or
early interstitial infiltrate. No [**Date Range **] consolidation is
identified and the mid and lower zones remain clear. No gross
effusion.
.
[**2181-1-20**] LEFT ANKLE AND PELVIS XR: 1. No acute fracture detected
involving the left ankle. Suspect osteonecrosis of the talar
dome, without collapse. Old healed calcaneal fracture noted. 2.
Allowing for overlying bowel gas, no displaced fracture detected
about the pelvis or proximal femurs on this single AP view of
the pelvis. Advanced changes of osteonecrosis of both femoral
heads, without obvious collapse.
.
[**2181-1-21**] MRI HEAD: 1. There is no evidence of acute/subacute
intracranial pathology, no diffusion abnormalities or areas with
abnormal enhancement are identified. 2. Mucosal thickening is
noted on the ethmoidal air cells, sphenoid sinus, and right
maxillary mucous retention cyst.
.
[**2181-1-21**] CT CHEST: 1. No lymphadenopathy evident. Concern for
widened mediastinum on previous radiographs, likely due to
patient rotation.
2. Progression of severe emphysematous changes as well as
unchanged
bronchiectasis and diffuse bronchial wall thickening,
particularly evident in the right lower lobe. 3. Faint
ground-glass opacity and heterogeneous nodular opacities in the
lower lobes, particularly the left whih may represent a
developing infectious process. 4. Unchanged compression
fractures within the mid thoracic spine with associated
kyphosis, unchanged compared to [**2179-2-25**].
.
[**2181-1-23**] TTE: The left atrium is mildly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no pericardial effusion.
.
DISCHARGE LABS:
[**2181-1-29**] 06:55AM BLOOD WBC-8.2 RBC-2.70* Hgb-8.9* Hct-27.0*
MCV-100* MCH-33.1* MCHC-33.2 RDW-16.2* Plt Ct-385
[**2181-1-29**] 06:55AM BLOOD Glucose-114* UreaN-20 Creat-0.7 Na-138
K-4.4 Cl-95* HCO3-37* AnGap-10
[**2181-1-29**] 12:45PM BLOOD Na-139 K-4.9 Cl-96
[**2181-1-29**] 06:55AM BLOOD Calcium-8.7 Phos-4.8* Mg-2.2
Brief Hospital Course:
49M w/ h/o COPD on home O2 (4L) and HIV (CD4 474 in [**2180-11-26**])
who p/w with fever, SOB, and mental status changes and was
transferred to the MICU with respiratory failure and multiple
metabolic derangements.
.
.
ACTIVE ISSUES:
#. Respiratory Failure/COPD: Pt has severe COPD at baseline w/
FEV1 of 17% predicted. On evaluation by the MICU team was
tachypneic to the 40s, using accessory muscles and w/
respiratory acidosis. He was intubated for hypercarbic
respiratory failure and was treated with nebulizers for his
COPD. He was also initiated on steroids, initially solumedrol
then tapered to prednisone 40 with a plan for continued taper
for COPD exacerbation treatment. He underwent bronch given
concern for PCP (was unclear if he was taken his home [**Name (NI) **]) which
was negative. He was continued on home dapsone for [**Name (NI) **]. Bronch
did show non-pseudomonas non fermenting GNRs so his broad
spectrum antibiotics which were started on admission were
narrowed to vanc/cefepime/azithro with a plan for an 8 day
course. He self extubated during his MICU stay [**12-28**] agitation and
needed to re-intubated, but eventually was successfully
extubated on [**12/2097**]. He was transferred to the floor on [**1-25**], after
which his tachypnea and oxygen requirement continued to improve
to baseline. He will finish his levofloxacin course and
prednisone course as an outpatient.
.
#. Toxic metabolic encephalopathy: Altered mental status was
felt most likely toxic metabolic in setting of positive cocaine
and altered electrolytes, specifically low phosphate level, as
well as hypoxia/hypercarbia as described above. Infectious
etiologies including C. diff infection may also have
contributed. EEG was negative for seizures. CSF was negative for
infectious etiology w/ exception of positive [**Male First Name (un) 2326**] virus titer,
which given his presentation and non-focal neuro exam ID did not
feel was clinically significant. CSF cytology negative for
malignancy. MRI was negative for acute pathology, signs of PML.
Atypical bone marrow cells led to cytology w/ atypical
lymphocytes suggestive of viral process per heme. He was
initially covered broadly for meningitis, which was narrowed to
acyclovir until his CSF returned negative for HSV. His
electrolytes, particularly his phosphate, were aggresively
repleted. Phosphate wasting may be due to tenofovir and a change
in his anti-viral regimen may be beneficial and should be
considered. Mental status had returned to baseline by time of
call out from ICU. On the medicine floor, mental status
continued to be clear. Patient was supplemented generously with
phosphate, and at the time of discharge level was on the high
side. This level should be followed as an outpatient.
.
#. C diff. Patient was found to have c. diff during this
hospitalization, which may have been brewing at home or have
developed during hospitalization. Has h/o at least 3 prior
episodes. Was treated w/ flagyl and PO vanco and then per ID
recommendations was continued on just PO vanco. Will need
extended course and taper, to finished 14 days after completing
levofloxacin.
.
# AIDS. Pt's CD4 count was 118 during this admission, most
likely decreased from acute illness causing myselosuppression.
He was continued on his home HAART regimen including
abacavir-lamivudine, lopinavir-ritonavir, and tenofovir. He was
started on dapsone for PCP [**Name9 (PRE) **] as above (had previously been on
bactrim but this was switched to dapsone given concern for
myelosuppression). CSF studies, beta glucan, and bronch were
negative for numerous infectious agents (see results above) w/
exception of [**Male First Name (un) 2326**] virus in CSF which ID felt not clinically
significant at this time w/ negative MRI, and [**Male First Name (un) 1074**] in bronch
which was felt to be colonizer. As above, may consider switching
off tenofovir given side effect of severe phosphate wasting. [**Male First Name (un) 2326**]
PCR in CSF was positive, most likely from immunocompromise;
however, patient without signs or symptoms of PML.
.
.
CHRONIC ISSUES:
# Macrocytic anemia: There have been no active signs of
bleeding, but hematocrit has been in the mid-20s, from a
baseline in the mid-30s. It may be related to phlebotomy while
in the unit, as well as myelosuppression from acute illness.
Macrocytosis most likely related to HIV meds. B12 high at 1356,
folate WNL at 12.5.
.
# Polyneuropathy: Held lyrica during ICU stay due to
encephalopathy, but restarted on the floor.
.
# Chronic pain. Held lyrica and home oxycontin during ICU stay,
then restart on the floor.
.
# Osteonecrosis. Patient has osteonecrosis of the left ankle
and both femoral heads likely related to his HIV and multiple
steroid courses in the past. Follow-up as an outpatient.
.
# Substance abuse: On admission, urine was positive for cocaine.
Patient also noted recent daily marijuana smoking, but is
interested in quitting smoking, as he knows that it is
contributing to decline in lung function. He was counseled
extensively.
.
.
TRANSITIONAL ISSUES:
# Patient noted to have atypical lymphocytes in peripheral blood
and CSF. On immunophenotyping, these cells were non-specific,
but not suggestive of B or T cell lymphoma. Most likely atypical
secondary to viral myelosuppression.
# Phosphate level should be followed closely as outpatient, as
tenofovir causes severe wasting, likely related to
encephalopathy.
# Vancomycin course should finish 14 days after completing
levofloxacin.
# Osteonecrosis symptoms should be followed.
# Continue counseling against smoking marijuana, given severe
lung disease.
Medications on Admission:
abacavir-lamivudine [Epzicom] 600mg-300 mg Tab
lopinavir-ritonavir [Kaletra] 200 mg-50 mg Tab 2 Tablet [**Hospital1 **]
tenofovir disoproxil fumarate [Viread] 300 mg Tab
albuterol
Serevent Diskus 50 mcg/Dose for Inhalation 1 puff inhaled twice
a day
Singulair 10 mg Tab
Spiriva with HandiHaler 18 mcg & inhalation Caps 1 capsule Qd
Pulmicort Flexhaler 180 mcg/Inhalation Breath Activated 1 puffs
[**Hospital1 **]
alendronate 5 mg Tab
Citalopram 10 mg Tab
Lorazepam 1 mg Tab 1 Tablet(s) by mouth once a day
folic acid 1mg
Vitamin B-1 100 mg Tab 1 Tablet(s) by mouth once a day
OxyContin 40 mg 12 hr Tab 1 Tablet(s) by mouth twice a day Pt
states that he also takes oxycontin 20mg & a 5mg once in the
afternoon once a day
pregabalin [Lyrica] 150 mg Cap 1 Capsule(s) by mouth three times
a day
Calcium 500 + D 500 mg (1,250 mg)-200 unit Tab
Docusate Sodium 100 mg Cap Capsule(s) by mouth as needed for
constipation
famotidine 20mg daily
Discharge Medications:
1. abacavir-lamivudine 600-300 mg Tablet [**Hospital1 **]: One (1) Tablet PO
once a day.
2. lopinavir-ritonavir 200-50 mg Tablet [**Hospital1 **]: Two (2) Tablet PO
twice a day.
3. tenofovir disoproxil fumarate 300 mg Tablet [**Hospital1 **]: One (1)
Tablet PO once a day.
4. albuterol sulfate Inhalation
5. Serevent Diskus 50 mcg/dose Disk with Device [**Hospital1 **]: One (1)
inhalation Inhalation twice a day.
6. Singulair 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
7. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
[**Hospital1 **]: One (1) capsule Inhalation once a day.
8. Pulmicort Flexhaler 180 mcg/Inhalation Aerosol Powdr Breath
Activated [**Hospital1 **]: One (1) puff Inhalation twice a day.
9. alendronate 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
10. citalopram 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
11. lorazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
12. folic acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
13. Vitamin B-1 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
14. pregabalin 150 mg Capsule [**Hospital1 **]: One (1) Capsule PO three
times a day.
15. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet [**Hospital1 **]: One
(1) Tablet PO once a day.
16. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID
PRN as needed for constipation.
17. famotidine 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
18. levofloxacin 750 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily) for 4 days: through [**2181-2-2**].
Disp:*4 Tablet(s)* Refills:*0*
19. vancomycin 125 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO Q6H (every
6 hours) for 18 days.
Disp:*74 Capsule(s)* Refills:*0*
20. oxycodone 5 mg Tablet [**Month/Day/Year **]: 1-2 Tablets PO q4 hours PRN as
needed for breakthrough pain: Do not drive while taking this
medication.
Disp:*15 Tablet(s)* Refills:*0*
21. prednisone 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day:
Two tabs on [**4-14**]. One tab on [**4-17**]. Half tab on [**4-20**].
Take with food.
Disp:*11 Tablet(s)* Refills:*0*
22. sodium phosphates Solution [**Date Range **]: One (1) packet PO once a
day.
Disp:*30 packets* Refills:*0*
23. oxycodone 40 mg Tablet Extended Release 12 hr [**Date Range **]: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] vna/vna hospica care
Discharge Diagnosis:
Primary diagnoses:
Encephalopathy
Hypophosphatemia
.
Secondary diagnoses:
Hypercarbic/hypoxemia respiratory failure
COPD
C. diff colitis
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 10132**],
It was a pleasure to participate in your care here at [**Hospital1 1535**]! You were admitted with
confusion, thought to be secondary to a low level of phosphate
and pneumonia making your lung disease worse. While you were in
the hospital, you were also treated for Clostridium difficile
(C. diff) colitis. Your confusion improved dramatically over the
course of your stay.
You were noted to have some atypical appearing cells in your
blood. We believe these appeared atypical because of effects of
systemic illness (your pneumonia and C. diff infection). On
further testing, these did not show any signs of cancer. We will
make your primary care physician aware of these findings.
We advise you to discontinue further use of marijuana, as this
use is worsening your lung disease, and may be causing some
confusion. It is strongly recommended that you stop for your
overall health benefit.
Please note, the following changes have been made to your
medications:
1.) START sodium phosphate, 1 packet by mouth once per day
2.) START vancomycin 125 mg by mouth every 6 hours through [**2-16**]
3.) START levofloxacin 750 mg by mouth daily through [**2-2**]
4.) START prednisone and taper as follows:
- 20 mg by mouth daily on [**3-18**] and [**2-1**]
- 10 mg by mouth daily on [**3-25**] and [**2-4**]
- 5 mg by mouth daily on [**4-3**] and [**2-7**]
5.) START oxycodone 5 mg, 1-2 tablets every 4 hours as needed
for breakthrough pain in your feet. DO NOT DRIVE while taking
this medication.
Please continue to take all of your other medications as you had
prior to this hospitalization. It is important that you keep the
follow-up appointment that has been made for you at [**Hospital1 778**] on
Thursday, as listed below.
Wishing you all the best!
Followup Instructions:
Name: [**Last Name (LF) **], [**First Name3 (LF) 1409**], PA.
Location: [**Hospital6 5242**] CENTER
Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 798**]
When: Thursday, [**2179-2-1**]:50 AM
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**]
|
[
"285.9",
"042",
"356.9",
"V46.2",
"349.82",
"275.3",
"518.81",
"733.49",
"008.45",
"491.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"96.04",
"33.24",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
24030, 24102
|
14986, 15205
|
329, 346
|
24293, 24293
|
6511, 6511
|
26263, 26616
|
5062, 5227
|
21600, 24007
|
24123, 24176
|
20642, 21577
|
24444, 26240
|
14637, 14963
|
5242, 5242
|
24197, 24272
|
20062, 20616
|
265, 291
|
15220, 19071
|
374, 3122
|
11500, 14621
|
6527, 7755
|
7777, 11491
|
5256, 6492
|
24308, 24420
|
19087, 20041
|
3144, 4032
|
4048, 5046
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,252
| 153,381
|
25077+57436
|
Discharge summary
|
report+addendum
|
Admission Date: [**2193-12-21**] Discharge Date: [**2193-12-24**]
Date of Birth: [**2116-1-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5438**]
Chief Complaint:
bleeding gastric ulcer
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
Central line placement and removal
History of Present Illness:
Pt went to PCP [**Last Name (NamePattern4) **] [**2193-12-18**] with symptoms of fatigue and
lightheadedness. Her Hgb at that time was 5.8. Pt was sent to
[**Hospital **] Hospital. EGD showed large ulcer in lesser curvature
with visualized bleeding vessel. Endoclip and cauterization
were unsuccessful. Pt received 3 units of PRBCs, last
transfusion was [**2193-12-19**] morning. Hct was 31 at time of
transfer. Pt was never hemodynamically unstable. She denies
hemoptysis, melena, hematuria, chest or abdominal pain.
.
She has required transfusions for low Hct in [**6-20**] and [**8-20**].
Past Medical History:
--CHRONIC ANEMIA, previously on Procrit, BM bx unrevealing,
followed by Dr. [**Last Name (STitle) 62919**] hematologist
--NECROTIZING VACULITIS, kidney bx [**2193-10-15**], prednisone taper
over last month from 70 mg to now 15 mg daily,
--POLYCLONAL GAMMOPATHY, thought to be cryoglobinopathy
--ESR 140s
--COPD, on home O2 2L, on spiriva, flovent, albuterol
--OSTEOPOROSIS, on fosamax
--LOW BODY WEIGHT always in 90s to 100 lbs
Social History:
Pt lives alone after husband's deth in [**2193-2-16**]. She has
2 duaghters who are very involved. She smoked [**2-17**] ppd tobacco
for 15 yrs, stopped in [**2138**]. She drinks one glass of wine per
day.
Family History:
Non-contributory
Physical Exam:
T=afebrile
BP=143/67
HR=90s
RR=20
O2sat=mid 90s on 2L NC
GEN: frail, cachetic female lying in bed in no acute distress
HEENT: MMM, PERRL, EOMI, non-pale conjunctiva, no JVD, no
cervical/supraclavicular adenopathy
CV: rrr, nl s1/s2
CHEST: CTAB
ABD: BS+, NT, ND, no masses
EXT: warm, no c/c/e, 2+ pulses throughout
SKIN: no rashes
Pertinent Results:
[**2193-12-21**] 05:07PM GLUCOSE-88 UREA N-40* CREAT-0.8 SODIUM-135
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-31 ANION GAP-9
[**2193-12-21**] 05:07PM CALCIUM-8.6 PHOSPHATE-1.9* MAGNESIUM-1.9
[**2193-12-21**] 05:07PM WBC-7.6 RBC-3.15* HGB-10.0* HCT-28.7* MCV-91
MCH-31.9 MCHC-35.0 RDW-15.8*
[**2193-12-21**] 05:07PM PLT COUNT-242
[**2193-12-21**] 05:07PM PT-12.0 PTT-27.6 INR(PT)-1.0
Brief Hospital Course:
A/P: 77 y/o F with chronic anemia of unclear origin, COPD, who
presents with gastric ulcer.
.
# Blood loss anemia from UGIB: The patient was hemodynamically
stable in MICU and continued on Protonix IV bid. GI and surgery
were consulted. Her hct remained stable without requiring blood
transfusion until [**2193-11-22**] when hct mildly dropped to 25 in the
setting of having received 2 L of NS. The patient received one
unit of PRBC and repeat EGD was done on [**12-23**]. Repeat EGD showed
a 2.5 cm lesser curvature deep cratered ulcer w/ clip, no bleed
and antral erosion. A biopsy was taken. After 1u PRBC, the
patient's hct remained stable, and the patient was tolerated
food well after EGD. GI recommended repeat EGD in 2 month and
continuing Protonix 40mg [**Hospital1 **]. The patient was instructed to
take Protonix [**Hospital1 **] for a month and then daily. The patient
preferred to get repeat EGD at [**Hospital **] Hospital.
.
#COPD: Was stable. Continued Spiriva and fluticasone and
supplemental O2 (home 2L O2 at baseline).
.
#. H/O acute renal failure: Renal biopsy c/w necrotizing
vasculitis [**3-20**] ?cryoglobulinemia in [**9-20**]. The patient has been
on a prednisone taper and was continued in the MICU. Creat
normal at 0.8 during this admission. Spoke with her outpatient
nephrologist on [**2193-12-23**] who recommended continuing prednisone
15mg qday. The patient has a follow-up appointment with her
nephrologist on [**2193-12-31**] and will go over prednisone taper.
# OSTEOPOROSIS: on fosomax q1wk. Restart calcium and vitamin D
on the floor after the repeat EGD.
.
#. FEN: NPO for EGD
.
#. PPX: Pneumoboots, protonix
Medications on Admission:
--Spiriva 1 capsule daily
--Flovent 220 mcg 1 inhalation daily
--Albuterol nebulizer tx every 6 hr prn
--Prednisone 15 mg daily
--Fosamax 70 mg 1x/wk
--Protonix 40 IV BID
--Tylenol prn
Discharge Medications:
1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation DAILY (Daily).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. CALCIUM 500+D 500-200 mg-unit Tablet Sig: One (1) Tablet PO
three times a day: with meals.
Disp:*90 Tablet(s)* Refills:*2*
5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO every twelve (12) hours.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO once a day:
until you see Dr. [**Last Name (STitle) 62920**].
Disp:*45 Tablet(s)* Refills:*0*
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for for sob or wheezing.
8. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a week: take
wtih water, 30min before first food/drink/med, avoid lying down
x 30minutes.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Blood loss anemia
Gastric ulcer
Secondary diagnoses:
Chronic obstructive pulmonary disease
Osteoporosis
? Cryoglobulinemia
Discharge Condition:
Stable
Discharge Instructions:
Return to the emergency department or call your doctor if you
develop blood in your stools, severe abdominal pain, vomiting
blood, shortness of breath, chest pain, or any other worrisome
symptoms.
.
Take your medications as prescribed.
.
Please keep your follow-up appointments.
.
AVOID any NSAIDS products (i.e. Motrin, Aleve, Advil, generic
name = ibuprofen) which can worsen your gastric ulcer. Ask a
pharmacist before you purchase any pain medication.
.
Please have a repeat esophagogastroduodenoscopy at [**Hospital **]
Hospital in 2 month.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) 62920**], your nephrologist, on
[**2193-12-31**] at 3:30pm.
.
You have an appointment with Dr. [**Last Name (STitle) 62921**], your PCP and
[**Name9 (PRE) 62922**] on [**2194-1-29**] at 11am.
Name: [**Known lastname 11261**],[**Known firstname 1940**] Unit No: [**Numeric Identifier 11262**]
Admission Date: [**2193-12-21**] Discharge Date: [**2193-12-24**]
Date of Birth: [**2116-1-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11263**]
Addendum:
Serum H.pylori serology was negative.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11264**] MD [**MD Number(2) 11265**]
Completed by:[**2193-12-25**]
|
[
"733.00",
"531.40",
"V58.65",
"273.2",
"285.1",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
6919, 7085
|
2529, 4198
|
340, 404
|
5609, 5618
|
2117, 2506
|
6213, 6896
|
1727, 1745
|
4433, 5393
|
5443, 5495
|
4224, 4410
|
5642, 6190
|
1760, 2098
|
5516, 5588
|
278, 302
|
432, 1033
|
1055, 1485
|
1501, 1711
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,177
| 181,716
|
17718
|
Discharge summary
|
report
|
Admission Date: [**2181-6-2**] Discharge Date: [**2181-6-22**]
Date of Birth: [**2122-10-20**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
hypoxic respiratory failure, transferred from [**Hospital3 3583**]
Major Surgical or Invasive Procedure:
intubation
extubation
HD cath placement
CVVHD
History of Present Illness:
This is a 58 year-old man with a history of HIV since [**2165**], not
on anti retrovirals, CD4 count>1000 about 1.5 months ago who
presented to [**Hospital3 3583**] this AM with acute respiratory
distress. On arrival: Febrile to 103.8, tachypneic to 40's,
tachycardic to 140's, satting low 90's on BIPAP.
.
As per notes and wife, 4 days of feeling unwell, non-productive
cough, shakes, chills and then yesterday patient began having
dyspnea. No history of chf, no edema.
.
OSH Labs significant for white count of 21 with significant
bandemia (30), new renal failure (creatinine of 2.3 from 0.7 one
month ago), hyponatremia to 127, ck to 4000's and trop to 0.17,
ldh of 810.
Left lower lobe consolidation by report on CXR at [**Hospital1 46**]. Given
lasix, ceftriaxone, azithromycin, solumedrol, albuterol,
atrovent. Vecuronium, versed and then intubation.
.
Given fentanyl, transiently on levophed during transfer.
Past Medical History:
1. HIV
2. Hypercholesterolemia
3. Lipodystrophy
4. h/o anal condyloma
Social History:
Current smoker 1 ppd/30 pk years, 1-2 drinks/day, married,
daughter.
Family History:
non-contributory
Physical Exam:
VS: Temp: 101.1 BP: 90/55 HR: 115
Vent: AC 650x14 100% PEEP 10 Satting 93%
.
general: intubated, sedated, not responsive
HEENT: PERLLA, EOMI, anicteric, no scleral icterus, MMM no
supraclavicular or cervical lymphadenopathy
lungs: coarse BS throughout, decreased BS LLL
heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops
appreciated
abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
extremities: warm, good cap refill, no cyanosis, clubbing or
edema
skin/nails: no rashes/no jaundice/no splinters
neuro: sedated/nonresponsive.
Pertinent Results:
[**2181-6-18**] 06:00AM BLOOD Hct-27.2*
[**2181-6-2**] 01:23PM BLOOD WBC-12.1* RBC-4.09* Hgb-13.7* Hct-38.7*
MCV-95 MCH-33.5* MCHC-35.4* RDW-13.9 Plt Ct-93*#
[**2181-6-21**] 05:51AM BLOOD Neuts-64.3 Bands-1.0 Lymphs-22.4
Monos-9.2 Eos-1.0 Baso-0 Metas-1.0* Promyel-1.0*
[**2181-6-2**] 01:23PM BLOOD Neuts-83* Bands-12* Lymphs-4* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2181-6-18**] 06:00AM BLOOD PTT-42.3*
[**2181-6-22**] 04:14AM BLOOD Glucose-119* UreaN-55* Creat-6.7*#
Na-131* K-4.1 Cl-92* HCO3-22 AnGap-21*
[**2181-6-17**] 11:45PM BLOOD Glucose-124* Na-131* K-3.8 Cl-97 HCO3-27
AnGap-11
[**2181-6-17**] 12:15AM BLOOD Glucose-114* Na-131* K-4.6 Cl-95* HCO3-25
AnGap-16
[**2181-6-15**] 01:50AM BLOOD Glucose-93 UreaN-39* Creat-3.0* Na-128*
K-4.5 Cl-94* HCO3-24 AnGap-15
[**2181-6-2**] 01:23PM BLOOD Glucose-176* UreaN-27* Creat-2.0*#
Na-131* K-3.7 Cl-100 HCO3-21* AnGap-14
[**2181-6-21**] 05:51AM BLOOD ALT-32 AST-40 AlkPhos-191* TotBili-0.5
[**2181-6-15**] 01:50AM BLOOD ALT-28 AST-47* AlkPhos-389* TotBili-0.5
[**2181-6-10**] 04:00AM BLOOD ALT-34 AST-87* LD(LDH)-333* AlkPhos-354*
Amylase-112* TotBili-1.1
[**2181-6-2**] 01:23PM BLOOD ALT-62* AST-178* LD(LDH)-797*
CK(CPK)-4825* AlkPhos-38* TotBili-0.5
[**2181-6-10**] 08:26PM BLOOD GGT-433*
[**2181-6-12**] 01:35AM BLOOD Lipase-22
[**2181-6-10**] 04:00AM BLOOD Lipase-33
[**2181-6-8**] 10:23AM BLOOD Lipase-23
[**2181-6-3**] 04:09AM BLOOD CK-MB-16* MB Indx-0.2 cTropnT-0.05*
[**2181-6-2**] 08:00PM BLOOD CK-MB-23* MB Indx-0.4 cTropnT-0.04*
[**2181-6-2**] 01:23PM BLOOD CK-MB-21* MB Indx-0.4 cTropnT-0.04*
[**2181-6-22**] 04:14AM BLOOD Calcium-7.9* Phos-8.2*# Mg-2.5
[**2181-6-10**] 08:26PM BLOOD Hapto-150
[**2181-6-2**] 01:23PM BLOOD TSH-0.27
[**2181-6-11**] 11:41AM BLOOD Cortsol-31.3*
[**2181-6-11**] 11:40AM BLOOD Cortsol-29.4*
[**2181-6-11**] 10:59AM BLOOD Cortsol-13.5
[**2181-6-6**] 03:02PM BLOOD Cortsol-33.6*
[**2181-6-22**] 12:30PM BLOOD HBsAg-PND
[**2181-6-12**] 02:20PM BLOOD Vanco-21.4*
[**2181-6-2**] 01:23PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2181-6-18**] 12:38PM BLOOD Type-ART Temp-36.3 pO2-105 pCO2-32*
pH-7.50* calTCO2-26 Base XS-1 Intubat-NOT INTUBA
[**Known lastname 49283**],[**Known firstname **] [**Numeric Identifier 49284**] M58 - Blood Specimen Results, Send Out
[**2181-6-12**] 08:43PM
ASPERGILLUS GALACTOMANNAN ANTIGEN
TEST RESULT EXPECTED
VALUES
---- ------ ---------------
Aspergillus Ag, S 0.184 < 0.5 Index
TEST PERFORMED AT:
[**Hospital 4534**] MEDICAL LABORATORIES, 3050 Superior Dr. [**Last Name (STitle) **], [**Location (un) **],
[**Numeric Identifier 49285**]
Complete report on file in the laboratory.
Comment: Source: Line-art line
CHEST, 1 VW
An ET tube is present, in satisfactory position approximately
4.2 cm above the carina. An NG tube is present, coiled in the
stomach, extending beneath the diaphragm, off the film. There is
patchy alveolar opacity in both lungs, most pronounced in the
left mid and right perihilar regions, with dense retrocardiac
opacity. More patchy opacity is seen in the right upper zone.
Air bronchograms are visible on both sides. No gross effusion is
detected.
IMPRESSION:
Patchy opacity involving both lungs, compatible with pneumonic
consolidation.
RENAL U.S. (PORTABLE)
Reason: ELEVATED CR
INDICATION: Elevated creatinine.
No prior studies are available for comparison.
FINDINGS: The right kidney measures 13.6 cm and the left 14.6
cm. The kidneys demonstrate normal parenchymal thickness and
echogenicity without evidence of calculi or hydronephrosis. The
bladder is not distended and cannot be evaluated.
IMPRESSION: Normal renal ultrasound.
Right upper quadrant ultrasound.
INDICATION: 58-year-old male with HIV and legionella pneumonia,
now with elevated alkaline phosphatase. Assess for biliary
obstruction.
COMPARISONS: None.
FINDINGS: The gallbladder is mildly distended. There is no
pericholecystic fluid or gallbladder wall edema. The common bile
duct is visualized and is not distended measuring approximately
6 mm in diameter. Just inferior to the neck of the gallbladder
are several shadowing foci which could represent either surgical
clips versus tiny calcified gallstones present within the cystic
duct. There is no intrahepatic or extrahepatic biliary
dilatation.
IMPRESSION: No evidence of biliary obstruction. Possible small
stones present within the cystic duct, though this is uncertain.
If persistent symptoms, an MRCP is recommended for further
evaluation.
CT CHEST W/O CONTRAST
Reason: assess pna, ? cavitation or other sign of fungal infxn
[**Hospital 93**] MEDICAL CONDITION:
58 year old man with intubated, with HIV, legionella pna,
aspergillous growing on sputum culture
REASON FOR THIS EXAMINATION:
assess pna, ? cavitation or other sign of fungal infxn
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 58-year-old man intubated with HIV, Legionella
pneumonia, Aspergillus growing on sputum and culture. Rule out
cavitation or other sign of fungal infection.
No prior CTs are available for comparison.
FINDINGS: Multiple focal areas of airspace consolidation are
noted involving almost all pulmonary segments, bilaterally with
linear and, reticular opacities, ground-glass opacities, and
consolidation, along the bronchovascular distribution. There is
no evidence of cavitary lesions. No evidence of pleural
effusions. No evidence of pneumothorax. A small bleb is noted in
the medial aspect of the left upper lobe.
The heart is normal in size. No evidence of pericardial
effusions. Signs of anemia are noted. Calcifications at the
aortic root are seen. The patient is intubated. The endotracheal
tube tip is 2.6 cm from the carina. An NG tube is noted with its
tip is excluded. Right-sided central venous line with its tip in
the SVC. A left-sided central venous line is noted with its tip
in the right atrium.
The visualized portions of the upper abdomen are unremarkable.
IMPRESSION:
1. Bilateral multfocal areas of airspace consolidation consitent
with pneumonia. No cavitary lesion is seen.
2. Left large bore central venous catheter with its tip in the
right atrium.
3. The endotracheal tube with its tip at 2.6 cm above the
carina.
SPECIMEN SUBMITTED: SKIN BX, RIGHT UPPER THIGH.
Procedure date Tissue received Report Date Diagnosed
by
[**2181-6-14**] [**2181-6-14**] [**2181-6-15**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 12033**]/nbh
Previous biopsies: [**Numeric Identifier 49286**] GI BIOPSY.
************This report contains an addendum***********
DIAGNOSIS:
Skin, right upper thigh, biopsy for light microscopy:
Superficial perivascular and interstitial mixed inflammatory
infiltrate including neutrophils, eosinophils, lymphocytes and
histiocytes with associated upper dermal edema and focal
subepidermal split (see note).
Note: The changes are most consistent with a hypersensitivity
reaction (bullous pemphigoid-like), as to a drug.
Immunofluorescence is being performed, the results of which will
be reported in an addendum.
ADDENDUM:
Skin, right upper thigh, direct immunofluorescence:
Linear IGA deposition is seen along the basement membrane zone
of the epidermis and eccrine ducts. No IgG, IgA, C3, or
fibrinogen deposition is seen.
These changes, in concert with the light microscopic changes,
are consistent with linear IgA dermatosis and, in the clinical
context, are compatible with a vancomycin-associated reaction.
ECHO - Conclusions:
The left atrium is elongated. There is mild symmetric left
ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). Regional
left ventricular wall motion is normal. There is no ventricular
septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic
root is moderately dilated at the sinus level. The ascending
aorta is
moderately dilated. The number of aortic valve leaflets cannot
be determined
(? Bicuspid valve). The aortic valve leaflets are mildly
thickened with focal
calcifcation. There is a minimally increased gradient consistent
with
minimal/trivial aortic valve stenosis. There is mild aortic
regurgitation.The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse.
Mild (1+) mitral regurgitation is seen. The tricuspid valve
leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension
CHEST, AP UPRIGHT PORTABLE: Comparison is made to the prior day.
The patient has been extubated, and a nasogastric tube has also
been removed. A left IJ central venous catheter terminates at
the cavoatrial junction.
Patchy consolidations in the right lung have a somewhat less
dense appearance, which could reflect slight improvement or
perhaps differences in technique, but the pattern is unchanged.
Consolidations in the left lung are unchanged. There are no
pleural effusions or pneumothorax.
IMPRESSION: Status post extubation. Similar multifocal
consolidations.
Brief Hospital Course:
58 M with HIV and -
# Acute respiratory failure from legionella pneumonia: after a
long ICU stay on mechanical ventilation he was extubated on
[**2181-5-18**]. Thereafter did well on NC. Should eventually be able to
come off o2 as tolerated. ID consult team followed in house and
recommended at least 4-6 weeks of levofloacaxin (day 1 =
[**2181-6-6**])
# Acute renal failure - was initially on CVVH. Started HD on
[**2181-6-21**]. HD to be continued on Mon, Wed, Fri. Epo with HD. Given
this is acute renal failure, the patient may eventually be able
to come off the dialysis if kidney function recovers. The
nephrologist at the dialysis center in rehab should follow the
renal function.
Avoid all nephrotoxic agents.
# Blood loss anemia - UGI bleed. The patient had a upper GI
bleed in the ICU that spontaneously stopped. Hct initially
dropped but then stable for 5 days prior to discharge. The
patient should follow up with PCP for EGD after discharged from
rehab. EGD deferred in hospital given recent sepsis etc. d/w GI
.
# Drug rash - from vanco (documented in OMR). Rash improving at
discharge. Called by derm resident who started that the skin
biopsy showed linear IgA which likely is a vanco rash; very
unlikely zosyn. Will remove zosyn from the OMR allergy list. PCP
informed to update records. The sutures at the site of skin
bipopsy may be removed 14 days after the biopsy.
- continue miconazole, mupirocin, clobetasol cream
.
# Decubitus ulcer, sacral - Wound care consult followed patient.
.
# HIV, lipodystrophy - on HAART. Given ARF/elevated CK stopped
tenofovir, emtricitabine, started lamivudine and stavudine
(renally dosed), continued efavirenz. The rehab did not have
efavirenz over the weekend and so the wife of patient was given
a prescription for meds for 3 days and then, the rehab will be
able to provide meds to patient.
# Repeat CBC - Diff should be done by PCP when seen in clinic in
1 month to follow up that there are no atypical cells. Some seen
here, could be due to infection.
For deconditioning, was discharged to rehab after PT and OT
evaluations
Medications on Admission:
1. simvastatin 80 qday
2. Atripla (EFAVIRENZ/EMTRICITABINE/TENOFOVIR)
3. viagra PRN
Discharge Medications:
1. Efavirenz 200 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily) for 3 days.
Disp:*9 Capsule(s)* Refills:*0*
2. Stavudine 20 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
3. Lamivudine 100 mg Tablet Sig: 0.5 Tablet PO once a day.
4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
9. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for rash.
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for yeast.
11. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-26**]
Drops Ophthalmic PRN (as needed).
12. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
13. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q1H PRN ().
14. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six
(6) Puff Inhalation Q4H (every 4 hours).
15. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
17. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
18. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
19. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID with
meals ().
20. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours): started on [**2181-6-6**]. Please continue for total
of 6 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
Acute respiratory failure from legionella pneumonia -
Acute renal failure
Blood loss anemia - UGI bleed
Drug rash from vancomycin
Decubitus ulcer, sacral
HIV, lipodystrophy
Abnormal differential of CBC
Discharge Condition:
stable
Discharge Instructions:
You are being discharged to a rehab facilty. The doctors there [**Name5 (PTitle) **] [**Name5 (PTitle) **] for further needs. Pleas eofllow up with Dr [**Last Name (STitle) 44068**]
after disharged from there.
Report any new symptoms of concern to you to your doctors [**First Name (Titles) **] [**Name5 (PTitle) 40837**].
The dialysis will be continued at rehab three times a week and
they will arrange for further dialysis if you need it when you
get discharged from there.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2181-9-10**]
10:00
Provider: [**Name10 (NameIs) **] WEST,ROOM FIVE GI ROOMS Date/Time:[**2181-9-10**] 10:00
after discharged from rehab, the patient should be following
with his primary care doctor - Dr [**Last Name (STitle) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 2393**].
Please send him a copy of the discharge summary from rehab. The
patient should also get a repeat chest XR in 4 weeks after
completion of antibiotics and also a CBC with diff with PCp
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32,348
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3519
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Discharge summary
|
report
|
Admission Date: [**2145-7-13**] Discharge Date: [**2145-7-18**]
Date of Birth: [**2068-1-28**] Sex: M
Service: MEDICINE
Allergies:
Clonidine
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Weakness, diarrhea.
Major Surgical or Invasive Procedure:
Tunnelled HD line placement.
History of Present Illness:
This is a 77M with systolic CHF with last EF 35% (last echo on
[**4-7**]), CAD s/p NSTEMI ([**5-8**]) with multiple stents, 3VD but not a
candidate for CABG, ESRD on HD (tues, thurs, sat), DMII, s/p CVA
approx 15 years ago with residual R side weakness, afib on
coumadin being held for fistula redo, hypertension, prostate
cancer s/p radiation therapy in [**2135**], doing well until this
morning, when he developed weakness, nausea, vomiting, increased
fecal incontinence.
.
Reports that at baseline, he is easily winded secondary to his
extensive cardiac history. However, this morning, after getting
out of the shower, felt as if he could not stand up. He had 6
episodes of increased, large volume fecal incontinence. No blood
or melena. Had nausea with emesis times one. Was with poor PO
intake for the rest of the day and decreased appetite. Denies
any fever, chills, abdominal pain.
.
Also endorses mild SOB, now resolved. Has not missed any HD
sessions. Denies any chest pain. Of note, reports that he had
been taking several weeks of antibiotics for a penile skin
infection. Per OMR, was given prescription for bactrim. Patient
stopped coumadin four days ago.
.
In the ED, initial vs were: T: 97.7, P: 46 BP: 79/57, R: 16, O2
sat: 96% RA. Patient was given 2.25L NS, and blood pressures
improved to 120/80. ECG demonstrated atrial fibrillation with
rate in the 40s. LAD. Labs notable for potassium of 7.4, repeat
value of 6.4. Glucose in the 400s. Was given albuterol, 10 units
of insulin and glucose, kayexelate. Was also given zofran.
.
On the floor, patient feels better after fluid resuscitation.
Nausea, vomiting, and shortness of breath have resolved. Repeat
FSBS: 279.
.
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:
- ESRD (CKD stage 5) on dialysis (Tues, Thurs, Sat) with left
arm AV fistula placed in [**2143**] requiring multiple revisions, with
attempted placement of PD catheter failed due to inguinal and
pleural hernias. Renal failure caused by phospho-soda.
- systolic CHF - last echo [**12/2144**] with EF 30%, severe
hypokinesis of the interventricular septum (anterior and
inferior) and anterior free wall, and extensive apical
hypokinesis with focal dyskinesis. 2+ MR, 2+ TR, severe PA
hypertension
- Diabetes mellitus, insulin-dependent
- Known CAD, s/p PCI with BMS to RCA for NSTEMI in [**5-/2142**]; 3VD
on last cath in [**7-/2144**]
- Atrial fibrillation: on coumadin for since ~[**2137**], with history
of embolic CVA
- Hypertension
- Hyperlipidemia
- CVA: Embolic in nature, over 15 years ago, with residual
weakness in his right leg and arm
- Prostate cancer status-post radiation therapy in [**2135**]
- Radiation proctitis with bleed in [**2142**] requiring PRBC
transfusion
- radiation cystitis, requiring hospitalization
- History of colon polyps
- Diverticulosis
- Hematuria requiring previous transfusions and cauterizations
- Concern for Factor V Leiden
- Hernias, inguinal and pleural
Social History:
- Lives w/children in [**Hospital1 3494**].
- Tobacco: Denies
- Alcohol: Denies
- Illicits: Denies
Lives in multilevel home w/children in [**Hospital1 3494**]. Denies
current smoking, significant alcohol use, or any use of illicit
drugs. Had significant alcohol use in the past, over 10 years
ago. Uses a cane to walk when outside of his house. At baseline
uses nothing to walk at home--lives on the [**Location (un) 448**]; lately
(2-3 weeks) has been using a walker around the house
Family History:
History of cardiac disease in family.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP at 8 cm, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Very faint heart sounds, irregularly irregular rate and
rhythm with 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, 3+ pitting edema bilaterally
Neuro: 4/5 strength on right arm, 5/5 strength on left arm. [**6-2**]
strength in both extremities. Sensation intact.
Pertinent Results:
[**2145-7-12**] 11:21PM BLOOD WBC-9.8 RBC-3.59* Hgb-11.7* Hct-36.5*
MCV-102* MCH-32.7* MCHC-32.1 RDW-15.9* Plt Ct-381
[**2145-7-12**] 11:21PM BLOOD Neuts-88.4* Lymphs-6.9* Monos-3.8 Eos-0.4
Baso-0.5
[**2145-7-13**] 12:21AM BLOOD PT-15.3* PTT-28.7 INR(PT)-1.3*
[**2145-7-12**] 11:21PM BLOOD Glucose-451* UreaN-83* Creat-6.3*#
Na-128* K-7.4* Cl-86* HCO3-24 AnGap-25*
[**2145-7-12**] 11:21PM BLOOD ALT-32 AST-33 CK(CPK)-43* AlkPhos-176*
TotBili-0.8
[**2145-7-12**] 11:21PM BLOOD Lipase-29
[**2145-7-12**] 11:21PM BLOOD cTropnT-0.80*
[**2145-7-13**] 04:35AM BLOOD CK(CPK)-49
[**2145-7-13**] 04:35AM BLOOD CK-MB-6 cTropnT-0.88*
[**2145-7-14**] 07:37AM BLOOD CK(CPK)-32*
[**2145-7-14**] 07:37AM BLOOD CK-MB-4 cTropnT-0.82*
[**2145-7-12**] 11:21PM BLOOD Albumin-3.8 Calcium-9.7 Phos-8.8*#
Mg-2.7*
[**2145-7-12**] 11:21PM BLOOD Digoxin-1.0
[**2145-7-16**] 05:25AM BLOOD WBC-8.9 RBC-3.07* Hgb-10.1* Hct-31.2*
MCV-102* MCH-33.0* MCHC-32.4 RDW-16.4* Plt Ct-284
-- DISCHARGE LABS --
[**2145-7-17**] 05:40AM BLOOD PT-30.0* PTT-47.7* INR(PT)-3.0*
[**2145-7-17**] 05:40AM BLOOD Glucose-153* UreaN-43* Creat-4.0*#
Na-128* K-4.5 Cl-96 HCO3-22 AnGap-15
[**2145-7-17**] 05:40AM BLOOD Calcium-8.6 Phos-4.7* Mg-2.2
EKG: Atrial fibrillation with controlled ventricular response
and decrease in rate as compared with previous tracing of
[**2145-5-8**]. Otherwise, no diagnostic interim change.
CXR: 1. Right lower lobe opacification and left hilar
enlargement concering for neoplasm - recommend chest CT.
2 Mild cardiomegaly and mild central vascular congestion.
3. Chronic right hemidiaphragmatic elevation with bibasal
atelectasis.
Glans penis, biopsy (A):
Spongiotic epidermal hyperplasia with confluent parakeratosis
and neutrophilic exocytosis (see note).
Note: PAS and [**Doctor Last Name 6311**] stains are negative for micro-organisms.
No ulcer or herpes virus-type cytopathic changes are found in
this sample. The findings are not diagnostically specific, but
raise a differential that includes non-specific reactive change
adjacent to ulcer, psoriasis, and Reiter's syndrome. Re-biopsy
incorporating the a portion of the ulcer may be further
informative. Initial and multiple level sections have been
examined.
Brief Hospital Course:
He was found to be hypotensive (79/57) and bradycardic (46) on
initial evaluation, but responded well to fluid resuscitation in
the ED and was admitted to MICU for further evaluation. He also
had metabolic derangements including hyperkalemia,
hyperglycemia, hyponatremia, and hyperphosphatemia in the
setting of a stenosed AV fistula.
The patient had been off his coumadin for the past four days
prior to admission with the intention of having a fistula
revision. However, on attempts to access this during his MICU
admission, it was found to be thrombosed. Attempted rescue of
the fistula with tPA met with no success. A tunneled line was
subsequently placed for HD access and dialysis was restarted
successsfully.
No clear etiology was found for the patient's nausea, vomiting,
and diarrhea, but they resolved during the hospitalization. The
patient denied prodromal symptoms or abdominal discomfort,
making viral syndrome (e.g. gastroenteritis) less likely but
still possible. C. diff was negative. His symptoms could have
been [**3-2**] uremia, especially if recent dialysis had been
ineffectual in setting of poor fistula function. Other
possibilities could have included digoxin toxicity although the
level was 1.0 on admission.
As the patient no longer needed to be off anticoagulation for a
revision of his fistula, heparin gtt was started as a bridge to
coumadin. The bridge was continued >24 hours after being
therapeutic on coumadin in the setting of known protein C
deficiency.
The patient had a recent penile lesion for which he had
presented to the ED several days prior and completed a five day
course of Bactrim. He had been scheduled to see Dermatology as
an outpatient but missed that appointment due to his
hospitalization. He was seen by Dermatology as an inpatient,
who recommended a repeat RPR (which was negative) and performed
a shave biopsy, the results of which are listed above. He will
follow up on these results with Dermatology as an outpatient.
On routine CXR during the patient's ICU admission, he was found
to have a RLL opacification which was felt to be worrisome for
neoplasm with interval progression in comparison to a prior CXR.
We instructed the patient to follow up with his primary care
physician promptly, at which time a CT chest should be obtained
if the primary care physician deems it necessary.
Medications on Admission:
1. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO QSUNWEDFRI ().
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)) as needed for with snack.
6. Humalog 100 unit/mL Solution Sig: per sliding scale units
Subcutaneous qAC and qHS: please dose according to sliding
scale.
7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM.
Discharge Medications:
1. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO every Sunday,
Wednesday, and Friday.
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1)
Capsule PO once a day.
4. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)) as needed for Snack.
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Fifteen
(15) units Subcutaneous qAM.
8. Insulin Lispro 100 unit/mL Solution Sig: PER SLIDING SCALE
Subcutaneous AS DIRECTED.
9. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
1. nausea and vomiting
2. diarrhea
3. hypotension
4. bradycardia
5. skin lesion on penis
Secondary Diagnoses:
1. end-stage renal disease on dialysis
2. diabetes mellitus, type 2
3. atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were seen at [**Hospital1 18**] for nausea, vomiting, and diarrhea. You
were found to have low blood pressure when you came to the
hospital and required fluids to bring your blood pressure back
up to normal. You spent a brief period of the time in the
intensive care unit.
During your hospitalization, it was found that your fistula for
dialysis had clotted. We tried to unclot it but were
unsuccessful. We instead inserted a dialyis catheter in order
to dialyze you without your fistula.
You were also found to have a slow heart rhythm during your
admission. This improved after we held your beta blocker and
digoxin. After a few days, your heart rate improved and we
gradually restarted your medications while keeping your heart
rate at a normal level.
As you no longer needed a procedure, we restarted your warfarin.
Because of your history of protein C deficiency, we needed to
keep you here on a heparin drip to keep you anticoagulated until
your warfarin reached a safe level.
You were seen by Dermatology during your admission for a lesion
on your penis for which you had previously taken antibiotics.
They performed a biopsy, the results of which are still pending
as of discharge. Use vaseline daily at home to keep the lesion
adequately moistuized. You will follow up with Dermatology as
an outpatient.
You were also found to have a nodule on your lung on a chest
X-ray while you were in the hospital. This needs to be further
investigated as an outpatient. We recommend that you discuss
with your primary care doctor about obtaining a chest CT as an
outpatient.
No medications were changed during this hospitalization.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
We recommend that you follow up with your primary care doctor,
Dr. [**First Name (STitle) 6624**], within four weeks of discharge. You can contact her
office at [**Telephone/Fax (1) 3329**] to set up an appointment. At the time of
your appointment, please discuss getting a chest CT to follow up
on the possible nodule seen on your chest X-ray during this
hospitalization.
We recommend that you follow up with Dr. [**Last Name (STitle) **] of Dermatology
within two weeks of discharge to follow up on the results of
your biopsy. You should be contact[**Name (NI) **] with an appointment at
home, but if you are not, please contact her office at
[**Telephone/Fax (1) 1971**] in [**4-2**] days to set up an appointment.
Please continue your dialysis per your prior regimen. Please
have your INR checked at dialysis to ensure that your blood is
adequately thinned.
Completed by:[**2145-7-18**]
|
[
"996.73",
"250.00",
"414.01",
"V45.11",
"412",
"787.91",
"V10.46",
"458.9",
"607.89",
"285.21",
"276.1",
"V45.82",
"585.6",
"289.81",
"428.22",
"428.0",
"403.91",
"276.7",
"787.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
11268, 11326
|
7151, 9513
|
289, 319
|
11591, 11591
|
4920, 7128
|
13539, 14438
|
4239, 4278
|
10419, 11245
|
11347, 11347
|
9539, 10396
|
11774, 13516
|
4293, 4901
|
11477, 11570
|
2052, 2499
|
230, 251
|
347, 2033
|
11366, 11456
|
11606, 11750
|
2521, 3720
|
3736, 4223
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,405
| 162,319
|
53151
|
Discharge summary
|
report
|
Admission Date: [**2136-1-19**] Discharge Date: [**2136-1-23**]
Date of Birth: [**2075-8-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Epinephrine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2136-1-19**]
1. Coronary bypass grafting x4. Left internal mammary
artery left anterior descending coronary; reverse
saphenous vein single graft from aorta to the first
diagonal coronary artery; reverse saphenous vein single
graft from aorta to first obtuse marginal coronary
artery; reverse saphenous vein single graft from aorta
to second obtuse marginal coronary.
2. Endoscopic left greater saphenous vein harvesting.
History of Present Illness:
60 year old male presented to LGH with
1-minute duration mild left-sided exertional chest pain and
pressure that radiating to his left arm, after carrying a night
table down the stairs that resolved with rest. Additional
symptoms was "twinge in his throat." He denied other associated
symptoms. The chest discomfort resolved with rest. He had
similar
pain in [**2117**] when he had a stent placed secondary to 90 %
occlusion of the LAD. He wanted to be safe, so he reported to
the
hospital given his cardiac history. Cardiac enzymes were
negative
x 3. EKG there revealed TWI in III and avF. Initially there were
no ST-T changes noted on EKG. He was given 325mg of aspirin. EKG
changes were noted during a stress test today. Stress MIBI
revealed a mild inferolateral pattern of ischema and EF 63 %. He
has had no further chest pain. He was offered cardiac cath but
elected to come to [**Hospital1 18**] given previous c. cath here. He was
transferred to [**Hospital1 18**] for further evaluation.
Past Medical History:
CAD
Dyslipidemia
Hypertension
s/p stent to LAD
Social History:
Lives with:wife
Occupation: insurance
Tobacco:quit smoking 20 years ago, only smoked intermitently
ETOH:occassionally
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Pulse:73 Resp:16 O2 sat:100/RA
B/P Right:192/92 Left:181/98
Height:5'8" Weight:179 lbs
General: NAD, WGWN, appears stated age
Skin: Dry [x] intact [x] no rash
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema none
Varicosities: None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left:
no bruits
Pertinent Results:
[**2136-1-22**] 03:03PM BLOOD WBC-10.4 RBC-3.52* Hgb-11.4* Hct-33.4*
MCV-95 MCH-32.4* MCHC-34.1 RDW-12.6 Plt Ct-152
[**2136-1-22**] 02:28AM BLOOD WBC-11.8* RBC-3.20* Hgb-10.9* Hct-30.2*
MCV-94 MCH-34.0* MCHC-36.0* RDW-12.5 Plt Ct-141*
[**2136-1-22**] 03:03PM BLOOD Glucose-112* UreaN-18 Creat-0.9 Na-139
K-3.8 Cl-104 HCO3-25 AnGap-14
[**2136-1-22**] 02:28AM BLOOD Glucose-122* UreaN-17 Creat-1.0 Na-138
K-3.9 Cl-103 HCO3-29 AnGap-10
Intraop TEE [**2136-1-19**]
Conclusions
Prebypass
No spontaneous echo contrast is seen in the body of the left
atrium or left atrial appendage. All 4 pulmonary veins are seen
entering the left atrium; however, a vessel is seen entering the
right atrium with a Doppler signature consistent with pulmonary
venous flow which may be an anomalous pulmonary vein. No
spontaneous echo contrast is seen in the body of the right
atrium. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion.
Postbypass
The patient is A-paced on a phenylephrine infusion. Left
venticular systolic function continues to be normal (LVEF 60%)
without regional wall motion abnormalities. Trace aortic
regurgitation, trace mitral regurgitation, mild tricuspid
regurgitation persist. The thoracic aorta is intact after
decannulation.
Dr. [**Last Name (STitle) 914**] was notified in person of the results at the time of
the study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2136-1-20**] 12:24
Brief Hospital Course:
The patient was brought to the operating room on [**2136-1-19**] where
the patient underwent CABG x 4 with Dr. [**Last Name (STitle) 914**]. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 4 the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged home in good condition with
appropriate follow up instructions.
Medications on Admission:
Bystolic 5 mg PO daily
Lipitor 40 mg PO daily
ASA 325 mg PO daily
Discharge Medications:
1. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
4. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 1 weeks.
Disp:*14 Tablet Extended Release(s)* Refills:*0*
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. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
CAD
Dyslipidemia
Hypertension
s/p stent to LAD
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema- trace LE
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2136-2-14**] 1:15 [**Telephone/Fax (1) 170**]
Cardiologist Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] [**2-3**] at 11AM
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **] [**2-28**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2136-1-23**]
|
[
"272.4",
"V45.82",
"401.9",
"V10.79",
"414.01",
"285.9",
"414.2",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6804, 6855
|
4874, 5939
|
288, 739
|
6946, 7118
|
2811, 4851
|
7906, 8514
|
1988, 2103
|
6056, 6781
|
6876, 6925
|
5965, 6033
|
7142, 7883
|
2118, 2792
|
237, 250
|
767, 1765
|
1787, 1836
|
1852, 1972
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,125
| 146,572
|
4992
|
Discharge summary
|
report
|
Admission Date: [**2177-6-19**] Discharge Date: [**2177-6-27**]
Date of Birth: [**2093-5-15**] Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
Traumatic fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
84M with previous hx of MI, DM and CABG presented after he
was foundoutside following an unwitnessed fall, blood on scene,
bleedingfrom head. Was mentating slowly per family, but
responsive. Ptdoes not recall what lead to the fall, thinks he
may have beendizzy. At this point the patient complains of mid
back pain and R elbow pain.
Pt is Italian speaking, wears a hearing aid in his left ear (not
available) and has blood in his right ear. He is currently
sedated and barely following commands. History obtained from
wife and daughter.
Past Medical History:
coronary artery disease
hypertension
hyperlipidemia
diabetes mellitus type II
osteoarthritis bilateral knees
h/o cataracts
CABG [**7-/2175**]
L VATS decortication on [**2176-3-27**]
Social History:
Patient lives with wife in [**Name (NI) **]. Daughter serves as
translator. Quit smoking 20+ years ago. No ETOH or drugs.
Family History:
Non-contributory
Physical Exam:
On Admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: R 2->1.5, L surgical EOMs intact, blood in ears
Neck: Collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and lethargic, cooperative with exam,
normal
affect.
Orientation: Oriented to person.
RUE
mild peripheral swelling; dark skin c/w hematoma
1+ R U
wwp
dressing in place; incision c/d/i
Fires EPL/FDP/EDC/EIP
sensory exam limited by cooperation, but grossly sensitive R U M
distributions
compartments soft
BLE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Thighs and legs are soft
No pain with passive motion
Patient wiggling toes
Pertinent Results:
[**2177-6-19**] 02:53AM GLUCOSE-232* UREA N-14 CREAT-0.7 SODIUM-137
POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
[**2177-6-19**] 02:53AM CALCIUM-8.3* PHOSPHATE-2.6* MAGNESIUM-2.1
[**2177-6-19**] 02:53AM WBC-10.2 RBC-4.87 HGB-12.6* HCT-39.9* MCV-82
MCH-25.8* MCHC-31.5 RDW-16.7*
[**2177-6-19**] 02:53AM PLT COUNT-133*
[**2177-6-19**] 02:53AM PT-12.0 PTT-25.6 INR(PT)-1.1
[**2177-6-18**] 06:50PM GLUCOSE-149* UREA N-18 CREAT-0.7 SODIUM-139
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-23 ANION GAP-15
Brief Hospital Course:
84M with previous hx of MI, DM and CABG presented to the ED
after he was found outside at the base of some porch stairs
bleeding from head following an unwitnessed fall, blood on
scene. Was mentating slowly per family, but responsive. Pt does
not recall what lead to the fall, thinks he may have been dizzy.
At this point the patient complains of mid back pain and R elbow
pain.
The patient was admitted to the intesive care unit for close
monitoring. He remained hemodynamically stable. His pain was
controlled with narcotic medication. He was alert and
appropriately responsive. His neuro exam was nonfocal and he was
moving all 4 extremities. His intracranial bleeds were stable.
He did well saturating on face tent and eventually nasal
cannula. He was kept NPO and then his diet advanced. He made
adequate UOP. For his olecranon fracture, he was to be
non-weight bearing on his R arm and had a sling for comfort. His
family did not wish for him to have surgery too soon. He got an
MRI for his anterior osteophyte fracture. He was taken off
logroll precautions. He was to wear a TLSO brace when out of
bed. He was stable to be transferred out of the ICU on HD3.
The patient was then transferred to the Orthopaedic Trauma
Service for repair of a R olecranon fracture. The patient was
taken to the OR and underwent an uncomplicated ORIF olecranon.
The patient tolerated the procedure without complications and
was transferred to the PACU in stable condition. Please see
operative report for details. The patient tolerated diet
advancement without difficulty. The patient was found to have
increased somnolence and neurosurgery was consulted. Repeat head
CTs w/o contrast showed a stable known subdural hematoma w/
midline shift. The patient was re-started on seizure
prophylaxis. Geriatrics colleagues assisted with his care and
management.
Weight bearing status: non weight bearing RUE, ROM as tolerated.
The patient received peri-operative antibiotics as well as
heparin SQ TID for DVT prophylaxis. The incision was clean,
dry, and intact without evidence of erythema or drainage; and
the extremity was NVI distally throughout. Neurosurgery was
consulted regarding DVT prophylaxis given ongoing stable
subdural hematoma and patient's risk factors for DVT (low level
of activity, recent orthopaedic surgery). Neurosurgery felt that
subQ heparin 5000U TID was appropriate. The patient was
subsequently discharged with 2 weeks of chemical DVT
prophylaxis. The patient was discharged in stable condition with
written instructions concerning precautionary instructions and
the appropriate follow-up care. All questions were answered
prior to discharge and the patient expressed readiness for
discharge.
Medications on Admission:
glyburide 2.5 qD
Toprol XL 25 qD
crestor
Tramadol 50 TID
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
2. Calcium Carbonate 500 mg PO TID
3. Docusate Sodium 100 mg PO BID
4. Milk of Magnesia 30 ml PO BID:PRN Constipation
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN Pain
after d/c PCA
RX *oxycodone 5 mg [**12-9**] tablet(s) by mouth q4hr Disp #*60 Tablet
Refills:*0
6. Senna 1 TAB PO BID
7. Vitamin D 1000 UNIT PO DAILY
8. LeVETiracetam 1000 mg PO BID seizure ppx
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
9. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
10. GlyBURIDE 2.5 mg PO DAILY
11. Acetaminophen 650 mg PO Q6H
12. Heparin 5000 UNIT SC TID Duration: 14 Days
RX *heparin, porcine (PF) 5,000 unit/0.5 mL inject subQ into
abdomen three times a day Disp #*42 Syringe Refills:*0
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Traumatic fall
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Discharge Instructions:
You were admitted to the hospital after having a traumatic fall
for unknown reason.
Please continue your anti-seizure prophylaxis (Keppra) for 1
month.
Please make sure you do not bear any weight on your right arm.
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse, changes location, or moves to your chest or back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-17**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
******SIGNS OF INFECTION**********
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
-Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. No baths or swimming for at least 4 weeks.
Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment. No dressing is needed
if wound continued to be non-draining.
******WEIGHT-BEARING*******
Non weight bearing R arm; Range of motion as tolerated
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink 8-8oz glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on Fridays.
****INFORMATION ON SUBDURAL HEMATOMA (BRAIN BLEED)****
You have a bleed in your brain called a subdural hematoma. The
neurosurgeons have evaluated you and believe it is stable (not
expanding). This subdural hematoma may make your mental status
wax and wane, meaning somedays you will be completely attentive
while others you may appear more fatigued or tired. The
neurosurgeons will continue to follow you as an outpatient and
will see you in 4 weeks for further examination.
Physical Therapy:
NWB RUE: AROM/PROM AT
Treatments Frequency:
if dry and non draining, no change needed; dry to dry otherwise
Followup Instructions:
Please call call ([**Telephone/Fax (1) 88**] to schedule a follow- up
appointment with Dr [**Last Name (STitle) 739**] in 4 weeks, with a
Non-contrast CT scan of the head. Our office is located in the
[**Hospital **] Medical Building, [**Hospital Unit Name 12193**].
Please have your staples removed at your rehabilitation facility
at post-operative day 14.
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**9-21**] days
post-operation for evaluation. Call [**Telephone/Fax (1) 1228**] to schedule
appointment upon discharge.
Please follow up with your PCP regarding this admission and any
new medications/refills.
Completed by:[**2177-6-27**]
|
[
"414.00",
"721.8",
"272.4",
"805.2",
"V58.67",
"813.01",
"V54.13",
"V45.81",
"V15.82",
"E888.9",
"801.21",
"715.96",
"511.9",
"348.89",
"348.4",
"802.8",
"412",
"805.4",
"401.9",
"780.09",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.32"
] |
icd9pcs
|
[
[
[]
]
] |
6286, 6376
|
2569, 5280
|
323, 330
|
6435, 6482
|
2034, 2546
|
10454, 11147
|
1262, 1280
|
5388, 6263
|
6397, 6414
|
5306, 5365
|
6545, 8318
|
8333, 8956
|
1295, 1295
|
10322, 10344
|
10366, 10431
|
269, 285
|
8968, 10304
|
358, 900
|
1309, 1518
|
6497, 6521
|
922, 1106
|
1122, 1246
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,354
| 101,853
|
37322
|
Discharge summary
|
report
|
Admission Date: [**2130-1-16**] Discharge Date: [**2130-1-20**]
Date of Birth: [**2052-5-31**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
Melanoma
Major Surgical or Invasive Procedure:
[**2130-1-16**]
1. Right modified radical neck dissection.
2. Right parotidectomy with facial nerve
monitoring/dissection.
History of Present Illness:
The patient is a 77-year-old male who in [**2125**]
was found to have a lesion overlying the right angle of the
mandible. Interestingly, he also had the same region biopsied
in [**2116**]. In both cases, the lesion was read as lentiginous
compound melanocytic nevus, dysplastic type, with apparent
complete excision. The pathology from [**2125**] was interpreted as
a darkly pigmented lentiginous junctional nevus with
architectural disorder and moderate cytologic atypia and
numerous pigment-laden macrophages extending to the tissue
edge. He underwent a re-excision of the lesion in [**2126-4-10**]
which showed residual atypical dysplastic nevus cells. This
was completely excised and there was a scar consistent with a
prior excision.
He did well until [**2129-10-11**] at which time he was noted
to have a swelling in the region of the tail of the right
parotid. A CT scan was obtained that demonstrated a 3-cm mass
involving the lower aspect of the right parotid. He was
presented at the Multidisciplinary Cutaneous [**Hospital **] Clinic
at which time surgery and probable postoperative radiation
was recommended.
Past Medical History:
Past medical history remarkable for coronary artery disease with
cardiac catheterization showing 2 completely blocked arteries
that were not stentable. He has angina with exertion, but this
is
largely controlled with topical worn Nitro patch. He rarely has
to take sublingual nitroglycerin. He underwent a transient
global attack in [**2127-10-11**] and has subsequently been on
Plavix. He has hypercholesterolemia, treated with Lipitor, and
is status post appendectomy in [**2117**] and cholecystectomy in [**2119**].
He is status post herniorrhaphy and has a history of chronic
thrombocytopenia of unclear etiology, with most recent platelet
count being 101,000.
Social History:
He is widowed from his
first wife and has a daughter, age 52. [**Name2 (NI) **] has been remarried
for
the past couple of decades, and he and his new wife have a
19-year-old son. [**Name (NI) **] does not smoke and drinks a glass of wine
per night.
Family History:
The family/social history: There is no family history of
melanoma. His father had [**Name2 (NI) 499**] cancer.
Physical Exam:
Elderly man in no acute distress.
NECK: There was a soft tissue mass approximately 3 cm in
diameter in the tail of the right parotid gland. There is a
surgical scar anterior to this
over his right jawline without surrounding pigmentation. There
is no cervical, supraclavicular, bilateral axillary or bilateral
inguinal adenopathy.
LUNGS:CTA-B
CV: reveals a 1/6 systolic ejection murmur.
ABD: Without masses, tenderness, or organomegaly.
NEURO: CN-II-XII intact grossly
Pertinent Results:
[**2130-1-16**] 04:45PM CK-MB-4 cTropnT-<0.01 proBNP-236
[**2130-1-16**] 04:52PM freeCa-1.09*
[**2130-1-16**] 04:52PM HGB-13.8* calcHCT-41
[**2130-1-16**] 04:52PM GLUCOSE-142* LACTATE-2.1* NA+-138 K+-3.7
CL--102
[**2130-1-16**] 04:52PM TYPE-ART PO2-207* PCO2-34* PH-7.46* TOTAL
CO2-25 BASE XS-1 INTUBATED-INTUBATED VENT-CONTROLLED
[**2130-1-16**] 07:48PM CK(CPK)-276*
[**2130-1-16**] 07:48PM CK-MB-4 cTropnT-<0.01
Brief Hospital Course:
77 yo M with history of CAD and recent diagnosis of melanoma who
is s/p parotidectomy w/ neck node dissection. Had ST depressions
intraoperatively and transferred to ICU for monitoring
overnight.
#. ST depressions: Anesthesia noted ST depressions
intraoperatively. Patient remained without chest pain or
dyspnea. His post-op EKG was significant for new RBBB and
associated diffuse T-wave inversions. The patient was
transferred to the ICU post-operatively for close hemodynamic
monitoring overnight. He had three negative sets of cardiac
enzymes over twelve hours and no further ECG changes. He
remained asymptomatic throughout and was transitioned to his
home cardiovascular medications except plavix and discharged
from the ICU on POD#1.
#. Melanoma s/p parotidectomy and node dissection: Patient felt
well post-op aside from hoarseness and some irritation from his
foley catheter. He received prophylactic antibiotics
peri-operatively and throughout his hospital stay. His JP
drains were removed on POD#3 and #4 when drainage was <30cc/day.
He recieved DVT prophylaxis throughout his hospitalization and
was restarted on his home dose of plavix on discharge. Patient
is being discharged: afebrile, tolerating regular diet without
nausea/vomiting, pain well controlled on oral medication,
voiding, incision clean, dry and intact, and ambulating well.
Medications on Admission:
1) Nitropatch 0.2 mg/hr DAILY (on in AM and off at bedtime)
2) Plavix 75 mg DAILY
3) Niaspan ER 1000 mg QHS
4) Atorvastatin 20 mg QHS
5) Lisinopril 5 mg DAILY
6) Metoprolol Succinate 100 mg DAILY
7) Nitroglycerin SL 0.4 mg PRN
8) Folic acid 1 mg DAILY
9) Aspirin 81 mg DAILY
10) ICaps MV 2 tabs [**Hospital1 **]
Discharge Medications:
1. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Nitroglycerin 0.2 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal Q24H (every 24 hours).
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for heartburn.
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic melanoma, right neck/parotid.
Discharge Condition:
Stable, A&O, ambulating
Discharge Instructions:
OK to shower but do not soak incision until follow up
appointment, at least. No strenuous exercise or heavy lifting
until follow up appointment, at least.
Do not drive or drink alcohol while taking narcotic pain
medications. Narcotic pain medications may cause constipation,
if this occurs take an over the counter stool softener.
Resume all home medications.
Your stitches/staples will be reomoved at your follow-up
appointment.
Followup Instructions:
[**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 41**] Date/Time:[**2130-1-24**]
10:00
|
[
"V10.82",
"196.0",
"426.4",
"414.01",
"997.1",
"401.9",
"198.89",
"287.5",
"600.00",
"272.4",
"411.89",
"E878.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.41",
"38.91",
"26.31"
] |
icd9pcs
|
[
[
[]
]
] |
6239, 6245
|
3663, 5026
|
330, 459
|
6330, 6356
|
3211, 3640
|
6837, 6978
|
2590, 2601
|
5389, 6216
|
6266, 6309
|
5052, 5366
|
6380, 6814
|
2719, 3192
|
282, 292
|
487, 1611
|
1633, 2304
|
2618, 2704
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,246
| 158,121
|
2750+2751
|
Discharge summary
|
report+report
|
Admission Date: [**2128-3-4**] Discharge Date: [**2128-3-14**]
Date of Birth: [**2067-10-24**] Sex: F
Service:
This dictation will cover the [**Hospital 228**] hospital course from
[**2128-3-5**] until [**2128-3-14**]. The remainder of the
[**Hospital 228**] hospital course will be dictated by the intern who
takes over the patient's care on [**2128-3-15**].
HISTORY OF THE PRESENT ILLNESS: The patient is a 60-year-old
female with a history of congestive heart failure on home
dopamine since [**2126-8-19**], status post recent
coagulase-negative Staphylococcus/Enterococcus line
infection. The patient was admitted to [**Hospital Unit Name 196**] last night with
the complaint of increasing weakness, malaise, and fatigue.
The patient denied fevers, chills, nausea, vomiting,
abdominal pain, chest pain, shortness of breath, and
dizziness.
While on the [**Hospital Unit Name 196**] Service, the patient was found to be
hypotensive with systolic blood pressure in the 60s. The
patient was given a 250 cc normal saline bolus and her
dopamine was increased to 50 micrograms/kg per minute. This
resulted in an increase in her systolic blood pressures to
the 100s. Furthermore, the patient was given a blood
transfusion and was noted to have a temperature to 101.
Blood cultures were drawn and revealed growth of
gram-negative rods. The patient was transferred to the CCU
for further management.
Of note, the patient also was noted to have a drop in her
hematocrit. On [**2128-2-24**], her hematocrit was 33. On
admission, her hematocrit was 25 and she was noted to have
Guaiac positive stools.
PAST MEDICAL HISTORY:
1. Mechanical mitral valve requiring chronic anticoagulation
with Coumadin.
2. Chronic occlusion of her abdominal aorta.
3. Diabetes mellitus.
4. Hickman related bacteremia with septic pulmonary emboli,
patient now completing a six week course of treatment,
currently with linazolid.
5. Renal insufficiency with recent antibiotic
administration.
6. Recurrent atrial tachy arrhythmia, aborted with pacing
overdrive.
7. DDD pacer placed in [**2123**].
8. Hypertension.
9. Peripheral vascular disease.
10. Proctitis noticed on colonoscopy in [**2126-8-19**].
11. Congestive heart failure with an ejection fraction of
less than 20% on home dopamine since [**2126-8-19**].
12. Coronary artery disease, status post CABG in [**2120**] with
re-do in [**2123**].
ALLERGIES: Cephalexin, codeine, sulfa, alprazolam.
HOME MEDICATIONS:
1. Lasix 80 mg b.i.d.
2. Bumex 2 b.i.d.
3. Dopamine 8 micrograms/kilogram per minute.
4. Vasotec 5 b.i.d.
5. Epogen 10,000 units each Thursday.
6. Coumadin 7.5 on Tuesdays and Thursdays, 5 other days.
7. Lipitor 10.
8. Zantac 150.
9. Trazodone 100 mg q.d.
10. Ativan 1 mg q.h.s.
11. Linazolid 600 mg p.o. b.i.d. to complete a six week
course of antibiotics.
12. Coreg 6.25 b.i.d.
13. Aspirin 81 mg q.d.
14. Zoloft 100 mg q.d.
15. Amiodarone 200 mg q.d.
16. Nitroglycerin p.r.n.
SOCIAL HISTORY: The patient lives with her husband. She
denied the use of alcohol. She smokes two to five cigarettes
per day.
PHYSICAL EXAMINATION ON ADMISSION: General: The patient was
an ill-appearing female in no apparent distress. Vital
signs: Temperature 99, blood pressure 91/48, heart rate 70,
respiratory rate 17, 02 saturation 99% on 2 liters. HEENT:
Normocephalic, atraumatic. Pupils equally round and reactive
to light. Extraocular movements intact. The mucous
membranes were moist. The oropharynx was clear. Neck: JVP
at mandible. Heart: There was a II/VI systolic murmur at
the apex. Mechanical S1, positive S3. Lungs: Clear to
auscultation anteriorly. Abdomen: Soft, mild tenderness in
midepigastrium. Positive bowel sounds, nondistended.
Extremities: No clubbing, cyanosis or edema. Good distal
pulses. Rectal: Guaiac negative per GI fellow. Neurologic:
Alert and oriented times three. Cranial nerves II through
XII grossly intact. The examination was otherwise nonfocal.
LABORATORY DATA: White count 6.3, hematocrit 24.4, platelets
62,000. Chemistries were notable for a BUN of 76, creatinine
1.7. The patient's baseline creatinine was 0.8 to 1. INR
3.9.
EKG: AV paced at 70, low voltage.
IMPRESSION: This is a 60-year-old female with congestive
heart failure on chronic dopamine at home admitted with
weakness associated with anemia and Guaiac positive stool.
The patient was with a recent admission for line infection,
most recently on a course of linazolid. INR was noted to be
elevated to 3.9.
The patient was transferred to the CCU due to labile
hypotension in the setting of gram-negative rod bacteremia
and thrombocytopenia/decreased hematocrit.
HOSPITAL COURSE: 1. CARDIOVASCULAR: A. Pump: As noted
above, the patient was hypotensive on admission with systolic
blood pressure in the 60s. The patient was transferred to
the CCU for further management of her hypotension. Her
dopamine was increased to 15 micrograms per kilogram per
minute. She continued on her Lasix, Bumex, Coreg, and ACE
inhibitor for treatment of her gram-negative rod bacteremia.
The patient's hemodynamics improved and she was eventually
weaned down to her home dose of dopamine at 8 micrograms per
kilogram per minute.
B. Rhythm: The patient has a DDD pacer and she is AV paced.
She continued on Amiodarone during her hospital course. On
[**2128-3-12**], the patient was noted to have atrial
tachycardia at 160 beats per minute. Overdrive pacing was
attempted to abort this rhythm. Overdrive pacing, however,
was unsuccessful. Dofetilide was administered
without success. The patient underwent DC cardioversion on
[**2128-3-13**] with good result.
C. Coronary artery disease: The patient continued on
aspirin and a statin during her hospital stay.
D. Anticoagulation: The patient is on chronic
anticoagulation with Coumadin due to her mechanical mitral
valve. Coumadin was held during the hospital day due to
procedures. Heparin was avoided due to the patient's
thrombocytopenia. The patient was anticoagulated with
bivalrudin (Angiomax) during her hospital stay.
E. Valvular disease: As noted above, the patient has a
mechanical mitral valve and requires chronic anticoagulation.
2. INFECTIOUS DISEASE: As noted above, the patient was
noted to have gram-negative rod bacteremia on admission.
Multiple blood cultures were also positive for gram-negative
rods. The organism was identified as "not Pseudomonas". ID
was consulted for recommendations regarding antibiotic
management. The patient was on broad spectrum antibiotics
but once sensitivities were determined the patient began a
course of Meropenem and gentamicin. The patient also
continued on vancomycin for treatment of her gram-positive
bacteremia from her last admission.
A transesophageal echocardiogram was performed to rule out
the presence of vegetations on the mitral valve. The TEE was
negative for vegetations. Abdominal imaging was also done to
investigate occult source of infection. CT of the abdomen
did reveal cholelithiasis without evidence of cholecystitis.
Due to concern for the patient's indwelling Hickman catheter
as a source for infection, this catheter was removed on [**2128-3-11**]. A right IJ catheter was placed under ultrasound
guidance on the same day.
The patient will complete a six week course of her
antibiotics as recommended by the ID service.
3. HEMATOLOGY: A. Thrombocytopenia: As noted on
admission, the patient's platelet count was 62,000. The
patient was initially on Linazolid for treatment of her
gram-positive bacteremia. Linazolid was discontinued. In
addition, effort was made to avoid agents which may cause
thrombocytopenia so the patient was not administered heparin.
The patient's platelet count rebounded during her hospital
stay.
B. Anemia: The patient was noted to have a hematocrit of
24.4 on admission. The patient required a transfusion of 5
units of packed red blood cells during her hospital stay. As
will be discussed below, GI workup was done to evaluate the
patient's anemia.
4. GASTROINTESTINAL: The patient underwent EGD and
colonoscopy during her hospital stay. EGD disclosed an AVM
in the third part of the duodenum. Colonoscopy was normal.
The patient continued on PPI and a bowel regimen during her
hospital stay.
5. PSYCHIATRIC: The patient continued on her Zoloft and
Ativan during her hospital stay.
6. RENAL: The patient was noted to have elevated creatinine
on admission. Her baseline creatinine is 0.8 to 1. The
patient's renal function improved during her hospital stay.
7. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient
continued on a 2 gram sodium/cardiac heart health diet during
her hospital stay. Her fluids were restricted to 2 liters
per day.
The remainder of this dictation will be completed by the
intern who takes over the patient's care on [**2128-3-15**].
[**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2128-3-14**] 10:42
T: [**2128-3-14**] 22:58
JOB#: [**Job Number 13579**]
Admission Date: [**2128-3-4**] Discharge Date: [**2128-3-18**]
Date of Birth: [**2067-10-24**] Sex: F
Service:
ADDENDUM TO HOSPITAL COURSE: Remainder Ms. [**Known lastname 13580**]
hospitalization included placement of a Hickman catheter on
[**2128-3-17**]. She continued on her antibiotic regimen. He
initially was planned for treatment with six weeks of
meropenem, however, given the national shortage, she was
arranged to receive home imipenem 500 mg IV q8h. She will be
continued to be followed by the Infectious Disease team, Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1005**] on follow-up appointment on [**3-25**]. She will
have followup chemistries and complete blood count checked
weekly by her home VNA and results faxed to Dr. [**Last Name (STitle) 1005**].
She remains stable on her cardiovascular regimen. She
remained on Angio-Jet while hospitalized and restarted on
Coumadin prior to discharge. She will bridge with Lovenox at
home while achieving a therapeutic INR.
DISCHARGE MEDICATIONS:
1. Imipenem 500 mg IV q8h x6 weeks.
2. Dopamine infusion 8 mcg/kg/minute.
3. Coumadin 5 mg po q Tuesday, Wednesday, [**Last Name (STitle) 2974**], Saturday,
Sunday.
4. Coumadin 7.5 mg po q Monday and Thursday.
5. Enteric coated aspirin.
6. Lasix 80 mg po bid.
7. Bumex 2 mg po bid.
8. Enalapril 5 mg po q day.
9. Carvedilol 6.25 mg po bid.
10. Amiodarone 200 mg po q day.
11. Atorvastatin 10 mg po q day.
12. Protonix 40 mg po q day.
13. Epogen 10,000 units subQ q Monday.
14. Trazodone 50 mg po q hs.
15. Sertraline 100 mg po q day.
16. Miconazole topical powder prn.
17. Colace 100 mg po q day.
18. Lovenox 60 mg subsequent q12h.
FOLLOWUP: Dr. [**Last Name (STitle) 1005**], Infectious Disease Clinic 9 am,
[**2128-3-25**]. Followup with Heart Failure Clinic per routine.
DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. Line sepsis.
3. Duodenal AVM.
CONDITION: Fair.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 420**] 11-628
Dictated By:[**Last Name (NamePattern1) 7485**]
MEDQUIST36
D: [**2128-5-23**] 13:04
T: [**2128-5-27**] 05:42
JOB#: [**Job Number 13581**]
|
[
"V45.81",
"428.0",
"V45.01",
"285.1",
"569.85",
"038.9",
"427.31",
"996.62",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.62",
"45.23",
"45.13",
"88.72",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
10990, 11307
|
10191, 10969
|
9295, 10168
|
2478, 2966
|
3132, 4672
|
1643, 2460
|
2983, 3117
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,157
| 135,181
|
11108
|
Discharge summary
|
report
|
Admission Date: [**2191-12-14**] Discharge Date: [**2191-12-15**]
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old
male who presented for cardiac catheterization, and during
the procedure experienced a perforation of his right coronary
artery during the procedure with subsequent drop in blood
pressure and heart rate approximately one hour after the
procedure while in the Recovery room which resolved secondary
to atropine 1 mg intravenous administration.
The patient was brought into the hospital for cardiac
catheterization after a 1-month history of chest tightness
with activity as well as one episode of angina at rest. His
evaluation began with a Myoview on [**2191-12-9**], which
was negative for angina but suggested ischemic territory in
the left circumflex distribution. The patient was admitted
on [**12-13**] to the [**Hospital1 69**] in
preparation for cardiac catheterization the subsequent day.
His cardiac risk factors include elevated cholesterol, a
family history, and increased age. During the cardiac
catheterization procedure the patient was noted to have a
clean left main coronary artery, a 70% lesion in his left
anterior descending artery, a 70% lesion in his left
circumflex, and a right coronary artery with proximal total
occlusion with good left coronary artery collaterals. An
attempt was made to cross the totally occluded right coronary
artery, and during the attempt the vessel was perforated by
the wire into the myocardium.
After the catheterization the patient remained
hemodynamically stable and approximately one hour after the
catheterization procedure, while the patient was in the
Recovery Room, the patient developed an episode of both
bradycardia and a drop in systolic blood pressure into the
90s which resolved after a few minutes as well as a 1-mg
intravenous infusion of atropine. The patient was emergently
reversed with protamine as well as having his Integrilin
discontinued. The patient was transferred at that time to
the Coronary Care Unit for continued monitoring overnight.
The patient remained hemodynamically stable after the episode
of bradycardia and drop in blood pressure.
A post catheterization echocardiogram at that time to
evaluate and rule out tamponade, and at that time no
tamponade was observed.
PHYSICAL EXAMINATION: On transfer to the Coronary Care Unit
the patient's temperature was 97.7, heart rate of 79 (ranging
from 79 to 89), his blood pressure was 160/84, he was satting
100% on 3 liters. On physical examination the patient was
lying flat, in no apparent distress. His cardiac examination
was regular with a normal S1 and S2 and a systolic ejection
flow murmur. No rubs or gallops were noted. His lungs were
clear to auscultation bilaterally. The abdominal examination
was benign, was soft, with normal active bowel sounds,
nontender, and nondistended abdomen, and no guarding.
Extremities were notable for warm extremities times four, 2+
pulses throughout and no clubbing, cyanosis or edema. The
patient's wedge at this time was noted to be 8. The right
ventricular pressure was noted to be 24/1, and pulmonary
arterial pressure was noted to be 24/9.
LABORATORY DATA: His laboratories at that time were sodium
of 138, potassium 3.6 chloride 105, bicarbonate 28, BUN 12,
creatinine 0.9. His glucose was 72. Magnesium was noted to
be 1.8. Uric acid 3.1. His white count was 10.8. He had a
hemoglobin of 14.4, hematocrit 39.8, and platelets of 196.
RADIOLOGY/IMAGING: The echocardiogram that was performed
demonstrated a normal sized left ventricle and left atrium.
His aortic root was noted to be mildly dilated. The ejection
fraction was greater than 55%. His aortic valve was mildly
thickened. His mitral valve was mildly thickened. There
were no effusions noted, and the only finding on the
echocardiogram was consistent with a hiatal hernia.
HOSPITAL COURSE: Overnight, the patient remained
hemodynamically stable with heart rates in the 70s and 80s,
and pressures in the 130s to 150s/50s to 70s.
On the morning of [**12-15**], the patient's laboratories were
noted to be significant for a potassium of 3.5. His
potassium was repleted with 40 mEq of p.o. K-Dur. His
cardiac enzymes remained within normal limits. On admission
they were 69, and on the day of discharge they were 53.
MEDICATIONS ON DISCHARGE: At the time of discharge, the
patient was on a medicine regimen that included
aspirin 325 mg p.o. q.d., his home medication of
Prilosec 20 mg p.o. q.d., Lipitor 10 mg p.o. q.d.,
atenolol 25 mg p.o. q.d., as well as sublingual nitroglycerin
to be used p.r.n. 0.4 mg for chest pain q.5min. times three.
The patient was admitted on [**12-14**] and was discharged on
[**2191-12-15**].
DISCHARGE DIAGNOSES: His discharge diagnosis was unstable
angina.
DISCHARGE FOLLOWUP: The follow-up discharge instructions to
the patient were that he see his primary care physician as
well as his cardiologist within a 1-week time period to
continue to medically manage his coronary artery disease as
well as to discuss the possibility of undergoing coronary
artery bypass graft as an elective procedure at a later date.
[**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) 2052**], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 35839**]
MEDQUIST36
D: [**2191-12-15**] 13:23
T: [**2191-12-18**] 08:30
JOB#: [**Job Number **]
(cclist)
|
[
"530.81",
"272.0",
"414.01",
"411.1",
"458.2",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.57",
"37.23",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
4770, 4816
|
4364, 4747
|
3909, 4337
|
2332, 3890
|
4837, 5458
|
118, 2309
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,264
| 111,946
|
54750
|
Discharge summary
|
report
|
Admission Date: [**2126-4-29**] Discharge Date: [**2126-5-5**]
Date of Birth: [**2059-11-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Cephalosporins / IV Dye, Iodine Containing
Contrast Media
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest discomfort
Major Surgical or Invasive Procedure:
[**2126-4-30**]
Coronary artery bypass grafting x4, with the left internal
mammary artery to the left anterior descending artery and
reversed saphenous vein graft to the diagonal artery, obtuse
marginal artery, and posterior descending artery
History of Present Illness:
66M with history of hypertension and hyperlipidemia developed
chest discomfort with exertion over the preceeding months.
Stress test was abnormal and he was sent for cath. This
revealed severe three vessel disease as well as a tight left
main. He did not receive Plavix. He is transferred for
surgical
revascularization.
Past Medical History:
Coronary Artery Disease
Hypertension
Hyperlipidemia
Mitral Valve Prolapse, Mitral Regurgitation
Tinnitus
GERD
Nephrolithiasis
Cervical Radiculopathy
Social History:
Lives with: wife in [**Name (NI) **]
Occupation: retired- works part time as executive coach
Cigarettes: Smoked no [x]
ETOH: < 1 drink/week [x] [**1-15**] drinks/week [] >8 drinks/week []
Illicit drug use: none
Family History:
Mother died young of liver cirrhosis
Father died at 92
Physical Exam:
Admission:
Pulse: 71 B/P 143/86 Resp: 18 O2 sat: 98%RA
Height: 5'3" Weight: 150
General: NAD, WGWN, appears fit
Skin: Dry [x] intact [x] no rash
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x]
Extremities: Warm [x], well-perfused [x] Edema _none___
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruits: no bruits
Discharge:
VS T 99.7 BP 112/65 HR 71 SR RR 20 O2sat 98%-RA
Gen NAD
Neuro A&O x3, nonfocal exam
Chest CV-RRR, no murmur. Sternum stable, incision CDI
Pulm basilar crackles
Abdm soft, NT/ND/+BS
Ext warm, well perfused. 1+ bilat LE edema
Pertinent Results:
Intra-op echo:
Conclusions
PRE BYPASS The left atrium is elongated. 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 a narrow jet of venous flow entering the right
atrium near the inferior vena caval junction. Difficult to
definitively define source - may represent coronary sinus flow
or hepatic vein flow. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Right ventricular chamber size and free wall motion are
normal. There are simple atheroma in the ascending aorta. There
are complex (>4mm) atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. 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. Mild (1+) mitral regurgitation is
seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was
notified in person of the results in the operating room at the
time of the study.
POST BYPASS The patient is atrially paced. Normal biiventricular
systolic function. No change in valvular function. The thoracic
aorta is intact after decannulation. No other changes from the
pre-bypass study.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2126-5-2**] 8:12
AM
Final Report: A small right pneumothorax may be slightly smaller
compared with yesterday at 4 p.m. Left-sided pneumothorax
remains questionable. [**Hospital1 **]-basilar atelectasis and a small left
effusion are unchanged. Postoperative changes to the
mediastinum are stable. Right-sided internal jugular catheter
remains in the low SVC. Cervical fusion hardware is again
present.
IMPRESSION: Slight decrease in size in small right apical
pneumothorax.
Presence of a left apical pneumothorax remains questionable.
DR. [**First Name8 (NamePattern2) 819**] [**Last Name (NamePattern1) **]
There is no report history available for viewing.
.
[**2126-5-5**] 06:35AM BLOOD WBC-7.1 RBC-3.37* Hgb-10.5* Hct-31.4*
MCV-93 MCH-31.2 MCHC-33.4 RDW-13.1 Plt Ct-315
[**2126-5-4**] 06:35AM BLOOD WBC-7.4 RBC-3.09* Hgb-9.5* Hct-28.8*
MCV-93 MCH-30.9 MCHC-33.1 RDW-13.0 Plt Ct-242
[**2126-5-5**] 06:35AM BLOOD Glucose-111* UreaN-17 Creat-1.2 Na-141
K-4.0 Cl-103 HCO3-25 AnGap-17
[**2126-5-4**] 06:35AM BLOOD UreaN-16 Creat-1.1 Na-140 K-4.0 Cl-102
Brief Hospital Course:
Mr [**Known lastname 111941**] was transferred to [**Hospital1 18**] from outside hospital
after cardiac catheterization revealed severe three vessel
coronary artery disease. He was transferred here for coronary
revascularization. After typical preoperative workup he was
brought to the Operating Room on [**2126-4-30**] where the patient
underwent CABG with Dr. [**First Name (STitle) **]. Please see the operative report
for details, in summary he had:
Coronary artery bypass grafting x4, with the left internal
mammary artery to the left anterior descending artery and
reversed saphenous vein graft to the diagonal
artery, obtuse marginal artery, and posterior descending artery.
His CROSS-CLAMP TIME was 80 minutes, with a BYPASS TIME of 92
minutes. He tolerated the procedure well and post-operatively
was transferred to the CVICU in stable condition for recovery
and invasive monitoring. He woke from anesthesia neurologically
intact and was extubated on the day of surgery. POD 1 found the
patient extubated, alert, oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable. Beta blockers were initiated and the patient was gently
diuresed toward the preoperative weight. Also on POD1 the
patient was transferred to the telemetry floor for further
recovery.
Chest tubes and pacing wires were discontinued per cardiac
surgery protocol without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility.He worked daily with nursing and physical
therapy to improve strength and endurance. On POD3 the patient
developed a fever and workup was negative. He did develop a
hematoma at the knee site of his EVH as well as a hematoma at
the proximal thigh site. He was started on antibiotics. The
hematoma at the knee resolved by discharge. The hematoma in the
groin remained firm. The remainder of his hospital course was
uneventful. By the time of discharge on POD 5 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged home with VNA
in good condition with appropriate follow up instructions.
Medications on Admission:
Chlorthalidone 25mg daily
Omeprazole 20mg daily
Pravastatin 20mg daily
Multivitamin
Aspirin 81mg daily
Vitamin D
Discharge Medications:
1. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(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. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every six (6) hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
8. chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
9. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Artery Disease s/p CABG x4
Hypertension
Hyperlipidemia
Mitral Valve Prolapse, Mitral Regurgitation
Tinnitus
GERD
Nephrolithiasis
Cervical Radiculopathy
Past Surgical History
[**2120**]- cervical surgery for herniated disc
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with Percocet
Sternal Incision - healing well, no erythema or drainage
Extensive ecchymosis of LLE, hematoma proximal/medial thigh
Edema 1+ bilat LE edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office
[**Doctor First Name **], [**Location (un) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2126-5-9**]
10:30
Surgeon: Dr [**Last Name (STitle) **] [**Name (STitle) **], Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2126-6-4**]
1:15
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**], [**2126-5-29**] at 12:30p
Please call to schedule the following:
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8049**] in [**3-14**] 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**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2126-5-5**]
|
[
"424.0",
"414.01",
"V45.4",
"401.9",
"V13.01",
"E878.2",
"530.81",
"998.12",
"272.4",
"780.62"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
8330, 8379
|
4870, 7048
|
354, 599
|
8654, 8887
|
2349, 4847
|
9567, 10437
|
1372, 1428
|
7211, 8307
|
8400, 8633
|
7074, 7188
|
8911, 9544
|
1443, 2330
|
298, 316
|
627, 953
|
975, 1126
|
1142, 1356
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,702
| 196,489
|
177
|
Discharge summary
|
report
|
Admission Date: [**2124-7-21**] Discharge Date: [**2124-8-18**]
Service: MEDICINE
Allergies:
Amlodipine
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
COPD exacerbation/Shortness of Breath
Major Surgical or Invasive Procedure:
Intubation
arterial line placement
PICC line placement
Esophagogastroduodenoscopy
History of Present Illness:
87 yo F with h/o CHF, COPD on 5 L oxygen at baseline,
tracheobronchomalacia s/p stent, presents with acute dyspnea
over several days, and lethargy. This morning patient developed
an acute worsening in dyspnea, and called EMS. EMS found patient
tachypnic at saturating 90% on 5L. Patient was noted to be
tripoding. She was given a nebulizer and brought to the ER.
.
According the patient's husband, she was experiencing symptoms
consistent with prior COPD flares. Apparently patient was
without cough, chest pain, fevers, chills, orthopnea, PND,
dysuria, diarrhea, confusion and neck pain. Her husband is a
physician and gave her a dose of levaquin this morning.
.
In the ED, patient was saturating 96% on NRB. CXR did not reveal
any consolidation. Per report EKG was unremarkable. Laboratory
evaluation revealed a leukocytosis if 14 and lactate of 2.2.
Patient received combivent nebs, solumedrol 125 mg IV x1,
aspirin 325 mg po x1. Mg sulfate 2 g IV x1, azithromycin 500 mg
IVx1, levofloxacin 750 mg IVx1, and Cefrtiaxone 1g IVx1. Patient
became tachpnic so was trialed on non-invasive ventilation but
became hypotensive to systolics of 80, so noninvasive was
removed and patient did well on NRB and nebulizers for about 2
hours. At that time patient became agitated, hypoxic to 87% and
tachypnic to the 40s, so patient was intubated. Post intubation
ABG was 7.3/60/88/31. Propafol was switched to
fentanyl/midazolam for hypotension to the 80s. Received 2L of
NS. On transfer, patient VS were 102, 87/33, 100% on 60% 450 x
18 PEEP 5. Patient has peripheral access x2.
.
In the ICU, patient appeared comfortable.
Review of sytems:
limited due to patient sedation
Past Medical History:
# COPD flare FEV1 40% in [**2120**], on 5L oxygen, s/p intubation
[**6-6**], s/p distal tracheal to Left Main Stem stents placed
[**2118-6-9**]. Stents d/c'd [**2119-4-19**]. Tracheobronchoplasty performed [**6-6**], [**2119**]
# CAD w/ atypical angina (cath [**2119**] - LAD 30%, RCA 30%, EF 63%)
# Dyslipidemia
# Hypothyroidism,
# Hypertension
# Hiatal hernia,
# lacunar CVA,
# s/p ped struck -> head injury & rib fx,
# depression
Social History:
The patient is married and worked as a clinical
psychologist. Her husband is a pediatric neurologist at
[**Hospital3 **]. They have several children, one of which is
a nurse. [**First Name (Titles) 1817**] [**Last Name (Titles) 1818**] with 40 pack years, quit 5 years ago.
Social ethanol user. No history of IVDU, but remote history of
marijuana use.
Family History:
(+) FHx CAD; Father with an MI in his 40's, died
of a CVA at age 59
Physical Exam:
On admission
Vitals: T: BP: 116/46 P: 92 O2: 100%
TV 60% 450 x 18 PEEP 5
General: Intubated, sedated, no apparent discomfort
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: crackles bases 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
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Initial Labs
[**2124-7-21**] 10:55AM BLOOD WBC-14.1*# RBC-4.20# Hgb-12.6# Hct-39.1#
MCV-93 MCH-30.1 MCHC-32.3 RDW-12.6 Plt Ct-319
[**2124-7-21**] 10:55AM BLOOD Neuts-93.9* Lymphs-4.4* Monos-1.3*
Eos-0.2 Baso-0.2
[**2124-7-22**] 03:50AM BLOOD PT-11.0 PTT-28.7 INR(PT)-0.9
[**2124-7-21**] 10:55AM BLOOD Glucose-168* UreaN-13 Creat-0.8 Na-140
K-3.5 Cl-92* HCO3-36* AnGap-16
[**2124-7-22**] 03:50AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.1
Cardiac Biomarkers
[**2124-7-21**] 10:55AM BLOOD CK(CPK)-321* cTropnT-0.02*
[**2124-7-21**] 06:25PM BLOOD CK(CPK)-345* CK-MB-14* MB Indx-4.1
cTropnT-0.01
[**2124-7-22**] 03:50AM BLOOD CK(CPK)-845* CK-MB-15* MB Indx-1.8
cTropnT-0.01
[**2124-7-22**] 12:04PM BLOOD CK(CPK)-1030* CK-MB-15* MB Indx-1.5
cTropnT-0.01
[**2124-7-23**] 03:15AM BLOOD CK(CPK)-530* CK-MB-9 cTropnT-0.01
proBNP-2535*
CXR ([**2124-7-21**]) - IMPRESSION: Hiatal hernia, otherwise
unremarkable. Limited exam.
Echo ([**2124-7-24**]) - There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size is normal. with normal free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Normal biventricular systolic function. Moderate
pulmonary artery systolic hypertension.
CXR ([**2124-8-5**]) - Kyphotic positioning. Compared with one day
earlier and allowing for technical differences, the right-sided
effusion may be slightly larger. Otherwise, no significant
change is detected. Again seen is retrocardiac opacity
consistent with left lower lobe collapse and/or consolidation
and a small left effusion. As noted, a right effusion is again
seen, possibly slightly larger on the current examination, with
underlying collapse and/or consolidation. Doubt CHF.
Degenerative changes of the thoracic spine are noted.
Cardiac Enzymes [**2124-8-12**]: Trop<0.01
[**2124-8-13**]: Trop 0.03
[**2124-8-14**]: Trop 0.02
LABS AT DISCHARGE:
[**2124-8-16**] 05:40AM BLOOD WBC-9.5 RBC-3.08* Hgb-9.6* Hct-28.3*
MCV-92 MCH-31.2 MCHC-33.9 RDW-13.5 Plt Ct-360
[**2124-8-16**] 05:40AM BLOOD PT-10.4 PTT-22.8 INR(PT)-0.8*
[**2124-8-17**] 05:30AM BLOOD Glucose-114* UreaN-18 Creat-0.8 Na-142
K-3.5 Cl-101 HCO3-36* AnGap-9
[**2124-8-16**] 05:40AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.3
[**2124-8-16**] 05:40AM BLOOD TSH-0.87
Brief Hospital Course:
87 yo F with h/o CHF, COPD on 5 L oxygen at baseline,
tracheobronchomalacia s/p stent, presents with acute dyspnea
over several days, no s/p intubation for hypercarbic respiratory
failure.
# Hypercarbic respiratory failure: Presents with dyspnea, but no
clear cough or fevers. Per report, patient felt like this with
prior COPD exacerbations. Leukocytosis supports possible
pneumonia, but history and CXR not entirely consistent with
this. EKG with signs of demand, but ROMI negative. Sputum gram
stain unremarkable, but respitatory viral culture grew
parainfluenze type 3 on [**7-24**]. Patient was initially managed on
solumedrol 60 mg IV Q8H, and was eventually tapered. With no
evidence of pneumonia on CXR and sputum gram stain, antibiotics
were stopped [**7-25**]. Beta-agonists and anticholinergics were
continued around the clock. TTE revealed mild symmetric lvh with
normal ef, increased pcwp (>18mmHg), Normal RV, and moderate
pulmonary artery systolic hypertension. On [**7-26**], bronchoscopy
revealed collapsible, unremarkable airways. Patient had
difficulty weaning from the vent, and would become
interimittenty hypertensive to SBP 200s and tachypnic to the
50s. Patient was extubatied on [**7-27**] after passing SBT 0/5, but
required re-intubation 30 minutes later for worsening
secretions, lack of gag reflex, and tachypnea to the 50s. Of
note, on [**8-1**], the patient was found to have MRSA growing in
sputum samples. Although it was felt that this likely
represented colonization as opposed to true infection, the
patient was started on a course of vancomycin (which was stopped
after 5 days). After multiple discussions between the patient's
family and the ICU team, the patient's PCP, [**Name10 (NameIs) **] the palliative
care service, the patient's family ultimately decided that she
would not want a tracheostomy. On [**2124-8-3**], extubation was pursued
again and was successful. After extubation, her respiratory
status improved and she was ultimately called out to the medical
floor. On the floor she was progressively weaned to 2LNC with
nebs (better than her baseline 5L @home). Because of clinical
exams revealing mild volume overload, she was intermittently
diuresed. She also experienced intermittent shortness of breath
with tachypnea but this was thought to be the result of attacks
of anxiety with tachypnea. After receiving prn morphine, her
breathing status would typically improve. A steroid taper was
begun. The patient should continue prednisone 30 mg daily for 3
more days, then 20 mg daily for 4 days, then 10 mg daily for 4
days, then 5 mg daily for 4 days, then stop.
.
# Upper GI bleeding: On [**7-22**], patient had coffee grounds from OG
tube. Lavage for approx 600ccs with clearance. GI perfomred EGD
which revealed esophagitis, ulcers and blood in the stomach
body, D2 diverticulum and large hiatal hernia. H pylori was
negative. Patient was continued on IV PPI, with plan for repeat
EGD in 8 weeks, and upper GI series once clinically improved
given abnormal anatomy on EGD. Her hematocrit remained stable
with no further episodes of upper GI bleeding throughout the
patient's hospitalization. On the floor she was switched to PO
pantoprazole twice daily. Aspirin was held.
.
# Weakness: The patient was found to have generalized weakness
at the end of her hospitalization. Neurology was consulted and
they felt it was likely due to a combination of steroid myopathy
and deconditioning from her prolonged bedbound status. A TSH was
checked which was normal. They recommended pulmonary and
physical rehab.
.
# CAD: History of LAD and RCA stenosis on Cath, but no stents.
Continued statin and beta blocker, but held aspirin for GI
bleeding (see above)
.
# Nutrition: Unable to pass NG without direct visualization due
to hiatal hernia. IR guided post pyloric NG tube was placed on
[**7-26**] for TFs and po medications. NG tube was pulled when patient
was extubated on [**2124-8-3**]. Speech and swallow were consulted
following the patient's extubation and she was eventually moved
to soft solids and thin liquids with 1:1 supervision.
# Goals of care: PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1407**] was very involved in discussions
regarding patient's code status. Palliative care also followed
along with the patient. Ultimately, at the time of the patient's
extubation on [**2124-8-3**], it was decided that the patient would be
DNR/DNI (although this was later change). The patient's family
felt that she would not want a tracheostomy. It was decided that
she would not be reintubated and that, if her respiratory status
were to worsen after intubation, care would be focused on
comfort. However, her status improved in the MICU and on the
floor and it was then decided that she would remain DNR with
intubation (but no tracheostomy) if her breathing deteriorated.
After several days with stable or improved overall clinical
status, she was deemed suitable for rehabilitation. At the timem
of discharge, the patient's code status was do not resuscitate,
okay to intubate.
Medications on Admission:
# Omeprazole 20 mg daily
# Furosemide 20 mg daily
# Toprol XL 50 mg daily
# Lipitor 20 mg daily
# Folic Acid 1 mg daily
# Centrum daily
# Diovan 80 mg daily
# Trazodone 75-100 mg qhs
# Melatonin 3 mg qhs
# [**Doctor Last Name 1819**] Aspirin 325 mg daily
# Albuterol neb prn
# Duoneb prn
# Advair 250/50 [**Hospital1 **]
# Zolpidem 2.5 mg qhs prn
# Synthroid 100 mcg daily
# Lexapro 20 mg daily
Discharge Medications:
1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
6. Melatonin 3 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. Valsartan 160 mg Tablet Sig: 1.5 Tablets PO once a day.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every 4-6 hours as
needed for shortness of breath or wheezing.
9. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) neb Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation twice a day.
11. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for
4 days: Start after 3 days of 30 mg daily.
14. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for
4 days: Start after 4 days of 20 mg daily.
15. Prednisone 5 mg Tablet Sig: One (1) Tablet PO daily () for 4
days: Start after 4 days of 10 mg daily.
16. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
18. Morphine 10 mg/5 mL Solution Sig: Five (5) mg PO every four
(4) hours as needed for respiratory discomfort: Hold for
oversedation or RR<12.
19. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 3 days.
20. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
22. Humalog insulin sliding scale
Please use attached Humalog insulin sliding scale while on
steroids.
Discharge Disposition:
Extended Care
Facility:
[**Location 1820**] center at [**Location (un) 1821**]
Discharge Diagnosis:
Primary:
1. Chronic Obstructive Pulmonary Disease Exacerbation
2. Respiratory failure with intubation
3. Upper gastrointestinal bleed/Peptic Ulcer Disease
4. Hypertension
5. Anxiety
Secondary:
1. Coronary Artery Disease
2. Hypothyroidism
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital with shortness of breath and
respiratory failure and lethargy. In the emergency department,
you were breathing very fast and a breathing tube was inserted
into your airway to help you breathe. You were admitted to the
intensive care unit. There, you were managed with steroids and
antibiotics and the tube was eventually removed from your
airway, allowing you to breathe on your own. You also underwent
bronchoscopy which looked at the inside of your airways.
.
During your time in the intensive care unit, you developed a
gastrointestinal bleed. A tube was placed into your stomach and
you underwent an endoscopic procedure to look at your esophagus
and stomach. This showed inflammation in your esophagusand
ulcers in your stomach.
.
You should continue to use nasal oxygen by nasal cannula as
needed. You should continue the steroid taper as instructed. You
should call your doctor or return to the emergency room if you
have increasing difficulty breathing or shortness of breath,
wheezing, chest pain, blood in your stool or vomiting blood.
.
There are some changes in your medications.
START pantoprazole 40 mg twice daily and STOP omeprazole
START hydrochlorothiazide
START prednisone, taking 30 mg for 3 days, then 20 mg for 4
days, then 10 mg for 4 days, then 5 mg for 4 days, then stop.
START colace and senna as needed for constipation
Can use morphine to alleviate symptoms of respiratory discomfort
STOP furosemide
STOP zolpidem
STOP aspirin
INCREASE Diovan to 240 mg daily
DECREASE trazodone to 50 mg daily
.
Follow up as indicated below.
Followup Instructions:
You have an appointment to follow up with Dr. [**Last Name (STitle) 1407**], your
primary care physician, [**Name10 (NameIs) **] [**8-29**] at 1pm. His address is [**Location (un) 1822**], [**Apartment Address(1) 1823**], [**Location (un) **],[**Numeric Identifier 1700**]. The phone is
[**Telephone/Fax (1) 1408**].
You have an appointment to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] in
the [**Hospital **] clinic on [**8-30**] at 3pm in the [**Hospital Unit Name 1824**] at [**Hospital1 18**] on the [**Location (un) 453**]. Their phone number is
[**Telephone/Fax (1) 463**].
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2124-8-30**] at 3:00 PM
With: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], 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
|
[
"531.90",
"578.0",
"276.0",
"458.29",
"V02.54",
"487.1",
"276.2",
"491.21",
"272.4",
"416.0",
"E932.0",
"414.01",
"519.19",
"584.9",
"348.30",
"244.9",
"518.84",
"276.6",
"530.10",
"553.3",
"401.9",
"359.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.6",
"96.72",
"38.93",
"96.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
13989, 14070
|
6396, 11448
|
255, 339
|
14353, 14353
|
3491, 5983
|
16142, 17138
|
2874, 2943
|
11894, 13966
|
14091, 14332
|
11474, 11871
|
14531, 16119
|
2958, 3472
|
178, 217
|
1999, 2033
|
6003, 6373
|
367, 1981
|
14368, 14507
|
2055, 2489
|
2505, 2858
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,691
| 189,716
|
34746
|
Discharge summary
|
report
|
Admission Date: [**2124-5-31**] Discharge Date: [**2124-6-7**]
Date of Birth: [**2049-11-26**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
finding of hemorrhagic conversion of ischemic stroke
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 74 yo female w/ CAD s/p CABG, hyperlipidemia, and L
MCA stroke in setting of cardiac cath two weeks ago who is
transferred via med flight for ICH. History was taken entirely
from notes as patient cannot provide history.
Pt was admitted to [**Hospital 487**] [**Hospital **] Hosp [**2124-5-17**] for chest pain. W/U
disclosed inferior myocardial wall inducible ischemia so pt
underwent coronary angiography. During the procedure, altered
sensorium and R hemiplegia were noted. Subsequent
investigations
confirmed L MCA stroke w/ some hemorrhage, by report, in
posterior L basal ganglia region. Hospital course significant
for increase in outpatient lopressor for high blood pressure,
initiation of Lantus for hyperglycemia, course of Rocephin for
undocumented reasons. Neurologically, she was described as
being
alert, albeit aphasic and had been cleared by speech/swallow for
modified diet. She was transferred to [**Hospital3 **] [**2124-5-30**].
On morning of [**2124-5-31**], she was noticed to be more lethargic than
at intake the previous day. Head CT was obtained and showed
hemorrhagic transformation into infarction bed. Lovenox was
d/c'd and she was started on IVF. She was transferred to
[**Hospital3 **] Hosp for further evaluation/care. At LGH ER,
GCS noted to be 8, Cr 1.46. [**Name (NI) 1094**] son consented to intubation
for
airway protection. Pt. transferred to [**Hospital1 18**] d/t lack of ICU bed
at LGH.
Past Medical History:
CABG, CEA, hyperlipidemia, COPD< CAD, DM
II, L CEA, R ICA stenosis 50-60%, chronic bronchitis
Social History:
unknown
Family History:
unknown
Physical Exam:
T 36.3 C; MAP 75-85; HR 80-90; VENT: PS/0.4/~400/10-14/+5
Gen:
Intubated, elder woman lying in bed, sleeping. Rouses to voice
but does not attend or follow commands.
No meningismus. No bruits. No JVD.
Coarse BS.
RR S1 + S2.
Abd NTND. +BS.
Neuro:
MS--intubated/nonverbal. Opens eyes to voice/tactile stim but
does not attend or follow commands..
CN--Fundi w/ sharp discs. PERRL. Blinks to threat on L field
only. EOMI w/ oculocephalic maneuver. R facial droop.
Motor--L side: normal tone; UE moves spont MRC 3+/5, LE MRC [**12-21**].
R side: low tone; UE MRC 0/5; LE MRC [**12-21**] to nox stim.
[**Last Name (un) **]--grimaces/ w/d to nox stim.
Cerebell--not tested.
Reflexes-- L/R: bic [**12-19**], br [**12-18**]+, tr [**12-18**], pat [**12-19**], Ach 0/0.
Right babinski response.
Pertinent Results:
[**2124-6-1**] 12:47AM BLOOD WBC-9.0 RBC-3.91* Hgb-10.8* Hct-32.5*
MCV-83 MCH-27.6 MCHC-33.2 RDW-15.1 Plt Ct-415
[**2124-5-31**] 08:30PM BLOOD WBC-9.3 RBC-3.94* Hgb-10.9* Hct-33.0*
MCV-84 MCH-27.6 MCHC-32.9 RDW-14.9 Plt Ct-413
[**2124-6-1**] 12:47AM BLOOD Plt Ct-415
[**2124-6-1**] 12:47AM BLOOD PT-13.4 PTT-26.4 INR(PT)-1.2*
[**2124-5-31**] 08:30PM BLOOD Plt Ct-413
[**2124-5-31**] 08:30PM BLOOD PT-13.8* PTT-25.4 INR(PT)-1.2*
[**2124-5-31**] 08:30PM BLOOD Fibrino-646*
[**2124-6-1**] 02:44PM BLOOD Na-136
[**2124-6-1**] 07:24AM BLOOD Na-133
[**2124-6-1**] 12:47AM BLOOD Glucose-165* UreaN-37* Creat-1.5* Na-132*
K-3.6 Cl-94* HCO3-23 AnGap-19
[**2124-5-31**] 08:30PM BLOOD UreaN-38* Creat-1.7*
[**2124-5-31**] 08:30PM BLOOD Amylase-73
[**2124-6-1**] 12:47AM BLOOD Calcium-9.5 Phos-4.1 Mg-1.8
[**2124-6-1**] 02:44PM BLOOD Osmolal-300
[**2124-6-1**] 07:24AM BLOOD Osmolal-303
[**2124-6-1**] 12:47AM BLOOD Osmolal-304
[**2124-5-31**] 08:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2124-5-31**] 08:52PM BLOOD Type-ART Rates-/10 Tidal V-500 PEEP-5
FiO2-100 pO2-382* pCO2-48* pH-7.34* calTCO2-27 Base XS-0
AADO2-290 REQ O2-54 -ASSIST/CON Intubat-INTUBATED
[**2124-5-31**] 08:52PM BLOOD Glucose-137* Lactate-1.0 Na-136 K-3.8
Cl-97*
[**2124-5-31**] 08:33PM BLOOD K-3.8
[**2124-5-31**] 08:52PM BLOOD Hgb-11.6* calcHCT-35
[**2124-5-31**] 08:52PM BLOOD freeCa-1.15
Brief Hospital Course:
This 74 yo F who sustained a recent L-MCA stroke in the context
of a cardiac catheterization, with baseline R hemiplegia and
aphasia, was found with incresaed lethargy at rehab hospital
with NCHCT showing hemorrhagic conversion. Pt remained minimally
responsive, although will open eyes to voice and spontaneously
moves RUE. Family decided to make pt [**Name (NI) 3225**] given poor prognosis
and have decided to take pt home with home hospice care.
Medications on Admission:
Norvasc 5 mg po q day, Catapres 0.1mg [**Hospital1 **], Lovenox
30mg SubQ daily, Glucophage 500mg w/ meals, Protonix 40mg daily,
Lopressor 50 mg [**Hospital1 **], RISS, Lantus 20 units sc, Glucotrol2.5
daily.
Discharge Medications:
1. Levsin/SL 0.125 mg Tablet, Sublingual Sig: [**11-17**] Sublingual
every four (4) hours: prn secretions.
Disp:*60 1* Refills:*2*
2. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO Q1hr
prn as needed: air hunger or pain.
Disp:*200 mg* Refills:*2*
3. Lorazepam 0.5 mg Tablet Sig: 1-4 Tablets PO Q2HRS PRN (): SL,
prn aggitation or seizures.
Disp:*60 Tablet(s)* Refills:*2*
4. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours: prn fever.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
hemorrhagic conversion of stroke
Discharge Condition:
comfort measures only
Discharge Instructions:
Patient is going home comfort measures only for hemorrhagic
conversion of a large stroke.
Followup Instructions:
not applicable
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2124-6-7**]
|
[
"272.4",
"438.11",
"431",
"496",
"414.00",
"V45.81",
"348.4",
"438.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5498, 5547
|
4272, 4723
|
368, 375
|
5624, 5648
|
2855, 4249
|
5786, 5923
|
2012, 2021
|
4983, 5475
|
5568, 5603
|
4749, 4960
|
5672, 5763
|
2036, 2836
|
276, 330
|
403, 1854
|
1876, 1971
|
1987, 1996
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,796
| 174,734
|
3784
|
Discharge summary
|
report
|
Admission Date: [**2147-10-9**] Discharge Date: [**2147-10-24**]
Date of Birth: [**2095-2-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy
History of Present Illness:
52 yo woman with Type 1 DM and HTN who presents in DKA in the
setting of a recent C.diff infection and worsening N/V/D over
the past 1 week. She states that her symptoms initally started
at the end of [**Month (only) 205**] with N/V/D (non-bloody) and crampy abdominal
pain. She was admitted to [**Hospital1 18**] from [**Date range (1) 16998**], was treated for
c. diff with Flagyl but experienced excessive nausea so she was
switched to oral Vancomycin. Her BSs were well controlled during
this admission. She is currently employed in a nursing home
facility and feels that she may have contracted c. diff at work.
.
After being discharged from [**Hospital1 18**] she felt better for several
weeks but continued to have [**7-6**] loose BMs but was better than
before. She was seen by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1586**] [**Doctor Last Name 2161**] in the [**Hospital **] clinic on
[**2147-9-25**], referred to him by her PCP. [**Name10 (NameIs) **] was thought that she may
have had recurrent c. diff or a post-infectious IBS like
syndrome at the time. On [**10-3**] she underwent a flexible
sigmoidoscopy with biopsy, which was unremarkable.
.
For the past week she has had non-bloody diarrhea, abdominal
discomfort, weakness, nausea, and vomiting which have all
progressively gotten worse. She was initally having 10+ loose
BMs each day but has not had any in the past day since she has
not eaten anything. She states that her appetite has been very
poor since last Monday. Whenever she tries to eat something she
feels nauseous and vomits what she eats. She localizes her
abdominal discomfort to the RLQ.
.
She states that her sugars have been extremely high on the day
of admission in the 400's and denies stopping or missing any of
her insulin she takes at home. She denies any recent fevers,
chills, cough, SOB, or chest pain. Denies any recent travel or
sick contacts. [**Name (NI) **] had some polydipsia but denies polyuria.
.
In the ED her vitals were T 95.1 BP 127/74 AR 140-150's RR 24 O2
sat 98% RA. Her BS>500 and she had an anion gap of 29. She was
started on continuous IVFs and was started on insulin drip
Past Medical History:
1. Diabetes mellitus type I x38 years, followed by [**Doctor Last Name 14116**] @
[**Hospital1 **]. mild peripheral neuropathy
2. Hypertension.
3. Hypercholesterolemia.
4. Mild COPD.
Social History:
Social History: The patient recently quit tobacco use
approximately 2 years ago. She has a 25-pack year history.
She denies alcohol use. She works as a secretory in the physical
therapy rehab center. She is married with two children. Her
daughter has fibromyalgia syndrome and irritable bowel syndrome.
Family History:
Family History: Sister has juvenile rheumatoid arthritis. Aunt
has rheumatoid arthritis. There is no known psoriasis,
osteoarthritis, thyroid disease or inflammatory bowel disease
known in the family. No family hx of bowel problems, IBD.
Physical Exam:
On admission -
VITALS: T 97.3 BP 152/67 AR 106 RR 22 O2 sat 96% RA
GEN: Pt awake but extremely tired and lethargic
HEENT: Dry mucous membranes
NECK: No lymphadenopathy, thyromegaly
HEART: nl s1/s2, no s3/s4, no m,r,g
LUNGS: CTAB, no crackles
ABDOMEN: soft, nt/nd, +BS
EXTREMITIES: 2+ DP/PT pulses, no edema
RECTAL: Heme negative
Pertinent Results:
[**2147-10-24**] 06:30AM BLOOD WBC-3.8* RBC-3.20* Hgb-8.9* Hct-27.5*
MCV-86 MCH-27.8 MCHC-32.3 RDW-16.4* Plt Ct-569*
[**2147-10-9**] 01:30PM BLOOD WBC-15.8*# RBC-4.39 Hgb-12.7 Hct-38.2
MCV-87 MCH-29.0 MCHC-33.4 RDW-14.4 Plt Ct-656*
[**2147-10-12**] 03:53AM BLOOD Neuts-79* Bands-1 Lymphs-10* Monos-7
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-2*
[**2147-10-9**] 01:30PM BLOOD Neuts-71* Bands-6* Lymphs-13* Monos-7
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-2* Promyel-1*
[**2147-10-17**] 04:10PM BLOOD PT-12.5 PTT-50.4* INR(PT)-1.1
[**2147-10-24**] 06:30AM BLOOD UreaN-4* Creat-0.4 K-3.7
[**2147-10-21**] 06:52AM BLOOD UreaN-5* Creat-0.4 Na-139 K-3.3 Cl-103
HCO3-26 AnGap-13
[**2147-10-9**] 01:30PM BLOOD Glucose-521* UreaN-18 Creat-1.3* Na-138
K-4.1 Cl-93* HCO3-16* AnGap-33*
[**2147-10-16**] 06:10AM BLOOD ALT-10 AST-15 AlkPhos-81 TotBili-0.3
[**2147-10-13**] 05:45AM BLOOD calTIBC-144* VitB12-779 Ferritn-284*
TRF-111*
[**2147-10-9**] 01:30PM BLOOD Acetone-LARGE
[**2147-10-17**] 04:10PM BLOOD TSH-3.9
Pleural fluid:
[**2147-10-18**] 02:12PM PLEURAL WBC-396* RBC-194* Polys-10* Lymphs-44*
Monos-36* Eos-1* Meso-2* Other-7*
[**2147-10-18**] 02:12PM PLEURAL TotProt-1.9 Glucose-137 LD(LDH)-70
Amylase-21 Albumin-1.2 Cholest-32
Cytology - NEGATIVE FOR MALIGNANT CELLS
CXR [**2147-10-18**]
COMPARISON: PA and lateral radiograph [**2147-10-16**].
Most of right pleural effusion has been removed. Minimal
parenchymal changes are identified within the right lung base,
presumably related to residual atelectasis. No pneumothorax
identified. Cardiomediastinal silhouette is normal in
appearance.
ECHO
The left atrium is elongated. 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. The aortic valve leaflets
(3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation
is seen. The estimated pulmonary artery systolic pressure is
normal. There is
a trivial/physiologic pericardial effusion.
CT chest -
IMPRESSION:
1. No evidence of pulmonary embolus.
2. Moderate-sized right pleural effusion
FINDINGS: Grayscale and color Doppler son[**Name (NI) 1417**] of the bilateral
lower extremities including the common femoral veins,
superficial femoral veins, and popliteal veins was performed.
Normal flow, augmentation, compressibility, and waveforms was
demonstrated bilaterally. Intraluminal thrombus was not
identified.
IMPRESSION: No DVT.
CXR [**2147-10-17**]
IMPRESSION:
1. A new moderately sized right pleural effusion.
2. New lingular atelectasis vs. early pneumonia.
US abdomen -
IMPRESSION: No evidence of megacolon. Cecum measures
approximately 7 cm in diameter.
[**2147-10-11**] 07:31AM STOOL NA-49 K-63
Brief Hospital Course:
# DKA: Treated in the ICU with insulin drip with eventual
closure of anion gap and transfer to the medical floor. [**Last Name (un) **]
was consulted and sugars were controlled with an insulin sliding
scale and glargine.
.
# C. Difficile colitis diarrhea: Positive stool c.diff. The
patient had a very protracted course while in the hospital. GI
followed her while in house. High doses of oral vancomycin was
started with some improvement initially. A combination of IV
flagyl and oral vanc was tried as well, with no improvement.
Rifaximin was started. The patient was advised a low-lactose
diet. A flexible sigmoidoscopy was done by GI after 2 weeks of
unremitting diarrhea - which revealed pseudomembranes. Biopsies
were done to r/o other processes the results of which are
pending at this time and should be followed up in clinic. The
overall appearance at flex. sig was more suggestive of a C. diff
colitis than an IBD.
After about a week of high dose vancomycin and rifaximin - the
patient started having decreasing stools at night and more
semi-formed stools. Her appetite improved. All along, she was
placed on contact precautions. She was observed for a few days
after the stools had decreased to ensure resolution and then
discharged home.
The plan is to continue vancomycin 500 PO Q6h for atleast a 3
week course. Then after a repeat stool c diff x 3, and if the
patient's symptoms are consistantly improving - a very slow
taper may be tried. The patient may need vancomycin for the next
many months to a year. This plan was communicated to PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **]
[**Last Name (STitle) **] and GI physician who will be following her - Dr [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 437**].
The patient was also advised to take potassium tablets till
diarrhea persists. She is advised not to return to work for the
next few weeks and also strictly follow C diff precautions at
home.
.
# Hypoalbuminemia - likely from protein loss from diarrhea. This
caused LE edema. ECHO showed no significant findings and LFT's
were normal. Small doses of lasix were tried with resolution of
the edema. Pleural effusion was noted on CXr which was tapped -
was transudate and cytology was negative for Cancer cells. The
effusion could be due to hypoalbuminemia.
# Skin - The patient developed transient LE erythematous lesions
when getting diureses - derm was consulted who recommend f/u in
clinic. Their differential diagnosis for these lesions include
resolving vesicles secondary to edema and mild stasis
dermatitis. Their recommendations include - Topical moisturizer
with aveeno [**Hospital1 **] and topical triamcinolone [**Hospital1 **] as needed for
pruritus. However, there was spontaneous resolution of the rash
# HTN: Metoprolol and Lisinopril continued.
.
# Hyperlipidemia: statin continued.
# Mild leucopenia was noted. They should be followed in primary
care clinic.
Medications on Admission:
1. Atenolol 100mg PO daily
2. Lisinopril 40mg daily
3. Pravastatin 20 mg daily
4.Insulin regimen:
a. Levemir 6U [**Hospital1 **]
b. Humalog sliding scale
5.Lorazepam 0.5 mg 1-2 Tablets PO every 4-6 hours
Discharge Medications:
1. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for Insomnia.
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
Disp:*60 Tablet, Chewable(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Vancomycin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 4 weeks.
Disp:*224 Capsule(s)* Refills:*0*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO DAILY (Daily): Continuue
to take as long as you have diarrhea.
Disp:*90 Capsule, Sustained Release(s)* Refills:*0*
10. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
11. Insulin Glargine 100 unit/mL Solution Sig: One (1) 15
Subcutaneous Q Am before breakfast.
Disp:*30 15* Refills:*0*
12. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) as
instructed Subcutaneous as instructed.
Disp:*30 * Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Recurrent C. Difficile Colitis
2. DKA, resolved
3. Hypoalbuminemia/ pleural effusion
4. Anemia of Chronic Disease
5. Mild leucopenia
Secondary Diagnoses
1. Hypertension
2. Type I diabetes mellitus uncontrolled with complications
3. Hyperlipidemia
4. Mild COPD
Discharge Condition:
Stable
Discharge Instructions:
Please return to the emergency room if you notice worsening
diarrhea, abdominal pain or distension, fever, nausea, vomiting
or any other unusual symptoms.
Please keep yur appointments. You should also have to get blood
work done for potassium and magnesium levels at that time.
Discuss with your doctor about the continuing need for lasix and
potassium. Also discuss with her about anemia and low white
blood cell counts as we had discussed.
Your anemia is likely due to loosing blood in stool bacause of
C. diff infection. You will likely need iron tablets for the
anemia.
Make an appointment at the [**Hospital **] clinic as well. Your insulin
doses have been changed for better control of sugars during this
hospitalization. Please continue monitoring the blood sugar
levels at home 1-2 times a day before meals till you are seen at
[**Hospital **] clinic.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2147-10-25**] 2:15
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2147-11-2**] 10:20 ( Dr[**Name (NI) 16999**] office)
GI Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12427**], MD Phone:[**Telephone/Fax (1) 1954**]
Date/Time:[**2147-10-30**] 10:00
[**Last Name (un) 387**] - Make an appointment with your doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] in the
next 10 days
|
[
"578.1",
"273.8",
"536.2",
"496",
"401.9",
"250.13",
"280.0",
"250.63",
"276.8",
"459.81",
"285.29",
"357.2",
"008.45",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
11294, 11300
|
6588, 9519
|
319, 344
|
11612, 11621
|
3683, 6565
|
12532, 13188
|
3094, 3318
|
9774, 11271
|
11321, 11591
|
9545, 9751
|
11645, 12509
|
3333, 3664
|
276, 281
|
372, 2532
|
2554, 2739
|
2771, 3062
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,741
| 106,703
|
8970
|
Discharge summary
|
report
|
Admission Date: [**2111-8-29**] Discharge Date: [**2111-9-2**]
Date of Birth: [**2059-1-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
Dizziness, nausea/vomiting coffee grounds
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
52yoM [**Location 7972**] speaking with hypertension and dyslipidemia
presenting for nausea/bloody emesis, black stool, and dizziness.
The patient reports he was experience abdominal pain for the
past two days and noted black tarry stool the day prior to
presentation. Tonight, he woke up tonight at midnight with
abdominal pain, nausea felt he had to have a bowel movement. He
then had two episodes of dark bloody emesis with subsequent
lightheadedness. He has no prior history of bleeding, denies
significant alcohol use, denies history of liver disease, and
reports minimal NSAID use occasionally for pain. He denies
fevers, chills, chest pain, but does report epigastric pain.
In the ED, initial VS were: 98.5 93 126/76 16 100%
He was noted to have coffee ground emesis with dark blood x1 and
an NGT was placed. NG lavage showed coffee grounds which did
not clear, and his hct was found to be 29, down from a baseline
of 42-45 most recently on [**2111-2-28**]. He had guiac positive black,
tarry stool on rectal. The patient was noted to be pale, cool,
diaphoretic, with epigastric pain and leukocytosis, and sugery
was consulted for concern for perforation. CXR showed no
evidence of free air under the diaphragm and surgery will follow
along but recommended CT abdomen/pelvis which was ordered to be
obtained en route to the ICU. GI was consulted and recommended
initiation of a PPI gtt which was started, and will perform an
EGD on arrival to the ICU. The patient was given a dose of
Cipro/Flagyl given his leukocytosis but remained afebrile in the
ED. He was type and crossed 2 units and x2 [**17**] gauge PIV's were
placed. His HR was in the 80's with BP's sustaining in the
130's, and he received a total of 2L NS. EKG showed no acute ST
changes per ED read. On transfer, VS were: 81 136/89 20
100%RA afebrile. He arrived with 2 units PRBC which were
ordered in the ED but not yet hung.
On arrival to the MICU, the patient denied any symptoms
including abdominal pain, chest pain, shortness of breath,
dizziness, or lightheadedness. He did have nausea with the NGT
in place.
Past Medical History:
- Hypertension
- Dyslipidemia
Social History:
- Tobacco: Active smoker, 1PPD x at least 30 years
- Alcohol: Reported initially EtOH use once weekly, but later
reported drinking 3-4 beers weekly.
- Illicits: Denies
He is married with four children and lives with wife and
children in [**Name (NI) 86**]. He worked in the past as a forklift driver,
now works various jobs.
Family History:
NC
Physical Exam:
Admission Exam:
Vitals: 96.3 88 139/87 28 97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, NGT in place
Neck: Supple
CV: Regular rate and rhythm, normal S1 + S2, GII holosystolic
murmer at apex, no rubs or 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+ DP pulses, no clubbing, cyanosis or
edema
.
Discharge PE:
Vitals: 98.2 132/82 74 18 98%RA
General: NAD. speaking full sentences, smiling, mentating
properly
HEENT: Sclera anicteric, MMM
CV: Regular rate, no m/r/g.
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: Soft NT, ND, no HSM
Ext: warm, well perfused, 2+ DP pulses, no cce
Pertinent Results:
Adm labs:
[**2111-8-29**] 01:40AM WBC-18.8* RBC-3.29*# HGB-10.8*# HCT-29.5*#
MCV-90 MCH-32.9* MCHC-36.7* RDW-13.8
[**2111-8-29**] 01:40AM NEUTS-65.7 LYMPHS-27.8 MONOS-3.2 EOS-2.8
BASOS-0.5
[**2111-8-29**] 01:40AM PLT COUNT-399
[**2111-8-29**] 01:40AM PT-12.5 PTT-18.9* INR(PT)-1.1
[**2111-8-29**] 01:40AM ALBUMIN-3.7
[**2111-8-29**] 01:40AM cTropnT-<0.01
[**2111-8-29**] 01:40AM LIPASE-25
[**2111-8-29**] 01:40AM ALT(SGPT)-18 AST(SGOT)-8 LD(LDH)-109 ALK
PHOS-78 TOT BILI-0.2
[**2111-8-29**] 01:40AM GLUCOSE-149* UREA N-39* CREAT-0.6 SODIUM-140
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-26 ANION GAP
Reports:
CXR [**2111-8-29**]: Low lung volumes with bibasilar atelectasis.
CT abd/pelvis [**2111-8-29**]: 1. No acute abnormalities in the abdomen
or pelvis to explain patient's symptoms. Nasogastric tube in a
stomach which still remains somewhat fluid-filled. 2. Left L5
pars defect. 3. Age indeterminate minimal T11 anterior wedging.
EGD [**2111-8-29**]: Medium hiatal hernia, Blood in the fundus,
[**Doctor First Name **]-[**Doctor Last Name **] tear
No esophageal varices, Otherwise normal EGD to third part of the
duodenum
.
CXR [**2111-8-31**]: Again seen is an area of volume loss or infiltrate
in the right lower lobe.There is improved aeration in the left
lower lobe. The right hemidiaphragm is mildly elevated. Cardiac
and mediastinal silhouettes are normal. The upperlungs are
clear.
.
EGD [**2111-8-31**]: Normal mucosa in the stomach. Clip in place at GE
junction at site of previously reported [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear
bleed. No stigmata of continued bleeding found. Erythema in the
duodenal bulb compatible with duodenitis. Otherwise normal EGD
to third part of the duodenum. Recommendations: Avoid all nsaid
usage. Continue protonix 40mg [**Hospital1 **] indefinitely.
.
Discharge labs:
[**2111-9-2**] 05:40AM BLOOD WBC-11.8* RBC-2.73* Hgb-8.6* Hct-24.7*
MCV-90 MCH-31.4 MCHC-34.8 RDW-15.5 Plt Ct-411
[**2111-8-29**] 01:40AM BLOOD PT-12.5 PTT-18.9* INR(PT)-1.1
[**2111-9-2**] 05:40AM BLOOD Glucose-100 UreaN-14 Creat-0.6 Na-141
K-4.1 Cl-109* HCO3-25 AnGap-11
[**2111-9-2**] 05:40AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.1
Brief Hospital Course:
52yoM with hypertension and dyslipidemia presenting for coffee
ground emesis, black tarry stool consistent with upper GI bleed.
#. Upper GI bleed: He had a Hct on admission of 29 down from his
baseline of 42-45 in the past year. He was given 3 units PRBCs
over the first 24 hours of hospitalization and then his Hct
remained stable. He had NG tube placed which initially drained
dark bloody stomach fluid. He was started on octreotide and IV
PPI drip. He had EGD the morning after admission which showed a
[**Doctor First Name 329**] [**Doctor Last Name **] tear and lots of old blood with difficulty
visualizing the whole stomach. Repeat EGD was initially planned
for HD #2, but his hemoglobin and hematocrit remained stable and
GI felt that repeat EGD was not necessary. He was switched to
PPI IV BID and octreotide was discontinued. NG tube was pulled
and he was called out to the floor. On the floor, his
hematocrit remained stable. GI did not recommend repeat
inpatient endoscopy. His diet was slowly advanced, and he was
tolerating a regular diet at discharge. It remains unclear as
to the inciting event, as the patient reports that his first
vomiting was bloody. A repeat EGD did not reveal any other
areas of concern. The patient was started on pantoprazole 40mg
[**Hospital1 **], and was instructed not to take NSAIDs.
.
#. Leukocytosis: Initially felt to most likely be a stress
response from his GI bleed. He was given a dose of cipro/flagyl
in the ED which was not continued. On further evaluation, it
was noted that his leukocytosis was chronic and had been seen on
labs as far back as [**2101**]. Unclear etiology. This will need to
be trended. His PCP was [**Name9 (PRE) 31142**] prior to transfer out of the
unit.
.
# Night sweats, cough, weight loss, smoking history: Was
concerning for malignancy. A PA/Lateral CXR did not reveal any
suspicious lesions. An abdominal/pelvic CT scan did not reveal
anything suggestive of cancer. His wife states he has frequent
night sweats when the patient is not ill, that he has not done
any exercising that would lead to weight loss, and that he is
cough more than he used to. However, per a different provider
seeing the patient in-house, when asking the patient through his
son, he states his sweats are when he has a cold, his wt loss is
intentional, and is cough isn't that bad. It is unclear whether
he is downplaying his symptoms, or if his wife is exaggerating.
This may warrant very close monitoring, and may consider a chest
CT as an outpatient.
#. Hypertension: His home Lisinopril was held given acute GI
bleed.
.
.
TRANSITIONAL ISSUES:
- Encourage pt to quit smoking! This was done in-house as well
- Unclear what precipitated his vomiting, his first episode was
bloody. [**Doctor First Name **]-[**Doctor Last Name **] tear was seen and clipped, but it is a bit
strange for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear to not be precipitated by any
vomiting or retching. However, repeat EGD did not reveal any
other areas of concern in the stomach, esophagus, or duodenum.
In the setting of a hiatal hernia, this makes it a bit more
likely to have occured. Perhaps he also was retching before
vomiting and has not been telling us.
- Had some subjective complaints suspicious for malignancy.
However pt tells a different story than his wife, and no
suspicious lesions seen on CXR or CT ab/pelvis. See above -
should be closely followed and may need an outpatient CT scan of
chest if concerned.
- Follow up of persistent leukocytosis
- [**Month (only) 116**] need to restart lisinopril at PCP [**Name9 (PRE) 702**] appointment.
Medications on Admission:
LISINOPRIL - 40 mg Tablet daily
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Outpatient Lab Work
Please check a CBC prior to your visit with Dr. [**Last Name (STitle) **] on
[**2111-9-8**] and fax the results to ([**Telephone/Fax (1) 22298**].
Discharge Disposition:
Home
Discharge Diagnosis:
[**Doctor First Name **]-[**Doctor Last Name **] Tear
Tobacco Abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for blood in your vomit. You were initially
admitted to the intensive care unit for close monitoring. You
were given blood transfusions given the amount of blood that you
lost. Your blood counts were followed very closely, and when
they remained stable you were transferred to the medical floor.
.
You were evaluated by the gastroenterologists, and you had an
endoscopy (a procedure that allows your doctors to [**Name5 (PTitle) 788**] the
inside of your throat and your stomach). This revealed a small
tear in your esophagus (the tube that connects your mouth to
your stomach). This tear is likely the reason for your bleeding.
Your blood counts dropped slightly, and you were taken back for
a repeat endoscopy. The repeat endoscopy did not reveal any
other sources of bleeding. It did reveal an inflammation of a
part of the gut that comes just after the stomach. You should
take a new medication for this, called pantoprazole.
.
It is also VERY important that you STOP smoking. Smoking is
incredibly dangerous, and is associated with many, many health
problems, including cancer and heart disease. Please try to
quit, it is one of the most important things that you can do for
your health.
.
Please note the following medication changes:
.
Please START:
Pantoprazole 40mg twice daily
.
Please STOP:
Lisinopril - this is a blood pressure medication. Your blood
pressures were in the normal range without this medication. You
should stop taking it until you see your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]c next week.
.
Please DO NOT take any NSAIDs for pain (these are medications
that include drugs like ibuprofin, aleeve, etc). If you need to
take medications for pain, please take TYLENOL.
.
We have written you for a prescription to have your blood counts
checked prior to your follow-up appointment with your primary
doctor next week.
Followup Instructions:
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: TUESDAY [**2111-9-8**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2111-9-22**] at 1 PM
With: [**Name6 (MD) 2606**] [**Name8 (MD) 2607**], 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
Completed by:[**2111-9-2**]
|
[
"401.9",
"305.1",
"288.60",
"530.7",
"780.8",
"553.3",
"272.4",
"790.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"42.33"
] |
icd9pcs
|
[
[
[]
]
] |
10069, 10075
|
5943, 8550
|
345, 357
|
10187, 10187
|
3722, 5574
|
12267, 12974
|
2908, 2913
|
9695, 10046
|
10096, 10166
|
9638, 9672
|
10338, 11586
|
5590, 5920
|
2928, 3416
|
8571, 9612
|
11606, 12244
|
3430, 3703
|
263, 307
|
385, 2493
|
10202, 10314
|
2515, 2546
|
2562, 2892
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,637
| 134,621
|
2243+55364
|
Discharge summary
|
report+addendum
|
Admission Date: [**2179-1-22**] Discharge Date: [**2179-1-28**]
Date of Birth: [**2111-1-6**] Sex: F
Service: [**Company 191**]
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: This is a 68 year old female
with end-stage renal disease previously on hemodialysis with
multiple access problems. She was recently switched to
peritoneal dialysis about three weeks ago. She presents
today with one day history of abdominal pain, fevers, chills
and shaking, which all started last night. Peritoneal
dialysis went in last night without any difficulty; no
nausea, vomiting, no change in her bowel symptoms. The
patient makes minimal urine at baseline. The patient was
complaining of aching abdominal pain which has subsided to
some extent. The patient denies chest pain or shortness of
breath.
In the Emergency Room, the patient was given her Dilaudid and
was also given one gram of Ancef as empiric treatment for a
question of an infected sacral decubitus. There was an
initial thought that the patient's symptoms represented
bacterial peritonitis from the peritoneal dialysis catheter.
Fluid was obtained and sent for cell counts and differential
and culture to rule out bacterial peritonitis. [**Known lastname 1007**] blood
cell count in the ascitic fluid was only 24. At that time,
no further work-up was done by the medical team for bacterial
peritonitis. It was felt that the leading diagnosis at the
time was an infected draining purulent left buttock abscess.
Meanwhile, while in the Emergency Room, the patient's blood
pressure had dropped initially from 140/60 to the 80s
systolic and at one point dropping to as low as 65 systolic
while in the Emergency Room. The patient received about two
liters of fluid and received Vancomycin and Ceptaz
intravenously. It was noted that the patient's fever was
down to 98.7 F., with improvement of the systolic blood
pressure to the 130s. A CT scan of the abdomen which was
done in the Emergency Room showed a small decubitus abscess
with extensive inflammation in the right buttock area.
Surgery was consulted in the Emergency Room and drained
abscess and packed it with sterile gauze.
PHYSICAL EXAMINATION: Vital signs: Temperature 98.7 F.;
heart rate 90; systolic blood pressure in the 130s over 60.
HEENT: Normocephalic, atraumatic. Extraocular muscles are
intact. Pupils equally round and reactive to light. Mucous
membranes were moist. Neck was supple. Lungs clear to
auscultation anteriorly and laterally. Heart examination:
S1, S2, regular rate and rhythm. No murmurs, rubs or gallops
were appreciated. Abdominal examination showed normoactive
bowel sounds, mild tenderness at the peritoneal dialysis
catheter site. No erythema. The left buttock had a purulent
and bloody drainage, a 1 cm lesion which probed down to at
least 3 to 4 cm. Extremities were status post amputation of
the left index finger, the right third and fifth fingers, and
a left below the knee amputation.
LABORATORY: On admission, [**Known lastname **] blood cell count 14,600,
hematocrit 31.6, platelets 257,000, 90% neutrophils, zero
bands, 5 lymphocytes. PT was 22.9, PTT was 54.2; INR was
3.6. Magnesium 1.7, phosphorus 6.2. Lactate 3.9. Sodium
138, potassium 6.8 which was hemolyzed. Chloride 98,
bicarbonate 26, BUN 47, creatinine 8.2. Glucose 88, AST 59,
ALT 18, alkaline phosphatase 74, total bilirubin 0.3, albumin
3.1, amylase 100, lipase 0. Blood cultures and wound
cultures were drawn in the Emergency Room.
The ascites showed amylase of 4, [**Known lastname **] blood cell count of
24.
Wound Gram stain showed two plus PMM, one plus Gram positive
cocci in pairs.
CT scan abdomen showed sacral decubitus abscess in the right
buttock region and sacral region with a destructive lesion in
the sacrum. Question of chronic osteomyelitis. There was no
abscess present in the peritoneum.
Chest x-ray showed increased pulmonary vascularity with
blunting of the costophrenic angles with mild retrocardiac
opacity.
PAST MEDICAL HISTORY:
1. End-stage renal disease on peritoneal dialysis secondary
to multiple access issues with hemodialysis.
2. Peripheral vascular disease status post left below the
knee amputation and finger amputations.
3. B-cell non-Hodgkin's lymphoma of the ribs, skull, pelvis,
status post palliative XRT.
4. Systemic lupus erythematosus.
5. Hypertension.
6. Rheumatoid arthritis.
7. Gout.
8. Sacral decubitus ulcer with osteomyelitis.
9. Hyperhomocystinemia.
10. Nephrolithiasis.
11. Bilateral bibasilar nodules on chest CT scan.
12. Chronic anemia.
ALLERGIES: To aspirin.
SOCIAL HISTORY: The patient lives with her daughter who is
the Health Care Proxy. [**Name (NI) **] [**Hospital6 407**] once
or twice a week. Denies tobacco, no drugs or ethanol.
MEDICATIONS: On admission:
1. Nephrocaps 1 tablet once a day.
2. Vitamin C 500 mg p.o. q. day.
3. Renagel 800 mg p.o. three times a day.
4. PhosLo 1 tablet p.o. three times a day.
5. Hydralazine 10 mg p.o. q. day.
6. Coumadin 3 mg p.o. q. day.
7. Dilaudid 4 mg q. three p.r.n.
8. Duragesic patch 75 micrograms q. 72 hours.
9. Elavil 25 mg p.o. q. h.s.
10. Senokot one tablet p.o. q. day.
11. Lovenox 30 mg subcutaneously twice a day.
12. Neurontin 100 mg p.o. three times a day.
13. Allopurinol 100 mg p.o. q. day.
14. MetroGel Cream, applied to the affected area twice a day.
HOSPITAL COURSE:
INCOMPLETE DICTATION; CUT OFF
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 11865**], M.D. [**MD Number(1) 11866**]
Dictated By:[**Name8 (MD) 9784**]
MEDQUIST36
D: [**2179-2-23**] 23:10
T: [**2179-2-26**] 13:20
JOB#: [**Job Number 11867**]
Name: [**Known lastname **], [**Known firstname 1683**] Unit No: [**Numeric Identifier 1684**]
Admission Date: [**2179-1-22**] Discharge Date: [**2179-1-28**]
Date of Birth: [**2111-1-6**] Sex: F
Service:
ADDENDUM:
HOSPITAL COURSE:
1. Infectious Disease: After much thought it was felt that
the best choice of antibiotics for the patient would be
Levaquin and Flagyl to treat for a diabetic wound infection
until further results of cultures were obtained. The patient
received Levaquin, a one time loading dose of 500 mg and then
was on 250 mg q o d. Patient was on IV Flagyl 500 mg tid for
the sacral decubitus infection. Throughout the hospital
course the patient remained afebrile while on these
antibiotics. The wound cultures subsequently came back with
staph aureus coag positive, Oxacillin resistant as well as
sparse growth of Corynebacterium. It was felt that the
Corynebacterium was most likely a contaminant, however, for
the staph aureus which was resistant to Methicillin, the
patient was started on Vancomycin. The patient received a
PICC line prior to discharge and was treated with Vancomycin
for full two week course. The patient also had negative
blood cultures throughout the hospital stay. The patient did
also have evidence of minimal diarrhea. While on these
antibiotics stool cultures were sent as well as C. diff which
were all negative. Patient's [**Known lastname **] cell count upon discharge
was within normal limits at 9.5.
2. Renal: Throughout the initial part of the [**Hospital 1325**]
hospital course she gained a total of 4 lbs of fluid. It was
difficult to remove fluid from her with the peritoneal
dialysis. This was likely attributed to adhesions within her
abdomen. The patient on day #3 of admission started to
develop shortness of breath as well as decreased O2
saturation. It was felt that this was most likely due to
volume overload secondary to not taking out enough fluid with
the peritoneal dialysis. The patient was subsequently
transferred to the medical Intensive Care Unit for
hemodialysis with a femoral catheter which was in place.
While in the medical Intensive Care Unit the patient had a
net removal of approximately 3300 cc of fluid with
hemodialysis and another 800 cc with the peritoneal dialysis
with marked improvement in the patient's breathing as well as
oxygen saturation. While in the medical Intensive Care Unit
the patient also received a transfusion of two units of
packed red blood cells along with the hemodialysis. The
patient was also started on Epogen 8000 units subcu biweekly
during the [**Hospital 1325**] hospital course. The patient's
antibiotics were all renally dosed throughout the hospital
stay. After dialysis in the medical Intensive Care Unit, the
patient was transferred back to the floor where peritoneal
dialysis was continued. While on the floor the patient had
peritoneal dialysis continued and subsequently patient did
have net removal of fluid with the peritoneal dialysis. The
patient's weight decreased significantly by [**2-17**] kg after
transfer from the medical Intensive Care Unit to the floor
with only the peritoneal dialysis. The plan was for the
patient to continue her usual peritoneal dialysis regimen
while at home with the assistance of her daughter and
[**Hospital6 **]. During the hospital course the
patient's RenaGel dose was increased to 1600 mg tid.
3. Hematologic: It was felt that the patient's anemia was
likely related to chronic renal insufficiency. The patient
was started on Epogen 8,000 units biweekly as well as
transfused two units while in the medical Intensive Care
Unit. The patient was continued on Coumadin as well as
Lovenox for her severe peripheral vascular disease as well as
recurrent thrombosis with the hemodialysis access. Patient's
dose of Coumadin was also increased given the fact that her
INR was slightly subtherapeutic.
4. Rheumatologic: The patient was continued on her usual
gout medications as well as her pain medications. During the
hospital stay the patient did complain of toe pain. Podiatry
service was consulted and they had drained a small hematoma
of the right hallux nail proximal to the nail fold. They
also recommended dressing changes [**Hospital1 **] to the area of the
hematoma and the debridement. It was also felt that part of
her toe pain may also be related to the gout. The patient
received good pain control with her Duragesic patch.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home with [**Hospital6 **].
DISCHARGE MEDICATIONS: Colace 100 mg po bid, RenaGel 1600 mg
po tid, Phos-Lo two tabs po tid, Allopurinol 100 mg po q d,
Elavil 25 mg po q h.s., Duragesic patch 75 mcg q 72 hours,
Coumadin 5 mg po q h.s., Epogen 8,000 units subcu q Monday
and q Thursday, Neurontin 100 mg po tid, Lovenox 30 mg subcu
[**Hospital1 **], Vancomycin 1 gm IV for level of less than 15. Total
duration of therapy at least an additional two weeks.
Patient was also to receive regular PICC line care, sacral
decubitus precautions as well as dressing changes [**Hospital1 **] to the
area that was incised and drained. The patient's Vancomycin
level was checked and the results were called in to Dr.
[**First Name (STitle) **] as well as PT INR.
DISCHARGE DIAGNOSIS:
1. End stage renal disease on peritoneal dialysis.
2. SLE.
3. Rheumatoid arthritis.
4. Gout.
5. Sacral decubitus ulcer infection.
6. B cell non Hodgkin's lymphoma.
7. Peripheral vascular disease.
8. Chronic anemia.
9. Chronic osteomyelitis.
10. Hypertension.
11. History of nephrolithiasis.
[**Name6 (MD) 116**] [**Last Name (NamePattern4) 1531**], M.D. [**MD Number(1) 1532**]
Dictated By:[**Name8 (MD) 1685**]
MEDQUIST36
D: [**2179-2-23**] 23:39
T: [**2179-2-24**] 13:58
JOB#: [**Job Number 1686**]
|
[
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"996.56",
"710.0",
"041.11",
"250.40",
"924.3",
"428.0",
"707.0",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"54.98",
"86.04"
] |
icd9pcs
|
[
[
[]
]
] |
10280, 10979
|
11000, 11549
|
5963, 10171
|
2200, 4017
|
163, 180
|
209, 2177
|
4833, 5393
|
4039, 4623
|
4640, 4819
|
10196, 10256
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,542
| 184,604
|
45931
|
Discharge summary
|
report
|
Admission Date: [**2197-12-6**] Discharge Date: [**2198-1-10**]
Date of Birth: [**2135-5-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Esophageal carcinoma
Major Surgical or Invasive Procedure:
[**2197-12-6**] Bronchoscopy, Esophagoscopy, Right thoracotomy with
transthoracic esophagectomy, laparotomy, and left cervicotomy
with cervical esophagogastrostomy.
[**2197-12-9**] Flexible bronchoscopy with therapeutic aspiration
[**2197-12-18**] Flexible bronchoscopy with therapeutic aspiration and
bronchoalveolar lavage
[**2197-12-20**] Tracheostomy, bronchoscopy, insertion of left subclavian
hemodialysis catheter
History of Present Illness:
Mrs. [**Known lastname 86746**] is a 62 year old female with stage T3 N1 signet
ring adenocarcinoma of the distal esophagus who recently
completed induction chemotherapy. Since that time she has had a
PET scan for repeat staging which showed persistent upper
mediastinal adenopathy, and head MRI revealing a suprasellar
lesion that was biopsied by Dr. [**Last Name (STitle) **] and found to be
consistent with a benign cyst. Biopsy of the mediastinal nodes
revealed only non-necrotizing granulomas with no evidence for
metastasis. Therefore she is admitted today for planned
esophagogastrectomy.
Past Medical History:
-Esophageal cancer (signet-ring cell carcinoma T3, N1), dx
[**2197-6-27**]: J-tube placed [**7-26**]
-h/o H Pylori '[**89**] & '[**92**]
-GERD
-Hiatal hernia
-HTN
-Hyperlipidemia
Social History:
Lives with husband. [**Name (NI) **] two children. Retired warehouse assembly
work. Tobacco: Quit [**2164**], 5y x1ppwk, occasional etoh, never
heavy use, no illicit drugs.
Family History:
Mother deceased 79: MI, Father deceased 87: MI, Siblings (3S,
2B): 1 brother deceased MI age 40, 1 brother deceased s/p kidney
transplant age 55
Physical Exam:
Postoperatively:
Tmax 99.9 Tcurrent 99.9 HR 106 BP 123/68 pO@ 98% on CPAP:
0.40/413x32/5/10
Gen: NAD, intubated, arousable
HEENT: Perrla, EOMI
Heart: S1S2 RRR no M/G/R
Chest: diffuse crackles right lung fields
Abd: Soft, nondistended, appropriately tender, no bowel sounds
Ex: No edema
Wound: clean/dry/intact.
Pertinent Results:
[**2197-12-6**] 05:08PM WBC-10.8 RBC-2.31* HGB-8.4* HCT-24.7*
MCV-107* MCH-36.3* MCHC-33.9 RDW-15.5
[**2197-12-6**] 03:22PM GLUCOSE-212* LACTATE-0.9 NA+-134* K+-3.6
CL--101
[**2197-12-6**] 07:24PM TYPE-ART PO2-140* PCO2-34* PH-7.43 TOTAL
CO2-23 BASE XS-0
[**2197-12-6**] 03:22PM freeCa-1.14
[**2197-12-6**] OPERATIVE REPORT:
PREOPERATIVE DIAGNOSIS: Carcinoma of the esophagus.
POSTOPERATIVE DIAGNOSIS: Carcinoma of the esophagus.
OPERATIVE PROCEDURE PERFORMED:
1. Bronchoscopy.
2. Esophagoscopy.
3. Right thoracotomy with transthoracic esophagectomy,
laparotomy, and left cervicotomy with cervical
esophagogastrostomy.
ASSISTANTS: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**Initials (NamePattern4) **]
[**Name6 (MD) **] [**Last Name (NamePattern4) 97797**], M.D.
ANESTHESIA: General endotracheal with thoracic epidural.
INDICATIONS: Ms. [**Known lastname 86746**] is a 62-year-old woman with biopsy-
proven T3, N1, stage III carcinoma of the distal esophagus
with lymph nodes that were PET-positive extending well up
into the superior thorax. She has been treated with induction
chemoradiotherapy with an objective response. Residual PET-
positive lymph nodes were evaluated thoracoscopically and
with mediastinoscopy and were found to be sarcoidal. Without
evidence of disease progression, I recommended resection and
she agreed to proceed.
DESCRIPTION OF PROCEDURE: The patient was brought to the
operating room after the insertion of a thoracic epidural
catheter. She underwent the uneventful induction of general
endotracheal anesthesia. A pediatric bronchoscope was used to
examine the central airways. The distal trachea was normal.
The main carina was sharp, and the segmental branching
pattern of the lungs was unremarkable. No endobronchial
purulence, tumor, or blood was noted to the subsegmental
level. A left-sided double-lumen endotracheal tube was
positioned above the left lobar carina, and the bronchoscope
was removed.
The upper GI endoscope was used to assess for residual
endoluminal tumor. There was what appeared to be a healed
bland ulcer in the distal esophagus, at the site of the
former tumor. This extended to the GE junction. The stomach
was entered, and the rugal folds distended normally. There
was no visualized tumor along the lesser curvature using a
retroflexed view of the GE junction. The gastric antrum was
not deformed. The pylorus was widely patent. The duodenum was
normal to its second portion. The scope was then removed.
The patient was positioned in the left lateral decubitus
position, and the right chest was prepped and draped as a
single sterile field. A standard serratus-sparing lateral
thoracotomy was made, and the chest was entered through the
sixth intercostal space. A 0-silk suture was placed in the
dome of the diaphragm to retract it inferiorly and improve
exposure. Circumferential dissection of the esophagus was
then carried out beginning in the subcarinal space. The
esophagus was looped with a Penrose drain and dissected free
of its mediastinal attachments down to the crura of the
diaphragm inferiorly. Subcarinal lymph nodes were sampled,
and one was submitted to pathology, which showed only a
hyalinized nodule. The balance was submitted as level VII
lymph nodes. The subcarinal space was entirely mobilized down
to the pericardium and to both main stem bronchi laterally.
Paraesophageal nodes in the inferior ligament and at level
VIII were included with the specimen. The esophagus was then
carefully separated from the membranous airway as we
dissected cephalad. The azygos vein had previously been
divided during the lymph node evaluation. Above the azygos
vein, we dissected directly on the longitudinal muscle of the
esophagus to attempt to avoid injury to the recurrent nerves.
This was continued up to the thoracic apex and well into the
neck. A small Penrose drain was knotted around the specimen
and passed into the neck for subsequent retrieval. Hemostasis
was achieved with the cautery. The inferior pulmonary
ligament was completely mobilized. Palpation of the lung
revealed no nodules.
The region of the thoracic duct was doubly ligated with 0-silk
sutures by mass ligating all the tissues between the periosteum
of the spine and the adventitia of the aorta, including the
azygos vein. Two of these were placed.
The chest was then drained with a 28-French chest tube passed
posteriorly and apically through a separate stab wound
inferiorly. It was secured to the skin with heavy suture and
connected to a Pleur-Evac with an underwater seal. The ribs
were then reapproximated with #1-Vicryl pericostal sutures.
The lung was reinflated. The muscular chest was closed in
layers with absorbable suture, and the skin was closed in the
subcuticular fashion. Steri-Strips and dry dressings were
applied.
The patient was returned to the supine position and
reintubated with a single-lumen endotracheal tube. She was
positioned supine with a roll between her scapulae and the
head turned right. She was prepped from the left ear to the
pubis, and 2 fields were created - one over the left neck and
one over the abdomen.
A midline abdominal incision was made, and the peritoneum was
entered through the linea [**Female First Name (un) **]. Inspection revealed no
ascites. There was no studding of the omentum. There were no
nodules palpated in the liver. There was thickening at the GE
junction and no gross adenopathy along the left gastric
artery. The small bowel was run from the ileocecal valve up
approximately to the level of the jejunostomy and there were
no lesions. The proximal bowel also was normal to palpation
from the jejunostomy to the ligament of Treitz. There were no
colonic abnormalities palpated, and no pathology was noted in
the pelvis.
The [**Doctor Last Name 634**]-[**Doctor Last Name 37393**] retractor and the [**Last Name (un) 34391**] were placed.
The left lateral segment of the liver was mobilized by
dividing the triangular ligament and reflecting this portion
of the liver rightward. Good exposure was gained. We incised
the phrenoesophageal ligament and delivered the mobilized
distal esophagus into the abdomen. The Penrose drain was
replaced around it. We then performed a greater curvature
dissection, using the LigaSure device to take all the short
gastric vessels and mobilize the stomach from the gastrocolic
ligament and transverse mesocolon down to the pylorus. Care
was taken to preserve the gastroepiploic arcade on the right
during this dissection. We then took inflammatory adhesions
of the stomach to the pancreas and dissected on the lesser
curvature side, identifying and dissecting the left gastric
pedicle and taking the artery and vein separately with silk
ties. Lymphoid tissue was then swept up towards the stomach,
and the balance of this dissection was done with the cautery.
We performed a generous [**Doctor Last Name **] maneuver, followed by a
Heineke-Mikulicz pyloroplasty by incising through the pylorus
longitudinally and closing it transversely with interrupted 2-
0 silk sutures. This concluded our gastric mobilization.
We enlarged the hiatus by ligating the phrenic vein on either
side of the hiatus and incising the diaphragm up to the
pericardial reflection. Hemostasis was ensured with the
cautery.
We turned our attention to the left neck where we made an
oblique incision along the anterior border of the
sternocleidomastoid muscle. This was carried through the
platysma with the cautery. We divided the omohyoid muscle and
dissected medial to the contents of the carotid sheath until
we could enter the prevertebral space where we encountered
the previously placed Penrose around the cervical esophagus.
Areolar tissue in the wound was separated, allowing adequate
mobilization in the neck. The esophagus was elevated and
controlled with a linear stapler at the level of the
clavicular heads. Umbilical tape was secured around the
proximal portion of the specimen, and the esophagus was
divided after pulling the NG tube back to above the stapler.
The specimen was delivered through the abdomen, pulling the
umbilical tape through the posterior mediastinum. There was
definite foreshortening and induration along the lesser
curvature, and we divided 2 branches of the right gastric
artery to clean off the lesser curvature of the stomach. This
was done between clamps and silk ties. We then prepared a
gastric tube along the greater curvature based on the right
gastroepiploic blood supply with 4 applications of the [**Female First Name (un) 3224**]
stapler. This liberated the specimen. The left gastric nodal
packet was dissected away from the specimen and this was
submitted to pathology. Frozen section of the proximal margin
showed normal squamous mucosa. Distally, there were a few
isolated signet cells in the submucosa with overlying normal
mucosa. The significance of these cells was unclear.
We then oversewed the new lesser curvature staple line with
running 3-0 PDS Lembert sutures. We secured a 30 mL balloon
Foley catheter to the umbilical tape and put the balloon
inside an arthroscopy drape which was secured around the
balloon with a silk tie. There were 30 mL of saline instilled
into the balloon. The umbilical tape was then pulled back to
the neck, bringing the Foley catheter through the posterior
mediastinum and to the neck. The gastric conduit was placed
in the arthroscopy drape, and the Foley catheter was placed
on suction, allowing the drape itself to clamp atraumatically
down around the conduit, which was then delivered to the neck
under no tension. We then performed an end-to-end anastomosis
by suturing the esophageal remnant proximally to the
posterior aspect of the gastric fundus. The esophageal staple
line was amputated. A gastrotomy was made in the posterior
wall of the tip of the fundic tube. The back row of 3-0 silk
interrupted sutures was placed and left with the knots on the
inside. These were placed and tied, and then the nasogastric
tube was advanced across the anastomosis. The anterior row of
sutures was placed with the knots on the outside. The
redundant portion of the fundic tip was then tacked around
the anastomosis with 3-0 silk Lembert sutures, completing the
anastomosis. This was returned to the posterior aspect of the
neck and upper mediastinum where it lay under no tension.
The neck was irrigated with saline and drained with a 10 mm
flat [**Location (un) 1661**]-[**Location (un) 1662**] drain. This was exited through a separate
stab wound, secured to the skin with nylon suture, and placed
to bulb suction. The neck was then closed, using 3-0 Vicryl
to close the platysma in a running fashion and Monocryl to
the skin of the neck. A dry dressing was applied.
The abdomen was then irrigated, and hemostasis appeared
adequate. The conduit was tacked to the enlarged hiatus with
2-0 silk interrupted sutures in 3 places to prevent
herniation of peritoneal contents into the thorax. The
midline was then closed with running looped PDS suture.
Subcutaneous tissues were irrigated, and the skin was closed
with clips. Dry dressings were applied.
The patient tolerated the procedure quite well and was
transferred intubated to the surgical intensive care unit in
satisfactory condition.
[**Name6 (MD) 4667**] [**Name8 (MD) **], M.D. [**MD Number(2) 39921**]
Dictated By:[**Name8 (MD) 65844**]
***** [**2197-12-6**] POSTOPERATIVE CHEST XRAY:
INDICATION: Status post esophagectomy. Pneumothorax and
effusion.
FINDINGS: AP single view of the chest obtained with patient in
sitting semi-upright position is analyzed in direct comparison
with a preceding similar study of [**2197-11-23**]. The patient
is now intubated, the ETT terminating in the trachea some 5 cm
above the carina. NG tube reaches below diaphragm. A right-sided
chest tube in place terminating in the right apical area. No
pneumothorax identified. Area of upper abdomen shows now status
post surgery with midline metallic staple line and surgical
clips in left hiatal area. Similar postoperative findings in
left neck area consistent with esophagectomy.
***** [**2197-12-8**] CHEST XRAY:
REASON FOR EXAMINATION: Shortness of breath in a patient second
day after esophagectomy.
Portable AP chest radiograph compared to [**2197-12-7**].
Interval significant progression of the right lung consolidation
currently involving almost entire right lung is consistent with
aspiration pneumonia progression. Left lung linear atelectasis
is unchanged. The small bilateral pleural effusions did not
change significantly and there is no pneumothorax
***** [**2197-12-10**] BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND:
Grayscale and Doppler son[**Name (NI) 1417**] of the right and left common
femoral, superficial femoral, and popliteal veins were
performed. Normal compressibility, augmentation, flow, and
waveforms are demonstrated. There is no evidence of intraluminal
thrombus.
IMPRESSION: No evidence of lower extremity DVT bilaterally.
***** [**2197-12-13**] CT TORSO:
INDICATION: Esophagectomy now with fever. Query source.
TECHNIQUE: Oral contrast was administered through the J-tube,
and MDCT was used to obtain contiguous axial images through the
torso without IV contrast. Multiplanar reformats were obtained.
The study was compared with [**2197-10-23**] CT scan from
PET-CT.
CT CHEST WITHOUT IV CONTRAST: Esophagectomy surgical drainage
tube to the left of the pull-through. Endotracheal tube
terminates in the appropriate location. Nasogastric tube
terminates just below the esophageal hiatus. Swan- Ganz catheter
terminating in the right pulmonary artery trunk. Right-sided
chest tube terminating in the right lung posterior apex. Aorta
is normal in caliber. A small pericardial effusion is noted. In
the mediastinum, just anterior to the left main stem bronchus, a
17 x 23-mm relatively high density (40 [**Doctor Last Name **]) round fluid
collection may represent a small hematoma. Stranding in the
mediastinum is likely due to recent esophagectomy. A small right
apical pneumothorax and small amount of air in anterior right
costophrenic angle. Extensive ground- glass opacity and
consolidation with air bronchograms in the right lower lobe, in
a pattern suggestive of aspiration. Similar findings in the left
lung, but to a lesser degree. A small-to-moderate left pleural
effusion is present.
CT ABDOMEN WITHOUT IV CONTRAST: Gallbladder is distended, but
without radiopaque stones or CT evidence of cholecystitis.
Liver, adrenals, pancreas, kidneys, and small-bowel loops are
within normal limits. Spleen has a tiny calcification within it,
representing a granuloma. A jejunostomy tube is seen in the left
lower quadrant. There are enlarged retroperitoneal lymph nodes,
for example, para-aortic node measuring 10 mm in short axis
(series 2 image 70). These lymph nodes are increased since the
last examination, probably due to recent esophagectomy.
Stranding in the root of the mesentery may also be related to
recent surgery. No free air or free fluid.
CT PELVIS WITH IV CONTRAST: Bladder is collapsed with a Foley.
Uterus and bowel loops are normal. Several phleboliths are noted
in the pelvis. Right femoral line terminates in the proximal
common iliac arteries. No free air. No lymphadenopathy. Small
amount of stranding surrounds the rectum.
BONE WINDOWS: No suspicious sclerotic or lytic lesions.
Degenerative changes of the thoracic spine are noted. There is
diffuse edema in the subcutaneous soft tissues, particularly on
the right side.
Multiplanar reformats were essential in delineating the findings
above, particularly in the absence of IV contrast.
IMPRESSION:
1. Bilateral, right greater than left air space consolidations,
which may represent an infectious process. Their dependent
distribution suggests aspiration as an etiology.
2. Small-to-moderate left pleural effusion.
3. Small pericardial effusion.
4. Inflammatory changes in mesentery and prominent lymph nodes,
likely due to recent abdominal surgery.
5. Small right pneumothorax.
***** [**2197-12-26**] POST PACER PLACEMENT XRAY
[**Hospital 93**] MEDICAL CONDITION:
62 year old woman with episodes of asystole, need to place
temporary pacing wire.
REASON FOR THIS EXAMINATION:
Portable C-arm needed for line placement.
INDICATION: pacer lead placement.
One video image was obtained after chest fluoroscopy. There were
no diagnostic films obtained. There is evidence of a pacer wire
in the right ventricle.
***** [**2197-12-26**] TRANSTHORACIC ECHO:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is a small
pericardial effusion. The effusion appears circumferential.
There are no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2197-12-11**],
the pericardial effusion now appears slightly larger.
[**2197-12-30**] CT SINUS:
[**Hospital 93**] MEDICAL CONDITION:
62 year old woman s/p esophagectomy complicated by pneumonia,
afib, ARF, sepsis, febrile from unknown cause.
REASON FOR THIS EXAMINATION:
assess for sinusitis, NO IV CONTRAST. IF IV CONTRAST IS NEEDED
PLEASE PAGE SICU RESIDENT PRIOR TO SCAN.
CONTRAINDICATIONS for IV CONTRAST: acute renal failure
HISTORY: 62-year-old female status post esophagectomy,
complicated by pneumonia, atrial fibrillation, acute renal
failure and sepsis. Please assess for sinusitis.
COMPARISON: Multiple prior chest radiographs, and head CT from
[**2197-11-2**].
TECHNIQUE: MDCT-acquired axial imaging of the paranasal sinuses
was performed without intravenous contrast. Multiplanar
reformatted images were obtained and reviewed.
CT OF THE SINUSES: Visualized paranasal sinuses are normally
aerated, with the exception of a small amount of fluid and/or
mucosal thickening in the sphenoid sinus and its lateral
recesses. The ostiomeatal units are patent bilaterally. The
cribriform plates are intact, with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 36826**] type 2 configuration
bilaterally. The lamina papyracea is intact bilaterally. The
nasal septum is midline, with a small leftward deviated spur.
Surrounding soft tissues are unremarkable.
IMPRESSION: No evidence of sinusitis.
***** [**2197-12-31**] RUQ ULTRASOUND:
RIGHT UPPER QUADRANT ULTRASOUND: The gallbladder is markedly
distended and contains shadowing stones. There is no gallbladder
wall thickening. A small amount of pericholecystic fluid is
thought more likely related to ascites, which was demonstrated
on the recent CT study. There is no fluid within Morison's
pouch. There is no biliary ductal dilatation. The common duct
measures normal maximal caliber of 4 mm. There is no focal or
textural hepatic abnormality. There is appropriate forward flow
in the main portal vein.
IMPRESSION: Cholelithiasis but no definite evidence of acute
cholecystitis. Distended state of the gallbladder is probably
related to n.p.o. status. Small amount of pericholecystic fluid.
***** [**2198-1-4**] CT TORSO:
INDICATION: 62-year-old status post esophagectomy with prolonged
stay in ICU, now with ARDS. Assess for interval change.
COMPARISONS: CT torso of [**2197-12-30**] and CT torso of [**2197-12-13**].
TECHNIQUE: Axial MDCT images through the chest without IV
contrast with coronal and sagittal reformatted images.
FINDINGS: Endotracheal tube remains well positioned. Left-sided
subclavian line terminates in the proximal SVC. There remains
dense bilateral multifocal consolidation. There has been slight
interval improvement in the right lower lobe consolidation which
still encompasses a large portion of the right lower lobe. Right
upper lobe consolidation is not significantly changed. There has
been slight interval worsening in consolidation in the lingula
as well as confluent ground-glass opacity and alveolar
consolidation in the lower lobe.
Bilateral pleural effusions remain small but are slightly
increased in size. Small pericardial effusion persists but is
slightly decreased in size. Patient is status post esophagectomy
with post-surgical changes.
No focal osseous lesions. Limited noncontrast imaging through
the upper abdomen demonstrates no gross abnormalities. Coronal
and sagittal reformatted images confirm the above findings.
IMPRESSION:
1) Persistent dense multifocal consolidation, slightly improved
in the right lung, but slightly worsened in the left lung.
2) Slight increase in small bilateral pleural effusions.
3) Slight decrease in small pericardial effusion.
4) Status post esophagectomy, not well evaluated without IV or
oral contrast.
***** [**2198-1-4**] CT HEAD:
INDICATION: 62-year-old woman status post esophagectomy, now
with dilated left pupil.
COMPARISON: [**2197-11-2**].
TECHNIQUE: Non-contrast head CT.
FINDINGS: Again seen is a hyperdense rounded lesion in the
suprasellar region corresponding the prior CT and MR; it appears
slightly smaller and more hyperdense than on prior CT, perhaps
post-procedural change. There is a burr hole in the right
frontal bone from prior biopsy. There is no acute hemorrhage,
edema, mass effect, or acute territorial infarction. The
ventricular and sulcal size is stable compared to prior study.
There has been resolution of the pneumocephalus.
There is an air-fluid level within the right sphenoid air cell,
and near total opacification of the posterior ethmoids as well
as the left sphenoid air cell. An air-fluid level is
incompletely visualized in the right maxillary sinus and there
is incompletely evaluated mucosal thickening in the left
maxillary sinus. Since the previous study, there has been
opacification of bilateral mastoid air cells. The middle ear
cavities appear clear.
IMPRESSION:
1. Air-fluid levels in the sphenoid and right maxillary sinus
and opacification of several ethmoid air cells, and bilateral
mastoid air cells are all suggestive of sinusitis.
2. Hyperdense rounded suprasellar lesion, which has been
previously biopsied, and whose pathology is most consistent with
a benign cyst such as a Rathke cleft cyst.
***** [**2198-1-8**] RUQ ULTRASOUND:
INDICATION: 62-year-old female with prolonged ICU stay for ARDS
presenting with increasing WBC.
COMPARISON: CT torso from [**2197-12-30**], abdominal ultrasound
from [**2197-12-31**].
RIGHT UPPER QUADRANT ULTRASOUND: The visualized right hepatic
lobe demonstrates normal echotexture without focal mass. The
gallbladder is moderately distended and contains small shadowing
stones. A small amount of pericholecystic fluid is again
identified, likely related to ascites and unchanged from the
prior study. The common bile duct is normal in caliber measuring
3 mm. The main hepatic vein is patent with hepatopetal flow.
Limited views of the right kidney demonstrate no evidence for
hydronephrosis.
IMPRESSION: No significant interval change. Cholelithiasis with
no definite evidence for acute cholecystitis. A small amount of
pericholecystic fluid is without change and is likely secondary
to perihepatic ascites.
Brief Hospital Course:
Mrs. [**Known lastname 86746**] underwent uncomplicated tri-incision
esophagogastrectomy on [**2197-12-6**] and was transferred to the SICU
postoperatively in stable condition. Please see operative
report dictated [**2197-12-6**] for details of the procedure. She was
extubated the next day. Pain service was consulted and replaced
her epidural.
On POD 1 she went into atrial fibrillation with rapid
ventricular response, and was started on amiodarone drip with
diltiazem for rate control. She also had an episode of
hypotension with concurrent ST elevations on EKG, so cardiac
enzymes were sent and she was started on Levophed. On the
morning of POD 3 she had an episode of respiratory distress,
hypotension, altered mental status, and associated rapid
ventricular response after suctioning, so was reintubated. A
post-intubation xray showed patchy opacities in the RML and LLL,
concerning for ARDS. Cardiology service was consulted and
recommended switching beta blockade to esmolol. She also became
febrile to 102.1, so pancultures were sent and she was started
on Vancomycin, Ciprofloxacin, and Zosyn in addition to Flagyl.
Sputum cultures grew out non-resistant Pseudomonas, and
pansensitive enterobacter.
On POD 4 Nephrology was consulted for her rising creatinine and
acute renal failure. D/C cardioversion was attempted multiple
times with little improvement in her Afib. As her renal
function was worsening she was started on CVVHD on POD 7. Her
tube feeds were DC'd and TPN was started on POD 8 because she
was regurgitating bilious material. She converted spontaneously
back to sinus rhythm, and pressors were briefly weaned. however
she continued to spike fevers, so all of her lines were changed
and cultures were resent.
Mrs. [**Known lastname 86746**] was improving slowly until [**2197-12-20**], when she went
back into rapid AFib and was restarted on amiodarone drip. The
next day she had a brief episode of asystole for 20 seconds
after suctioning, but recovered after chest compressions. She
had several further episodes of brief asystole/acute bradycardia
over the next few days, so a transvenous temporary pacemaker
lead was placed by EP on [**12-26**]. ARDS protocol was started on [**12-27**].
She remained relatively stable, requiring constant pressors and
ventilation and intermittently in Afib, but her chest xrays
continued to show increased infiltrates bilaterally. She
continued to require heavy sedation to synchronize with the
vent.
On [**1-3**] Mrs. [**Known lastname 86746**] went back into atrial fibrillation with
rapid response unresponsive to amio and betablockers, and
hypotensive to the 60s-70s. Esmolol was restarted briefly and
she was started on pitressin in addition to neo for additional
pressure support. She was rotated into the prone position in an
effort to improve her oxygenation. Her pupils were noted to be
unequal on [**1-4**] so a CT head was ordered which showed only
sinusitis and the previously visualized suprasellar mass. Her
WBC count started to rise again on [**1-6**] and peaked at 46.5 on
[**1-8**]. Her pO2 began to decrease gradually despite continued
aggressive ventilation with [**Last Name (LF) 97798**], [**First Name3 (LF) **] she was paralyzed in an
attempt to prevent vent dyssynchrony. Nonetheless her
respiratory status continued to worsen, and her pressure
continued to drop despite pressors. A family meeting was called
on the morning of [**1-10**] and the decision was made to make her
CMO. She expired at 10 AM on [**2197-1-10**].
Medications on Admission:
1. Docusate Sodium 100 mg Capsule [**Date Range **]: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Metoprolol Tartrate 50 mg Tablet [**Date Range **]: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Atorvastatin 40 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Prevacid 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
5. Enoxaparin 100 mg/mL Syringe [**Last Name (STitle) **]: One (1) Subcutaneous [**Hospital1 **]
(2 times a day).
Disp:*10 10 mL* Refills:*2*
6. Menthol-Cetylpyridinium 3 mg Lozenge [**Hospital1 **]: One (1) Lozenge
Mucous membrane PRN (as needed).
7. Fentanyl 25 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
8. Oxycodone-Acetaminophen 5-325 mg Tablet [**Hospital1 **]: One (1) Tablet
PO every 4-6 hours as needed.
Disp:*60 Tablet(s)* Refills:*0*
9. Zofran 8 mg Tablet [**Hospital1 **]: One (1) Tablet PO every six (6) hours
as needed for nausea.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Medications:
none.
Discharge Disposition:
Expired
Discharge Diagnosis:
Esophageal carcinoma
Discharge Condition:
Expired.
Completed by:[**2198-1-10**]
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[
"37.78",
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icd9pcs
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[
[
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30473, 30482
|
25663, 29204
|
296, 719
|
30547, 30587
|
2251, 18343
|
1759, 1905
|
30443, 30450
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19602, 19711
|
30503, 30526
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29230, 30420
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1920, 2232
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236, 258
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|
1568, 1743
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,819
| 188,400
|
11468+11469
|
Discharge summary
|
report+report
|
Admission Date: [**2162-2-18**] Discharge Date: [**2135-2-21**]
Date of Birth: [**2094-1-24**] Sex: F
Service: ACOVE
REASON FOR ADMISSION: Direct admission for jejunostomy
feeding tube.
HISTORY OF THE PRESENT ILLNESS: The patient is a 68-year-old
with chronic pancreatitis versus papillary tumor, right
multiple abdominal surgeries. She presents with chronic
symptoms of abdominal pain and nausea and vomiting which
occur with eating. In the past, she has undergone
esophagectomy with a colonic interposition and treatment of
an apparent esophageal stricture. In addition, she has
undergone several gastric surgeries and multiple lysis of
adhesions for small bowel obstruction.
She was last admitted to [**Hospital1 18**] in [**2161-9-22**] for acute
on chronic abdominal pain. After a few days of
hospitalization, she developed what appeared to be an acute
abdomen and she was transferred to [**Hospital6 15291**] where her primary general surgeon, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
was. During the procedure, she underwent a seven hour
laparotomy, much of which involved lysis of adhesions in an
attempt at performing a pancreatic resection.
The procedure, however, was aborted apparently due to
anatomic abnormalities introduced by prior surgeries. A
celiac alcohol ablation was performed instead for pain
control.
Since the surgery in [**2161-9-22**], she has complained of
worsening abdominal pain and inability to tolerate p.o. She
has lost approximately 20% of her weight since then. TPN has
been attempted in the past; however, due to extensive SVC,
and internal jugular thrombi, a PICC line could not be
maintained and this was not a current option.
She was recently switched from methadone to Oxycodone and
slowly titrated up her dose for chronic pain control. She
describes that her pain is constant, sharp, and diffuse
abdominal pain with intermittent diarrhea and constipation.
She has constant nausea but little to no emesis. She eats
small meals throughout the day. She denied any melena or
bright red blood per rectum.
PAST MEDICAL HISTORY:
1. Chronic pancreatitis versus intraductal papillary
mucinous tumor, status post sphincterotomy and five failed
ERCP attempts. Failed placement of pancreatic duct stent,
status post alcohol ablation.
2. Hiatal hernia repairs times five.
3. Esophageal stricture status post resection and colonic
interposition.
4. Status post TAH.
5. Status post cholecystectomy in [**2157**].
6. Breast cancer, status post right lumpectomy and XRT in
[**2156**].
7. Recurrent subclavian thrombi bilaterally.
8. Status post exploratory laparotomy with lysis of
adhesions.
9. Anxiety/depression.
10. Irritable bowel syndrome.
ALLERGIES:
1. Compazine causes seizures.
2. Keflex causes rash.
3. Morphine causes anxiety.
4. NSAIDs cause GI upset.
SOCIAL HISTORY: She is a retired secretary. She is married
with two children and four grandchildren. She has a 60 pack
year smoking history, but quit 11 years ago. Social alcohol
use with no intravenous drug use reported.
FAMILY HISTORY: Her father died of a myocardial infarct at
56-years-old. Mother with coronary artery disease, valve
repair, and diabetes. Maternal grandmother with breast
cancer.
ADMISSION MEDICATIONS:
1. Colace.
2. Dilaudid 8 mg p.o. p.r.n.
3. Buspar 10 mg p.o. b.i.d.
4. Zoloft 100 mg p.o. q.d.
5. Elavil 25 mg p.o. q.d.
6. Ambien 10 mg p.o. q.d.
7. Klonopin 0.5 mg p.o. t.i.d.
8. Prevacid 30 mg p.o. q.a.c.
9. Diltiazem 180 mg p.o. q.d.
10. Senna one tablet p.o. b.i.d.
11. Viokase two tablets q.i.d.
12. Zofran p.r.n.
13. Oxycontin 40 mg q.a.m., 20 mg q. noon, 40 mg q.p.m.
14. Donnatal two tablets p.r.n.
15. Restoril 30 mg p.o. q.h.s.
16. Lovenox 80 mg subcutaneously q.d.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Blood
pressure 130/87, heart rate 96, respiratory rate 18,
temperature 98.0, oxygen saturation 92% on room air.
General: The patient is an elderly female in mild abdominal
pain, no apparent respiratory distress. HEENT: The pupils
were equal, round, and reactive. The mucous membranes were
dry. The extraocular muscles were intact. Neck: No jugular
venous distention was noted. The neck was supple with no
appreciable lymphadenopathy. Chest: Decreased breath sounds
at the left base secondary to previous surgery, right fine
crackles at the right base. Cardiovascular: Regular rate.
No murmurs, rubs, or gallops noted. Abdomen: Multiple
well-healed surgical scars. Normoactive bowel sounds. No
rebound or guarding, tenderness to palpation which was most
prevalent in the right lower quadrant and left lower
quadrant. No incisional hernias noted. Extremities: Warm
and dry. No clubbing, cyanosis or edema. Palpable
peripheral pulses. Neurologic: She was alert and oriented
times three. Cranial nerves II through XII were intact.
LABORATORY VALUES ON ADMISSION: White count 10.3, hematocrit
35.8, platelets 454,000. PT 14.5, PTT 34.3, INR 1.4. Sodium
137, potassium 3.3, chloride 99, bicarbonate 24, BUN 14,
creatinine 0.4, glucose 83, amylase 25.
PERTINENT IMAGING STUDIES DURING HOSPITALIZATION: Please see
hospital course below.
IMPRESSION: This is a 68-year-old with chronic abdominal
pain, extensively worked up in the past, admitted electively
for feeding jejunostomy tube placement secondary to failure
to thrive and inability to establish access for TPN.
HOSPITAL COURSE: 1. GASTROINTESTINAL: The patient was
admitted to the ACOVE Medicine Service for elective
jejunostomy feeding tube to be placed by Interventional
Radiology. An NG tube was placed at the bedside on the
evening of admission and she went to Interventional Radiology
the following morning for fluoroscopic guided J tube
placement. However, due to her unusual anatomy with status
post esophagectomy, her stomach was above the costochondral
margin and was unable to be insufflated with either NG tube
or Dobbhoff feeding tube. Therefore, the procedure was
aborted as Interventional Radiology would not be able to
safely place the feeding tube.
General Surgery was then contact[**Name (NI) **] for evaluation of
placement of jejunostomy in the OR. She went to surgery on
[**2162-2-23**] for open jejunostomy feeding tube and lysis of
adhesions. A #12 French feeding tube was inserted into what
appeared to be the jejunum lumen. Although adhesions were
lysed while in the Operating Room there did not appear to be
a significant number of small bowel adhesions at this time.
Tube feeds were started at low rate after surgery; however,
the patient developed significant nausea, vomiting, and
abdominal pain and tube feeds were subsequently held. A CT
of the abdomen was performed on postoperative day number
three which showed dilated small bowel with pneumatosis
raising the question of obstruction versus ischemia. The
dilatation occurred proximal to the J tube and, therefore, it
was felt that this may be leading to a mechanical
obstruction. A lactate level was sent at that time and was
found to be mildly elevated at 3.6.
However, clinically, the patient did not have signs of acute
ischemia and, therefore, it was felt necessary to repeat the
CT scan with oral contrast for better evaluation.
An NG tube was again placed under fluoroscopy the evening of
[**2162-3-1**] and a repeat CT of the abdomen with contrast through
the NG tube was performed the following morning. A repeat CT
scan showed delayed contrast passage but filling past the
transition point (at the J tube insertion site) between
dilated and collapsed bowel loops. Therefore, the Surgical
Team did not feel that there was significant obstruction at
that point and tube feeds were restarted. She was not taken
to the OR as it was not felt that the jejunostomy tube was
causing an obstruction.
The nasogastric tube, however, was left in place and placed
on low-intermittent suction and the patient's nausea and
vomiting resolved. The NG tube was clamped on postoperative
day number ten and as the patient did not develop any emesis
for 24 hours, the NG tube was discontinued the following
morning. Unfortunately, significant nausea and vomiting
developed after the tube was removed and, therefore, it was
replaced at bedside by the surgical attending, Dr. [**Last Name (STitle) 519**], on
[**2162-3-9**]. It has been on low continuous suction since with
trials of clamping the tube being unsuccessful.
An upper GI series was performed on postoperative day number
nine and showed passage of barium with distended small bowel
loops at the J tube transition site which was worrisome for
mechanical obstruction. Therefore, on [**2162-3-9**],
postoperative day number 14, the jejunal feeding tube was
changed over a wire by Interventional Radiology and replaced
with a 8.5 French pediatric feeding tube. The tube extended
37 cm into the small bowel which was at the site of previous
jejunostomy feeding tube placed by General Surgery.
It was felt by the Surgical Team that if any mechanical
obstruction had been occurring from the feeding jejunostomy
tube that this would be lessened by placing a smaller caliber
feeding tube.
A repeat upper GI series will be performed on [**2162-3-12**] to
reassess for mechanical obstruction now that the smaller
feeding tube is in place. At the time of this dictation, it
is unclear what the ultimate outcome will be; however,
possible outcomes include: Removing the J tube entirely and
maintaining the patient on TPN, returning to the OR for
repeat feeding tube placement, repeat attempt at
pancreatectomy or gradual resolution of nausea and vomiting
and no further intervention will be needed.
2. FLUIDS, ELECTROLYTES, AND NUTRITION: As stated above,
Mrs. [**Known lastname 36621**] was admitted for failure to thrive secondary
to poor p.o. tolerance. TPN was attempted in the past;
however, the line had to be discontinued secondary to chronic
subclavian and SVC thrombi. Tube feeds were initiated as
described above intermittently throughout the first half of
her hospitalization. As her tube feeds were inconsistent and
were not providing adequate nutrition, TPN was initiated on
[**2162-3-6**], postoperative day number 15. They were continued
through the end of this dictation.
Her nausea and vomiting was difficult to control with
antiemetics, however, Ativan and high-dose Zofran appeared to
be most effective.
3. HEMATOLOGY: Mrs. [**Known lastname 36621**] has a history of chronic
catheter-associated thrombi in bilateral subclavian and
Superior vena cava veins. She is on Lovenox as an outpatient
for possible hypercoagulable state which is being followed by
a community hematologist. It is not clear what the
hypercoagulable state it. However, given her history of
breast cancer it could be malignancy related.
Venous access was a major issue during this and previous
hospitalizations and, therefore, a midline was placed on
[**2162-2-26**] to expedite blood draws and maintain suitable
intravenous access. During placement of the midline she was
noted to have obstruction of left axial A vein with
collaterals from the lateral thoracic vein. The midline was
nonfunctional and, therefore, a reposition attempt was made
on [**2162-3-2**], but this did not work. The line was
discontinued.
On [**2162-3-4**], she went for repeat interventional radiology
procedure for line placement. The procedure showed occlusion
of the mid to distal SVC with multiple collaterals noted.
The SVC was dilated and stented and a #7 French dual-lumen
Hickman catheter which was inserted through the right
internal jugular vein was placed through the SVC stent. The
tip of the catheter is in the SVC. The procedure took
approximately six hours and there were no difficulties
encountered afterwards. The line functioned properly
throughout the remainder of her hospitalization.
Her 80 mg q.d. Lovenox was switched to 40 mg b.i.d. for which
it was continued during the remainder of the hospitalization.
IV heparin was not able to be used due to inability to
monitor PTT as peripheral blood could not be drawn. Coumadin
was not able to be administered as she has variable
absorption due to chronic nausea and vomiting.
4. INFECTIOUS DISEASE: On postoperative day number one, the
patient had a temperature spike to 101.2 and was pan
cultured. She defervesced and there were no signs of
infection by chest radiograph or culture data. She re-spiked
on postoperative day number seven, again to 101.2. At which
time, empiric coverage with Levaquin and Flagyl were
initiated. Coverage was discontinued after five days as she
had been afebrile with a normalized white count. However, on
postoperative day number 15, she had an elevation of her
white blood cell count up to 21. She was re-cultured at this
time and again culture data and chest x-ray showed no signs
of infection.
As there were no signs of infection, antibiotics were not
restarted and she continued to be afebrile. Her surgical
site showed no signs of infection.
5. PAIN CONTROL: Mrs. [**Known lastname 36621**] is on a well-established
regimen of pain control as an outpatient with the addition of
alcohol ablation to celiac plexus performed in [**2161-9-22**]. For her acute pain after surgery, she was transiently
on a Dilaudid PCA and was transitioned to p.o. and IV
Dilaudid for which she required episodically.
6. PSYCHIATRY: Mrs. [**Known lastname 36621**] has a history of anxiety and
depression and was continued on her outpatient regimen of
Buspar, Elavil, Zoloft, and Klonopin.
This is an interim discharge summary and the remainder of the
hospital course will be dictated in a discharge summary
addendum at the time of final discharge. At this current
time, her following diagnosis and medications are listed
below.
DISCHARGE DIAGNOSIS:
1. Chronic pancreatitis versus intraductal papillary
mucinous tumor leading to chronic nausea and vomiting.
2. Status post feeding jejunostomy tube placement.
3. Status post SVC stent and Hickman catheter placement
through the right internal jugular vein.
4. Malnutrition.
5. Hypercoagulable state leading to chronic bilateral
subclavian and superior vena cava thrombi.
6. Small bowel obstruction.
7. Status post lysis of adhesions.
DISCHARGE MEDICATIONS (a more current list will be dictated
in subsequent discharge summary):
1. Ativan 0.5 mg to 1.0 mg q. 4-6 hours p.r.n. nausea.
2. Dilaudid 2-8 mg p.o. p.r.n.
3. Lovenox 40 mg p.o. b.i.d.
4. Prilosec 30 mg q.d.
5. Donnatal two tablets p.o. p.r.n.
6. Zofran 6-12 mg q. six hours p.r.n.
7. Phenergan 12.5 to 25 mg IV p.r.n.
8. Senna one tablet p.o. b.i.d.
9. Diltiazem 180 mg p.o. q.d.
10. Elavil 25 mg p.o. q.h.s.
11. Zoloft 100 mg p.o. q.d.
12. Buspar 10 mg p.o. b.i.d.
13. Klonopin 0.5 mg p.o. t.i.d.
14. Ambien 10 mg p.o. q.h.s.
15. Oxycontin 60 mg p.o. q. 12 hours.
DISCHARGE DISPOSITION: To be determined by subsequent
discharge summary addendum.
as of this time, patient will not be discharged.
[**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 36622**]
Dictated By:[**Last Name (NamePattern1) 6240**]
MEDQUIST36
D: [**2162-3-12**] 03:22
T: [**2162-3-12**] 16:35
JOB#: [**Job Number 36623**]
Admission Date: [**2162-2-18**] Discharge Date: [**2162-3-26**]
Date of Birth: [**2094-1-24**] Sex: F
Service: ACOVE Medicine Service
ADDENDUM: This is an Addendum to the Discharge Summary which
was dictated on [**2162-3-12**]. This Addendum will cover the
time span from [**2162-3-12**] until present. The attending
of record was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3315**] initially and then switched
to [**Doctor Last Name 22583**] attending Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**].
HOSPITAL COURSE: (From [**2162-3-13**] until [**2162-3-25**])
The patient had an upper gastrointestinal series on [**2162-3-12**] to rule out obstruction with her persistent nausea and
vomiting with a jejunostomy tube in place.
The upper gastrointestinal series revealed no obstruction.
The patient continued to have nausea and vomiting. She was
continued on antiemetics including Ativan and Zofran. Her
total parenteral nutrition was continued, and her tube feeds
were held over [**3-13**].
On [**3-14**], jejunostomy tube feedings were restarted, and
the patient was given toast for oral intake. This was
followed by two episodes of emesis, and again the tube feeds
were stopped.
On [**3-14**], the patient's white blood cell count had bumped
from 10.3 to 33.6. The patient had been administered empiric
antibiotics with Levaquin and Flagyl as described in the
previous Discharge Summary. Blood cultures and urine
cultures showed no growth to date. It was decided to repeat
a chest x-ray, and to obtain repeat blood cultures, and to
recheck Clostridium difficile toxins.
Over the evening of [**3-14**], the patient spiked a
temperature to 101. A repeat chest x-ray showed bilateral
pulmonary infiltrates; most likely consistent with aspiration
pneumonia.
Therefore, on [**3-15**], the patient was empirically started
on Flagyl 500 mg intravenously q.8h. and levofloxacin 500 mg
intravenously q.24h. She was dropping her oxygen saturation.
She was 90% on room air and required oxygen via nasal cannula
at 6 liters. The patient also had transient episodes of
hypotension with a systolic blood pressure in the low 80s,
requiring a 500-cc normal saline bolus over the evening of
[**3-14**]. It was decided to continue to hold her tube feeds
over the [**3-15**] with the recent aspiration. The patient's
urinalysis was negative at this point, and her blood
cultures, as well as fungal blood cultures, showed no growth
to date. Her Clostridium difficile toxin which was sent was
also negative. The patient was continued on total parenteral
nutrition.
On [**3-16**], the patient was again vomiting in the early
morning. It was bilious vomitus. She dropped her oxygen
saturation at the same time to 74% on room air, which
increased to 88% on 3 liters, and subsequently 92% on 2
liters. Again, she had a low-grade temperature with a
temperature maximum of 100.9. Her white blood cell count had
dropped to 22.6 by this date, and she was on day two of
Flagyl and day two of levofloxacin.
As the patient's oxygen saturations continued to drop
periodically throughout the day, it was decided to obtain a
computed tomography angiogram to rule out a pulmonary
embolism; especially with the patient's history of multiple
clots including the superior vena cava, axillary vein, and
subclavian vein. The patient's hematocrit was also noted to
drop on this day to 24. Iron studies were checked which were
consistent with anemia of chronic disease. As the patient
was persistently hypoxic, it was decided she would benefit
for one unit of packed red blood cells which would perhaps
help with her oxygenation. It was decided to continue to
hold the tube feeds over [**3-16**] with her tenuous
respiratory status.
Unfortunately, the patient's computed tomography angiogram
had suboptimal images. With the patient's line in place,
there was a limited rate at which the contrast could be
injected. Therefore, the radiologists were only able to
conclude that there was no large saddle embolus and no
embolus of the main pulmonary artery branches. However, they
could not comment on whether or not the patient had smaller
pulmonary emboli in the periphery of the lungs. However, the
patient had been on Lovenox 40 subcutaneously b.i.d. which
would be a treatment dose for a pulmonary embolism, so she
was continued on this. This had originally been started (as
stated in the prior Discharge Summary) for her right internal
jugular thrombus and for her superior vena cava thrombus.
As the patient continued to spike temperatures with a
temperature maximum of 101.3 on [**3-16**], it was decided to
broaden her antibiotic coverage and to change the
levofloxacin and Flagyl to levofloxacin and Zosyn. She was
started on Zosyn 4.5 g intravenously q.8h. on the evening of
[**3-16**].
The patient's blood count responded appropriately to the unit
of blood, and she went from 25 to 27.
For the patient's aspiration pneumonia, as stated above, she
was continued on Zosyn, Flagyl, oxygen via nasal cannula to
keep oxygen saturations between 94% and 96%, and albuterol
and Atrovent nebulizer treatments.
Her tube feeds were restarted on [**3-17**] with methylene blue
at a low rate of 10 cc per hour and were not advanced. The
patient was also started on Reglan in hopes that this would
help prevent forward motility.
Also on [**3-17**], it was noted that the patient was on
multiple different medications for both pain and depression.
It was decided to try and prevent this polypharmacy and taper
down her medications. She was continued on the
amitriptyline, sertraline, BuSpar, and clonazepam for her
depression as these were longstanding outpatient medications.
For her nausea, it was decided to discontinue the
intravenous lorazepam as she already had a benzodiazepines
orally for her anxiety, and to instead just continue the
ondansetron for her nausea. She was continued on the
oxycodone and Dilaudid for pain, as this was a longstanding
pain regimen that worked well for the patient.
On the evening of [**3-18**], the patient's oxygen saturations
again dropped to the high 70s to 80% on room air. However,
this time the patient's oxygen saturation did not respond to
a nonrebreather, and she maintained low saturations even with
100% oxygen. The patient also became somewhat lethargic, was
diaphoretic, and noted to have a temperature of 101.
At this point, the patient was unstable and possibly septic,
she was transferred to the Cardiothoracic Intensive Care Unit
for further management. In the Cardiothoracic Intensive Care
Unit, the patient was continued on her current doses of Zosyn
and Flagyl. She was maintained on a face mask. It was
decided to add vancomycin for the possibility of line sepsis.
While on the Unit, the patient's oxygenation improved, and
her blood pressure stabilized. She was continued on
vancomycin, and blood cultures from the line and periphery
were resent.
The patient did well and was actually transferred back to the
ACOVE Medicine Service team (General Medicine floor) on the
afternoon of [**3-19**]. It was decided to keep her on
vancomycin, Flagyl, and Zosyn until the blood cultures from
the line were negative for 48 hours. The patient was
continued on total parenteral nutrition, and her tube feeds
were held during this period.
By [**3-22**], the patient's blood cultures had been negative
for over 48 hours. It was decided to discontinued vancomycin
and to continue the Zosyn and levofloxacin for aspiration
pneumonia.
The patient's tube feeds were started, and at this point it
was decided to advance the tube feeds to an eventual goal of
50 cc per hour. A proton pump inhibitor was added to the
patient's regimen; lansoprazole 30 mg p.o. q.d. and the
intravenous H2 blocker was discontinued. It was felt that
the proton pump inhibitor might help the patient if some of
her pain was related to gastritis.
The computed tomography scan that was done on [**3-16**] to
evaluate for a pulmonary embolism was evaluated again at this
time with the radiologist to see if there was any recurrence
of clot in the superior vena cava; the thinking being that
perhaps the patient was having transient septic emboli from
the clot resulting in her intermittent desaturations. The
radiologist said that there was no obvious clot in the
superior vena cava, that the stent was patent. However,
because of the line that was tunneled through the superior
vena cava, there was no way to be certain that there were not
small clots somewhere within the vein. Since the patient was
stable from an oxygenation standpoint, it was decided not to
pursue this further.
On [**3-23**], the patient was still on Zosyn and Flagyl for
aspiration pneumonia. The patient was no longer using
nebulizers and no longer had inspiratory wheezes or
bronchospasm.
For the patient's pain, she was started back on oxycodone at
a lower dose of 30 mg b.i.d. and clonazepam at 0.5 mg b.i.d.
These medications had been transiently held while the patient
was in the Cardiothoracic Intensive Care Unit with decline in
mental status and decline in respiratory function.
On [**3-23**], the patient's tube feeds were up to 40 cc, and
she tolerated this well.
On [**3-24**], the gastroenterology attending (Dr. [**First Name (STitle) 2405**]
evaluated the patient again and felt that for the patient's
chronic abdominal pain, there was no further workup warranted
at this point. The patient's pain was most likely secondary
to either chronic pancreatitis or an obstructive pancreatic
duct. The patient has had a full workup plus two attempts at
pancreatic surgery, and she has also had two intraoperative
celiac plexus alcohol blocks without improvement. Therefore,
it was the Gastroenterology Service opinion that there was no
further workup of her pain indicated at this time. It was
felt that the pain with her tube feeds may have been related
to the fact that her gastrointestinal system had not seen any
nutrition for months, and it was also felt that she may have
Clostridium difficile. Therefore, Clostridium difficile
cultures were sent times three and were all negative. The
patient was given Donnatal, and this medication was increased
with improvement of her pain.
On [**3-24**], the patient had been working with Physical
Therapy and had been up and out of bed walking stairs for two
to three days; and, per the physical therapist, doing quite
well. Her tube feeds were at goal at this point at 50 cc per
hour. The patient was stable from a pulmonary perspective,
requiring minimal oxygen via nasal cannula.
On [**3-25**], it was decided to discontinue the oxygen by nasal
cannula and to change all intravenous medications to oral.
Now that the patient was at goal with tube feeds for 24
hours, the total parenteral nutrition could be stopped, and
the patient's central line could be discontinued with its
risk of infection and clotting. Therefore, all of her
medications were changed from intravenous to oral. The Zosyn
was stopped, and she was changed to levofloxacin 500 mg p.o.
q.d. to continue for five days further (for a 14-day course)
for aspiration pneumonia.
DISCHARGE DISPOSITION: The plan was to discharge the patient
to a rehabilitation facility on [**2162-3-25**].
DISCHARGE DIAGNOSES:
1. Chronic pancreatitis with resultant chronic abdominal
pain.
2. Chronic aspiration secondary to no lower esophageal
sphincter. The patient had previously had a esophageal
stricture which was surgically removed, and a piece of colon
was placed into this area. Therefore, the patient had no
lower esophageal sphincter and suffered from chronic bilious
vomiting.
3. Aspiration pneumonia and bilateral lower lobe pneumonia.
4. Status post jejunostomy tube placement for nutrition; no
longer requiring total parenteral nutrition, at goal for tube
feeds.
5. Blood clots in the superior vena cava; status post stent
to the superior vena cava. Also blood clots of the
subclavian and axillary veins.
6. Depression.
MEDICATIONS ON DISCHARGE:
1. Maalox 15 cc to 30 cc per nasogastric tube t.i.d. as
needed.
2. Zofran 8 mg per nasogastric tube t.i.d. as needed (for
nausea).
3. Reglan 10 mg per nasogastric tube q.i.d. and q.h.s.
4. Levofloxacin 500 mg per nasogastric tube q.d. (times
five days for a 14-day course total for pneumonia).
5. Dilaudid 2 mg to 6 mg per nasogastric tube q.6h. (for
abdominal pain).
6. Phenobarbital belladonna alk one tablet p.o. q.4h. (for
abdominal pain).
7. Oxycodone sustained release 30 mg per nasogastric tube
q.12h. (for abdominal pain).
8. Clonazepam 0.5 mg per nasogastric tube b.i.d. (for
anxiety).
9. Lansoprazole 30-mg solution per nasogastric tube q.d.
10. Ambien 10 mg per nasogastric tube q.h.s.
11. Tylenol 500 mg to 1 g per nasogastric tube q.8h. as
needed (for fever).
12. Lovenox 40 mg subcutaneously q.12h.
13. Senna one tablet per nasogastric tube q.h.s. as needed.
14. Amitriptyline 25 mg per nasogastric tube q.h.s.
15. Sertraline 100 mg per nasogastric tube q.d.
16. Buspirone 10 mg per nasogastric tube b.i.d.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. For treatment the patient was to have tube feeds at 50 cc
per hour with Peptamen VHP full strength.
2. She was to be placed on aspiration precautions at all
times with the head of the bed never lower than 45 degrees
and 90 degrees when the patient is receiving tube feeds.
3. Gastroenterology concluded that the patient could have
oral intake as tolerated; including broth without fat,
crackles, and gingerale.
4. The patient was to receive physical therapy at the
rehabilitation facility and would eventually be discharged to
home on tube feeds.
[**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 36622**]
Dictated By:[**Last Name (NamePattern1) 5851**]
MEDQUIST36
D: [**2162-3-25**] 14:26
T: [**2162-3-25**] 16:01
JOB#: [**Job Number 36624**]
|
[
"300.4",
"263.9",
"569.62",
"507.0",
"453.8",
"577.1",
"564.1",
"560.9",
"453.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"39.50",
"97.03",
"99.15",
"39.90",
"46.39"
] |
icd9pcs
|
[
[
[]
]
] |
26490, 26578
|
3117, 3283
|
26599, 27317
|
13818, 14859
|
27344, 28390
|
15863, 26466
|
3306, 3814
|
28423, 29258
|
4928, 5436
|
2132, 2873
|
2890, 3100
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,957
| 199,654
|
54230
|
Discharge summary
|
report
|
Admission Date: [**2111-1-29**] Discharge Date: [**2111-1-31**]
Date of Birth: [**2059-3-29**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Loss of consciousness while driving causing motor vehicle
collision
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname 9056**] is a 51 yo LHF who was admitted to the trauma service
following a MVC preceded by LOC. She was driving at 40 mph when
she suddenly began feeling sweaty, nauseous and dizzy as if she
was going to pass out. The next thing she remembers is being
awoken in her crashed car by sternal rub. She was GCS of 15
after being awakened. Per report she t-boned another car and hit
a trash bin on a sidewalk by the Cheesecake Factory. On arrival
to the ED her blood glucose was 95. She endorsed only
mid-low-back pain, denying HA, dizziness, vision changes, focal
weakness, paresthesias or numbness.
Past Medical History:
Low back pain
Headaches
Right arm parasthesias
Social History:
Lives with her mother and special-needs sister. Worked until
[**Month (only) **] at [**Hospital1 112**] as a medical administrator. Denies tobacco,
etoh and illicit drug use.
Family History:
Notable for paternal prostate cancer and DM, maternal DM.
Multiple paternal aunts with breast cancer. Healthy 21 year old
daughter.
Physical Exam:
At discharge:
VSS 97.4 67 93/60 16 95%RA GCS 15
General: Awake, cooperative,conversant, NAD, A&Ox4.
Head and Neck: NCAT, no scleral icterus, MMM, no midline c-spine
TTP as well sa full painless ROM at the neck.
Pulmonary: CTAB
Cardiac: RRR, normal S1, S2. No M/R/G
Abdomen: soft, non-tender, normoactive bowel sounds, no masses
or
organomegaly noted.
Extremities: Tender arms bilaterally. 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neuro: intact for 2+ DTRs, 5/5 strength bilat, sensation grossly
intact, PERRL. Noted by neuro to have: [**Hospital1 **]-occular diplopia worse
on distant gaze. Slight palsy of left eye on lateral gaze.
Pertinent Results:
12.7
7.1>----<259
35.7
Na:142
K:3.4
Cl:104
TCO2:21
Glu:95
Lactate:1.7
pH:7.45
Hgb:14.0
CalcHCT:42
TRAUMA
PT: 11.9 PTT: 26.8 INR: 1.0
Fibrinogen: 351
[**2111-1-29**] 6:10p
UA: Yellow / clear / >/= 1.035 / 6.5 / Urobil Neg / Bili Neg /
Leuk
Sm / Bld Neg / Nitr Neg / Prot Tr / Glu Neg / Ket Neg / RBC 0 /
WBC
[**5-28**] / Bact Mod / Yeast None / Epi [**2-20**]
3:44p
BUN 13 / Cr 0.8
estGFR: >75
CK: 68
Lip: 25
Cardiac enzymes: troponins x 4
ECG Sinus rhythm.
Imaging [**2111-1-29**]:
CT CHEST/ABD/PELVIS
1. No fractures or other acute traumatic injury seen.
2. Fibroid uterus.
3. 3.7 cm left adnexal cyst. If the patient is still
menstruating, then follow up with pelvic ultrasound is
recommended in six weeks. If the patient is postmenopausal, then
a follow up pelvic ultrasound is recommended in three months for
further [**Year/Month/Day 2742**].
CT HEAD
IMPRESSION: 1.0 x 0.9 x 0.8 cm area of hyperdensity located
within the posterior aspect of the right pons, likely
hemorrhage,
but an underlying vascular malformation (ie. capillary
telangiectasia) or mass is not excluded. Recommend MR for
further
[**Year/Month/Day 2742**].
CT C-Spine
IMPRESSION: No fracture or malalignment. Multilevel degenerative
changes, most prominent at level C6-C7 with mild posterior disc
bulge resulting in mild central canal stenosis.
MRI brain:
Findings are most suggestive of a cavernoma with adjacent
developmental venous
anomaly. No evidence of underlying nodular or mass-like
enhancement. Given
lack of surrounding edema, acute hemorrhage in this area is
unlikely. Follow
up MRI can be performed to assess for any change if clinical
concern persists
Repeat CT head [**2111-1-30**]:
1.0cm hyperdense lesion in right superoposterior pons, likely a
cavernoma
Brief Hospital Course:
The patient was admitted to the trauma service on [**2111-1-29**] after
a loss of consciousness which resulted in an MVC. The only
abnormality on [**Date Range 2742**] for traumatic injury found was a
pontine cavernoma suspicious for slow hemorrhage.
Neuro: Due to the finding of the cavernoma, both neurology and
neurosurgery were consulted. Neurology thought it was likely
that the cavernoma was bleeidng slowly, causing her symptoms and
subsequent accident. She did, however, maintain normal mental
status for her entire hospitalization. As cavernomas can be
genetic, neurology said screening siblings and daughter as
out-patient could be considered. Both teams recommended follow
up with the neurosurgeon Dr. [**First Name (STitle) **]. Additionally, the
neurosurgery team recommended follow up with ENT as an
out-patient for [**First Name (STitle) 2742**] of chronic vertigo symptoms.
Additionally, while admitted, the patient took oral pain
medications with excellent control of pain. Prior to discharge,
she was verbally instructed not to drive by several parties,
including the trauma team.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored and were normal. A syncope
work-up was initiated, including cycling cardiac enzymes
(negative x 4), ECG on arrival (NSR) and monitoring on telemetry
x 2 days (no significant arrhthymias noted). The patient will
need to have an echocardiogram as an out-patient to evaluate for
wall motion abnormalities, valvular dysfunction or chamber
enlargement. She had no murmurs on cardiac exam.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: After admission, the patient was resuscitated with IV
fluids until tolerating oral intake. Her diet was advanced when
appropriate, which was tolerated well. Intake and output were
closely monitored.
Prophylaxis: The patient not started on subcutaneous heparin
during this stay, given the concern for bleeding cavernoma, but
was encouraged to get up and ambulate as early as possible,
which she did on HD1. She took a PPI while admitted.
MSK: The pt did complain of low back pain after the accident,
with stable neurologic exam as noted above as well as no
incontinence, LE weakness, fevers, decreased rectal tone or
other concerning symptoms. She was treated for this with
Percocet. Additionally, her c-collar was cleared on HD#1 as she
had no cervical tenderness and full painless ROM.
At the time of discharge on HD#3, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
Ibuprofen, MVI, primrose oil.
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain for 7 days.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: 1) syncope, 2) motor vehicle collision (loss of
consciosness while driving causing MVC), 3) right pontine
cavernoma, 4) vertigo
Secondary: 1) Low back pain, 2) headaches, 3) right arm
parasthesias
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
VSS 97.4 67 93/60 16 95%RA
GCS 15, neurologically intact for 2+ DTRs, 5/5 strength bilat,
sensation grossly intact, PERRL. Noted by neuro to have:
[**Hospital1 **]-occular diplopia worse on distant gaze. Slight palsy of left
eye on lateral gaze.
Discharge Instructions:
You were admitted to the trauma service at [**Hospital1 18**] after your
motor vehicle collision.
*In [**Hospital1 2742**] after your accident, you were found to have a
lesion in your brainstem called a Cavernoma (a malformed vein).
You were evaluated by neurology and neurosurgery, who thought
you were safe to go home at this time. However, it is important
to carefully monitor your condition and, if you develop any of
the warning symptoms below, please call or return to the ED.
* Additionally, neurosurgery has recommended that you follow up
with the ENT (ear nose and throat) doctors [**First Name (Titles) **] [**Last Name (Titles) 2742**] of
your vertigo (sensation of room spinning).
*Given the loss of consiousness prior to your accident, you were
kept in the hospital to evaluate your heart with continuous
monitoring (to look for any abnormal heart rhythms) and blood
tests (to look for a heart attack). No abnormalites of these
tests were found. You will need to have an ultrasound
[**Last Name (Titles) 2742**] of your heart (called an echocardiogram) as an
out-pattient. Please talk to your regular doctor [**First Name (Titles) **] [**Last Name (Titles) 111122**]g this test.
* Car accidents very commonly cause muscle strains and aches,
especially in the shoulders and low back. Symptoms often
develop a few hours after the accident, and can last from [**12-22**]
days. Apply cold compresses for the first 24-48 hours, and hot
packs thereafter.
* You should plan on resting for a few days until you feel well.
Many people get more sore for 1-2 days before starting to feel
better.
* Over the counter pain-relievers such as ibuprofen (Advil,
Motrin) are very helpful (unless your doctor has told you not to
take this medication.)
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Warning signs:
Call your doctor or return to the Emergency Department right
away if any of the following problems develop:
* [**Name2 (NI) **] or worsening pain in your head, chest or abdomen (belly).
* Difficulty breathing or fevers greater than 101 degrees (F)
* Numbness, tingling, weakness or shooting pain in an arm or
leg.
* New trouble controlling your bowels or urine.
* If you are vomiting and cannot keep in fluids or your
medications.
* You have recurrent loss of consciousness in the next 6 months.
* You experience new chest pain, pressure, squeezing,
tightness, a rapid heartbeat or palpitations.
* You have new or worsening difficulty breathing.
* You develop severe headache, dizziness, confusion or change in
behavior.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
Please call Ear, Nose and Throat (ENT) Clinic for an
appointment. Phone [**Telephone/Fax (1) 41**]. Location [**Hospital Ward Name **] 6E. The purpose
of your [**Hospital Ward Name 2742**] is to rule out a vestibular cause of your
vertigo, as recommended by neurosurgery.
You will need to follow up with Neurosurgery 1 week after you
are seen by ENT. Please call [**Telephone/Fax (1) 88**] for an appointment
with Dr. [**First Name (STitle) **].
Please follow up with Trauma Clinic in [**1-21**] weeks. Phone
[**Telephone/Fax (1) 6429**] for an appointment.
Call your PCP to let him know about the accident and schedule a
follow up appointment.
|
[
"621.8",
"780.2",
"724.2",
"782.0",
"228.02",
"E812.0",
"784.0",
"218.1",
"368.2",
"E849.5"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6825, 6831
|
3893, 6578
|
338, 345
|
7082, 7082
|
2105, 2524
|
10469, 11122
|
1271, 1406
|
6658, 6802
|
6852, 7061
|
6604, 6635
|
7477, 10446
|
1421, 1421
|
1435, 2082
|
2541, 3870
|
231, 300
|
373, 991
|
7096, 7453
|
1013, 1061
|
1077, 1255
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,776
| 165,034
|
11440
|
Discharge summary
|
report
|
Admission Date: [**2105-8-27**] Discharge Date: [**2105-8-31**]
Date of Birth: [**2048-5-17**] Sex: M
Service: NSU
HISTORY OF PRESENT ILLNESS: This is a 54-year-old gentleman,
with difficulty walking, first noting left leg weakness about
5 years ago. Over the past several years, increased left leg
weakness and difficulty lifting left leg up, has been
dragging left leg for past year. He has been using cane for
past 2 weeks. No bowel or bladder incontinence. PPD
negative. Biopsy reportedly negative.
PAST MEDICAL HISTORY: Negative.
PAST SURGICAL HISTORY: Appendectomy.
MEDICATIONS: Propoxy-N/APAP.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Nonsmoker. Works as a [**Company 2318**] bus driver.
PHYSICAL EXAM: He is 5 feet 8 inches, 280 pounds. Spastic
gait, using cane. Upper extremities: Strength 5/5. IP: On
the right 4, on the left 3 plus. Hamstrings: On the right
5, on the left 4 plus. Quads: On the right 5, on the left
5. Dorsiflexion: On the right 5, on the left 4 plus.
Plantar flexion: On the right 5, on the left 5. Plus 4
patellar reflexes. Upper extremity hyperactive. Eight beat
clonus on the right. A sustained clonus on the left.
MRI shows T10-11 destructive process with paraspinal mass and
irregular enhancement. There was positive cord compression
at T10-11 with his pharynx extending to the C-spine.
Impression at the time was thoracic myelopathy.
HOSPITAL COURSE: The patient received a thoracic laminectomy
and placement of syringopleural shunt. Postoperative course
was uncomplicated. Physical therapy and occupational therapy
were consulted. He was discharged to extended care facility
for acute rehab.
DISCHARGE INSTRUCTIONS: Keep the staples dry. Call for
fever or any signs of infection, redness, swelling or
drainage from wound.
Please monitor for the following: Fevers, chills, nausea,
vomiting, inability to tolerate food or drink. If any of
these occur, please contact your physician [**Name Initial (PRE) 2227**].
FINAL DIAGNOSES: Syringomyelia
Status post thoracic laminectomy and placement of
syringopleural shunt.
RECOMMENDED FOLLOW-UP: Follow-up with Dr. [**Last Name (STitle) 1327**] for staple
removal 2 weeks postop, [**2105-9-8**]. Call for an appointment
at [**Telephone/Fax (1) 3231**].
MAJOR SURGICAL OR INVASIVE PROCEDURE: Thoracic laminectomy
and placement of syringopleural shunt.
DISCHARGE CONDITION: Neurologically stable.
DISCHARGE MEDICATIONS:
1. Percocet.
2. Colace.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 12001**]
Dictated By:[**Last Name (NamePattern1) 15649**]
MEDQUIST36
D: [**2105-8-31**] 10:48:11
T: [**2105-8-31**] 11:17:45
Job#: [**Job Number 36562**]
|
[
"336.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.79"
] |
icd9pcs
|
[
[
[]
]
] |
2356, 2417
|
2439, 2463
|
2486, 2763
|
1457, 1703
|
1728, 2028
|
589, 673
|
761, 1439
|
2046, 2317
|
165, 531
|
554, 565
|
690, 745
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,551
| 122,828
|
35261
|
Discharge summary
|
report
|
Admission Date: [**2192-6-19**] Discharge Date: [**2192-7-8**]
Date of Birth: [**2138-10-1**] Sex: M
Service: SURGERY
Allergies:
Iodine; Iodine Containing / Optiray 350
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
cholangioca
Major Surgical or Invasive Procedure:
[**2192-6-19**]: Exploratory laparotomy
[**2192-6-30**]: Umbilical hernia repair and exploratory laparotomy
Social History:
Married.
Brief Hospital Course:
On [**2192-6-19**], he underwent exploratory laparotomy noting multiple
peritoneal nodules allconfirmed by frozen section to be
consistent with metastatic cholangiocarcinoma.Based upon the
presence of carcinomatosis he was not surgically resectable. He
was given dilaudid pca for pain, but experienced intermittent
nausea requiring zofran.
On postop day 3, he vomited a small amount and experienced
bright red blood from his incision. Hematocrit had trended down
to 31 from preop of 40.5. Dr. [**First Name (STitle) **] opened the medial portion
of the incision a small amount. No further bleeding was noted. A
CXR was obtained for decreased O2 sats as well as sinus
tachycardia. This showed distended stomach. An NG tube was
placed to decompress the stomach.KUB revealed a nonspecific
bowel gas pattern. He was transferred to the SICU for
management. Two units of prbc were administered. Serial hcts
remained stable. Once stable, he was transferred out of the SICU
on TPN.
Diet was slowly advanced, but not well tolerated over the
following 2 days. He became increasingly distended and
experienced emesis. On [**2192-6-26**], a KUB demonstrated dilated loops
of small bowel measuring up to 4.8 cm that was compatible with
obstruction without gas seen distally. He was made NPO again. NG
tube was placed. Distension did not resolved. An ABD CT was
done on [**6-29**] showing a small-bowel obstruction with transition
point at a small bowel-containing hernia in the mid anterior
abdominal wall. Small amount of free fluid was noted in the
abdomen. On [**2192-6-30**], Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] took him to the OR for
exploratory laparotomy and repair of an umbilical hernia for
ileus and elevated WBC (31).
Postop, he was continued on TPN. Upon slow return of bowel
function, diet was advanced and tolerated. WBC decreased. Vital
signs were stable. The incision had a fair amount of ascitic
appearing drainage from the lateral portion. A wound pouch was
applied. This drainage averaged 560-750cc/day.
Physical therapy worked with him throughout his hospital course.
After his second surgery, he was assisted out of bed and became
independent with ambulation.
He was discharged home with VNA of Southeastern MA
1-[**Telephone/Fax (1) 80441**] for nsg services, hospital bed from [**Last Name (un) 8529**]
1-[**Telephone/Fax (1) 80442**].
Medications on Admission:
lisinopril 10'
Discharge Medications:
1. Hospital Bed
Semi-Electric Hospital Bed
DX: cholangiocarcinoma (unresectable)
Abdominal Incision
Indication: Needed for position changes/comfort
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety. Tablet(s)
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
metastatic cholangiocarcinoma, unresectable
ileus
small bowel obstruction
umbilical hernia, repaired
Discharge Condition:
stable
Discharge Instructions:
Please call Dr. [**First Name (STitle) **] or return to the ED if you experience
fevers >101.5F, chills, nausea, vomiting, bleeding or
foul-smelling drainage from your wound, increased abdominal pain
or bloating.
You may change your wound collection bag as needed to contain
wound drainage. If the drainage becomes bloody or
foul-smelling, please call Dr.[**Name (NI) 670**] office. If you prefer
to have a vac dressing applied to the wound instead of the
collection bag, please call Dr.[**Name (NI) 670**] office as well.
Followup Instructions:
Please call Dr.[**Name (NI) 670**] office at [**Telephone/Fax (1) 673**] to schedule a
follow-up appointment for 2 weeks post-discharge.
Completed by:[**2192-7-12**]
|
[
"E878.8",
"198.89",
"997.4",
"155.1",
"998.12",
"197.6",
"401.9",
"998.11",
"197.8",
"552.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.4",
"53.49",
"99.15",
"54.11"
] |
icd9pcs
|
[
[
[]
]
] |
3589, 3645
|
468, 2856
|
309, 419
|
3790, 3799
|
4373, 4541
|
2921, 3566
|
3666, 3769
|
2882, 2898
|
3823, 4350
|
258, 271
|
435, 445
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,868
| 198,600
|
42207
|
Discharge summary
|
report
|
Admission Date: [**2185-8-15**] Discharge Date: [**2185-8-21**]
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2185-8-15**]
1. Aortic valve replacement with a 27-mm [**Company 1543**] Ultra
bioprosthesis, model number 305, serial number
[**Serial Number 91507**].
2. Coronary artery bypass grafting times 3 with left
internal mammary artery to left anterior descending
coronary artery; reverse saphenous vein single graft
from the aorta to the first obtuse marginal coronary
artery; reverse saphenous vein single graft from the
aorta to the distal right coronary artery.
3. Endoscopic left greater saphenous vein harvesting.
History of Present Illness:
This is an 88yo male with known
aortic stenosis and chronic atrial fibrillation. Serial
echocardiograms have [**Last Name (un) 22315**] progression of his aortic valve
disease. He remains active but has noted worsening dyspnea on
exertion. He denies chest pain, chest tightness, palpitations,
pedal edema, orthopnea, PND, syncope and presyncope. He is now
referred for cardiac surgical intervention by his local
cardiologist.
Past Medical History:
Aortic Stenosis
Coronary Artery Disease
PMH:
- Hypertension
- Atrial Fibrillation, History of DCCV [**2180**](none since)
- Right Inguinal Hernia
Past Surgical History:
s/p Left Ankle
s/p Left Lower Extremity ORIF
s/p Bilateral Lens Implants
Social History:
Lives with: Wife
Occupation: Retired businessman
Cigarettes: Remote, no tobacco for over 50 years
ETOH: occasional, no history of abuse
Illicit drug use: denies
Family History:
Denies premature coronary artery disease
Physical Exam:
Pulse: 52 Resp: 16 O2 sat: 100%
B/P Right: 154/85 Left: 170/85
General: Elderly male, WDWN, in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [x] grade 3/6 systolic
ejection murmur best heard at RUSB, radiates to carotids
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
+ small right inguinal hernia noted
Extremities: Warm [x], well-perfused [x] Edema: None
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: transmitted murmurs
Pertinent Results:
[**2185-8-19**] 06:00AM BLOOD WBC-12.6* RBC-3.32* Hgb-10.1* Hct-28.3*
MCV-85 MCH-30.4 MCHC-35.6* RDW-13.9 Plt Ct-147*
[**2185-8-18**] 06:05AM BLOOD WBC-15.5* RBC-3.23* Hgb-9.8* Hct-27.8*
MCV-86 MCH-30.3 MCHC-35.3* RDW-13.8 Plt Ct-109*
[**2185-8-19**] 06:00AM BLOOD PT-13.9* INR(PT)-1.2*
[**2185-8-18**] 06:05AM BLOOD PT-14.4* INR(PT)-1.2*
[**2185-8-15**] 01:14PM BLOOD PT-17.2* PTT-34.2 INR(PT)-1.5*
[**2185-8-19**] 06:00AM BLOOD Glucose-89 UreaN-36* Creat-1.6* Na-135
K-3.6 Cl-98 HCO3-24 AnGap-17
[**2185-8-18**] 06:05AM BLOOD Glucose-93 UreaN-34* Creat-1.7* Na-131*
K-3.7 Cl-96 HCO3-25 AnGap-14
[**2185-8-17**] 01:56AM BLOOD Glucose-124* UreaN-29* Creat-1.9* Na-132*
K-4.7 Cl-99 HCO3-22 AnGap-16
[**2185-8-18**] 06:05AM BLOOD Mg-2.3
Intra-op TEE [**2185-8-15**]
Conclusions
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. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is dilated with normal free wall contractility. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. There are simple atheroma in the
ascending aorta. There are simple atheroma in the aortic arch.
The descending thoracic aorta is mildly dilated. There are
complex (>4mm) atheroma in the descending thoracic aorta. There
appear to be three aortic valve leaflets but the valve is
functionally bicuspid. The aortic valve leaflets are severely
thickened/deformed. There is systolic doming of the aortic valve
leaflets. There is critical aortic valve stenosis (valve area
<0.8cm2). No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**12-5**]+) mitral
regurgitation is seen. Dr. [**Last Name (STitle) 914**] 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 is well seated and the
leaflets appear to be moving normally in limited views. There is
no aortic regurgitation seen. The peak gradient through the
valve was 11 mmHg with a mean of 6 mmHg at a cardiac output of
4.5 liters/minute. The effective orifice area is approximately
1.6 cm2. The tricuspid regurgitation appears slightly worsened
from the pre-bypass study. The thoracic aorta appears intact
after decannulation. No other significant changes from the
pre-bypass study.
Brief Hospital Course:
The patient was brought to the Operating Room on [**2185-8-15**] where
the patient underwent AVR, CABG with Dr.[**Last Name (STitle) 914**].
Cardiopulmonary bypass time was 144 minutes and cross clamp time
was 113 minutes. 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 hemodynamically stable,
weaned from inotropic and vasopressor support. He did exhibit
some post-op delirium and was treated with Haldol. This cleared
by POD 3. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. The patient was
transferred to the telemetry floor for further recovery. QTc
was slightly prolonged initially, but would show progressive
improvement. He continued to exhibit paroxysmal atrial
fibrillation, consistent with his pre-op rhythm. Coumadin was
resumed. Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. Following
discussion with Dr. [**Last Name (STitle) 39975**] (the patient's cardiologist) Sotalol
was resumed and Lopressor discontinued. By the time of
discharge on POD #6 the patient was ambulating freely, the wound
was healing and pain was controlled with oral analgesics. The
patient was discharged to home in good condition with
appropriate follow up instructions.
Medications on Admission:
Warfarin 5mg daily, Sotalol 40mg twice
daily, Diovan 40mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. sotalol 80 mg Tablet Sig: [**12-5**] Tablet PO twice a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day:
Indication; afib
Goal INR 2.0-2.5.
Disp:*60 Tablet(s)* Refills:*2*
9. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 7 days.
Disp:*28 Tablet Extended Release(s)* Refills:*0*
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Home health and hospice care
Discharge Diagnosis:
Aortic Stenosis
Coronary Artery Disease
PMH:
- Hypertension
- Atrial Fibrillation, History of DCCV [**2180**](none since)
- Right Inguinal Hernia
Past Surgical History:
s/p Left Ankle
s/p Left Lower Extremity ORIF
s/p Bilateral Lens Implants
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2185-9-20**] 1:45pm in the [**Hospital **] medical office building
[**Hospital Unit Name **]
You are scheduled for the following appointments:
Wound Check [**Telephone/Fax (1) 170**] in the [**Hospital **] medical office building
[**Hospital Unit Name **]
Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39975**] [**9-14**] at 1:20pm
Please call to schedule the following:
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**3-8**] weeks, ([**Telephone/Fax (1) 74441**]
**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 atrial fibrillation
Goal INR 2-2.5
First draw Monday, [**2185-8-22**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**Last Name (STitle) **]
Completed by:[**2185-8-21**]
|
[
"424.1",
"276.1",
"780.09",
"427.31",
"401.9",
"414.01",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.12",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
8181, 8240
|
5327, 6880
|
245, 792
|
8526, 8697
|
2531, 5304
|
9485, 10573
|
1709, 1752
|
6995, 8158
|
8261, 8407
|
6906, 6972
|
8721, 9462
|
8430, 8505
|
1767, 2512
|
185, 207
|
820, 1248
|
1270, 1416
|
1530, 1693
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,180
| 166,213
|
28920+57614
|
Discharge summary
|
report+addendum
|
Admission Date: [**2130-7-29**] Discharge Date: [**2130-8-15**]
Date of Birth: [**2063-2-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
67M with acute onset of back pain.
Major Surgical or Invasive Procedure:
Replacement of ascending aorta and hemiarch/Resuspension of the
aortic valve [**2130-7-29**]
Fem-fem bypass [**2130-7-30**]
Fasciotomy of R leg [**2130-7-31**]
History of Present Illness:
This 67WM has no significant PMHx and presented to the [**Hospital 4683**] ED with acute back pain. He had a type A dissection of
the aorta extending from the aortic arch to the aortic
bifurcation and the R common iliac. He was transferred via Med
flight and went directly to the OR.
Past Medical History:
None
Pertinent Results:
[**2130-8-5**] 05:30AM BLOOD PT-13.9* PTT-29.3 INR(PT)-1.2*
[**2130-8-11**] 07:10AM BLOOD Glucose-101 UreaN-24* Creat-1.2 Na-139
K-4.4 Cl-101 HCO3-27 AnGap-15
[**2130-8-3**] 06:50AM BLOOD ALT-92* AST-184* LD(LDH)-598*
CK(CPK)-3098* AlkPhos-47 TotBili-0.5
[**2130-8-12**]: WBC 13,000, Hct 30.6 Plt 618,000
RADIOLOGY Final Report
CHEST (PA & LAT) [**2130-8-10**] 11:35 AM
CHEST (PA & LAT)
Reason: pleural effusion
[**Hospital 93**] MEDICAL CONDITION:
67 year old man Type A dissection involving iliac arteries s/p
Aortic Arch/hemiarch repair
REASON FOR THIS EXAMINATION:
pleural effusion
TYPE OF EXAMINATION: Chest PA and lateral.
INDICATION: Status post aortic repair area, followup
examination, evaluate effusion.
FINDINGS: AP and lateral chest views obtained with the patient
in sitting upright position are analyzed in direct comparison
with an AP portable chest examination obtained on [**2130-8-8**]. Heart size is unchanged. No pulmonary congestion has
developed. During the interval, the right-sided chest tube has
been removed, but the left-sided chest tube remains. No
pneumothorax has developed. However, the blunting of the
right-sided pleural sinus has increased slightly with the
density reaching the level of the minor fissure. No new
pulmonary infiltrates have developed. No pneumothorax
identified.
IMPRESSION: Removal of right-sided chest tube with slightly
increased pleural fluid accumulation on the right base. No other
new abnormalities.
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
Cardiology Report ECHO Study Date of [**2130-8-5**]
PATIENT/TEST INFORMATION:
Indication: R/o Thrombus.
Height: (in) 67
Weight (lb): 204
BSA (m2): 2.04 m2
BP (mm Hg): 130/47
Status: Inpatient
Date/Time: [**2130-8-5**] at 14:54
Test: Portable TTE (Focused views)
Doppler: No Doppler
Contrast: None
Tape Number: 2006W027-0:52
Test Location: West [**Hospital Ward Name 121**] [**1-6**]
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV cavity size. Suboptimal technical
quality, a focal
LV wall motion abnormality cannot be fully excluded. Cannot
assess LVEF. No LV
mass/thrombus.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3).
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
PERICARDIUM: No pericardial effusion.
Conclusions:
1. The left atrium is mildly dilated.
2. 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 cannot be reliably assessed.
No masses or
thrombi are seen in the left ventricle.
3. The aortic valve leaflets (3) are mildly thickened.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1445**], MD on [**2130-8-5**] 15:09.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
Brief Hospital Course:
Pt transferred from [**Hospital3 10310**] Hospital after CT scan
showed Type A aortic dissection. He was brought emergently to
operating room were he had a Replacement of Ascending Aorta and
Hemiarch/resuspesion of Aortic valve and repair of intimal tears
w/plegets. His bypass time was 162 minutes, crossclamp 95
minutes, Circ arrest 5 minutes. Please see OR report for full
details. Additionally the patient was noted to have right leg
ischemia with a mottled right foot and had a CFA-CFA bypass w
#8ringed PTFE by Dr [**Last Name (STitle) 3407**] of the Vascular surgery service.
Please see OR report for details. Pt tolerated the operations
and was transferred from OR to ICU he was hemodynamically
stable.
The patient was kept sedated through POD1 and on POD2 sedation
was weaned and extubated. The patient was also noted to have
right leg compartment syndrome and returned to the operating
room for fasciotomy of right lower leg with Dr [**Last Name (STitle) 3407**]. The
patient remained in the ICU until POD4 when he was transferred
to the stepdown floor for continued post-op care.
On POD6 the patient was noted to have left sided weakness and
facial droop, a CT showed multiple bilateral strokes and a
Neurology consult was obtained. The facial droop resolved, left
sided weakness gradually resolved and the patient continued to
work with PT/OT postoperatively.
On POD 15/14 it was decided that the patient was stable and
ready to be discharged to rehabilitation. He is to be followed
by CT surgery, Vascular surgery and Neurology after discharge
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. 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*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
Disp:*50 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:*2*
5. Oxycodone 10 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*
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day.
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 8 days.
Disp:*8 Tablet(s)* Refills:*0*
11. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale unit Injection QAC&HS.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Ao arch and hemiarch repair
s/p Fem-fem bypass, s/p R fasciotomy
s/p Lft sided CVA
Discharge Condition:
good
Discharge Instructions:
keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds
Do not drive for 4 weeks.
Do not lift more than 10 lbs for 2 months
Followup Instructions:
Dr [**Known firstname **] [**Last Name (NamePattern1) 1968**] in [**12-5**] weeks
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8573**] in [**1-6**] weeks
Dr [**Last Name (STitle) 7772**]/[**Doctor Last Name **](Cardiac surgery) in 4 weeks
Dr [**Last Name (STitle) **](Vascular) in 2 weeks.
Dr [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **](Neurology) in [**2-4**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2130-8-14**] Name: [**Known lastname 11861**],[**Known firstname **] Unit No: [**Numeric Identifier 11862**]
Admission Date: [**2130-7-29**] Discharge Date: [**2130-8-15**]
Date of Birth: [**2063-2-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 741**]
Addendum:
Patient had his Foley removed last week, he had difficulty
urinating, and it was subsequently replaced. He was started on
Flomax at that time. His catheter was again removed this
morning, and he is due to void by [**3-9**] pm today.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2130-8-15**]
|
[
"424.1",
"997.02",
"443.29",
"434.11",
"438.20",
"305.1",
"729.9",
"441.03",
"728.89",
"443.22",
"788.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.59",
"88.72",
"38.45",
"39.29",
"35.11",
"99.07",
"39.61",
"83.09",
"99.05",
"39.59",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8725, 8918
|
4097, 5655
|
355, 517
|
7272, 7279
|
879, 1297
|
7548, 8702
|
5710, 7048
|
1334, 1425
|
7162, 7251
|
5681, 5687
|
7303, 7525
|
2530, 3954
|
281, 317
|
1454, 2504
|
545, 832
|
3986, 4074
|
854, 860
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,933
| 124,281
|
8357
|
Discharge summary
|
report
|
Admission Date: [**2111-4-17**] Discharge Date: [**2111-6-30**]
Date of Birth: [**2055-3-2**] Sex: F
Service: SURGERY
Allergies:
Cipro / Doxycycline / Paxil / Quinine / Compazine / Levaquin /
Lithium / Cefepime
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Diarrhea and vomiting
Major Surgical or Invasive Procedure:
Endoscopy, intubation, central line placement, PICC line
placement, LOA with enterotomies and ostomy creation
History of Present Illness:
Mrs. [**Known lastname **] is a 56 year old woman with a history of hepatic
sarcoidosis s/p TIPS, chronic partial small bowel obstructions,
and know grade II varices and esophagitis who was recently
discharged from this service who was re-admitted with melanotic
stools and vomiting. The day following discharge she reports
crampy abdominal pain and 14 episodes of tarry stools as well as
nausea and vomiting of bilious fluid, no coffee grounds or
blood. She denies dizziness, lightheadedness, or sweats. She
went to the ED where she was guaiac positive with no frank
blood. She was started on IV PPI, octreotide drip, and admitted
to medicine. Of note, she was discharged with an HCT of 24.6 and
re-admitted with a HCT of 22.5 which fell to 21.0 after 8hrs.
She was transfused 1U pRBC and bumped to 23.7 and stabilized
thereafter. She is transfered back to the [**Doctor Last Name 3271**] [**First Name4 (NamePattern1) 679**] [**Last Name (NamePattern1) 4869**]
for further management.
.
On the floor her diarrhea initially improved ad then recurred on
tube feeds, erythromycin, and metoclopramide. She was also noted
to have eosinophilia and a low grade fever. There was concern
for malabsorption of the tube feeds v eosinophilic
gastroenteritis v sarcoid of the GI tract.
.
On [**2111-4-23**] underwent EGD to biopsy the small bowel for ?
eosinophilic enterocolitis and ? sarcoid of the GI tract. In
spite of being NPO she had a large volume of undigested food in
the stomach consistent with her ongoing GI dysmotility. She
aspirated during the procedure. Post procedure she became
increasingly hypoxic. She was transfered to the MICU where she
was intubated for hypoxia. She was empirically started on
vancomycin + pip/tazo for aspiration PNA. She became hypotensive
and was dependent briefly on pressors. On [**2111-4-24**] she underwent
bronchoscopy with BAL which showed GNRs in the lungs. She was
continued on vanco and pip/tazo. She improved and was extubated
and weanted from pressors. She was transfered back to the
[**Doctor Last Name 3271**] [**First Name4 (NamePattern1) 679**] [**Last Name (NamePattern1) 4869**] for further management of her ongoing GI
dysmotility. As of transfer her tube feeds had been restarted
and she began again to have diarrhea.
.
Past Medical History:
# Hepatic sarcoidosis and regenerative hyperplasia
- s/p TIPS [**12-19**] placed d/t GI bleeding from varices and portal
gastropathy
- TIPS re-do with angioplasty and portal vein embolectomy
- severe portal hypertensive gastropathy
- Grade II varices
- grade 3 esophagitis
# Multiple SBOs and partial SBOs, most recent [**2-20**]
# Concern for GI dysmotility syndrome pending further workup
# Idiopathic cardiomyopathy:
-ECHO demonstrating an EF of 15-20% (no report, ?OSH) and a
p-mibi that confirmed an EF of 23% with no ischemic changes-->
improving [**6-17**] to EF 40-45%, mild-to-moderate global left
ventricular hypokinesis
-Cardiac cath [**2-17**]: no angiographically apparent flow-limiting
lesions, mild mitral regurgitation, and severe systolic
ventricular dysfunction with a left ventricular ejection
fraction of 20%.
-Right heart cath: [**2109-2-18**]: Normal right sided filling
pressures. Mild pulmonary artery hypertension. Preserved cardiac
index.
# COPD, followed by [**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **], PFTs WNL
# Hx of SAH [**2101**] s/p coiling, 2 new aneurysms seen on angio
[**2108-6-21**]
# Colonic AVM and diverticulum
# Evidence of CVA/TIA
# Hypothyroidism
# Anemia
# s/p hysterectomy
# s/p cholecystecomy
# s/p appendectomy
# Reflex Sympathetic Dystrophy s/p fall, on disability, now
resolved
# Raynauds
# [**2111-2-7**] repair of abdominal fascial defect/ascites leak
Social History:
Married, lives in [**Hospital1 **], has 2 sons and 5 grandchildren, 36
pack-year smoking hx quit 2.5 years ago, does not drink EtOH and
denies former abuse, no h/o illicits or IVDU, does not work [**3-16**]
disability for RSD.
Family History:
[**Name (NI) 29555**] MI, [**Name (NI) 29556**]
Physical Exam:
GEN: NAD, sad, cachectic
VS: 98.9 141/74 86 20 97% on RA
HEENT: Dry MM, NG and Dophoff tube in place, no scleral icterus,
pale mucosa, flat jugular veins, R IJ in place
CV: RR, NL S1S2 II/VI SEM at the RUSB with no radiation to the
carotids, no S3S4, pulses 2+ at the radial and DP bilat
PULM: Distant breath sounds, clear to auscultation bilaterally,
no dullness to percussion
ABD: BS+, collaterals and telangectasia present, soft,
non-tender, mildly distended, no masses, spleen and liver not
palpable, gas on perussion, small amount of fluid on exam
LIMBS: 1+ LE edema, clubbing, dry skin with some excoriations
NEURO: PERRLA, EOMI, reflexes 2+ at the biceps and patella, toes
down bilaterally, no asterixis
Pertinent Results:
Baseline labs [**2111-4-16**]
WBC RBC Hgb Hct MCV RDW Plt C
4.1 2.86 8.5 24.6 86 17.6 114
PT PTT INR
12.9 31.4 1.1
Glucose UreaN Creat Na K Cl HCO3
115 12 0.7 134 4.2 109 19
ALT AST AlkPhos TotBili
21 29 502* 0.3
.
ABDOMEN (SUPINE & ERECT) Study Date of [**2111-4-17**] 10:42 PM
Multiple dilated air-filled loops of small bowel are seen
measuring up to 4.3 cm. On the upright view, there are several
differential air-fluid levels demonstrated. Gas is demonstrated
within the colon, which is not distended. A post-pyloric feeding
tube is seen with the tip of the feeding tube likely within the
jejunum. A TIPS is seen within the right upper quadrant of the
abdomen. The osseous structures are unremarkable. IMPRESSION:
Findings suggestive of early or partial small-bowel obstruction.
Feeding tube within the post-pyloric position.
.
MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS Study Date
of [**2111-4-20**] 11:18 AM FINDINGS: Again seen is moderate distention
of the small bowel. There is also some fluid distention of the
right colon. The small bowel is mildly thick-walled. There is
moderate edema within the right colonic wall. On the
post-contrast images, there is moderate enhancement of the
mucosa in these regions. There is no obvious transition seen in
the bowel dilatation. Overall, given that the patient has portal
hypertension, the findings are most likely secondary to that. No
evidence to suggest Crohn's disease. No abscess or fistula is
identified. A nasoduodenal tube is present. Foley catheter in
the bladder. 2-mm cyst in the upper pole of the left kidney. The
liver appears nodular. It is only partially imaged. Partially
imaged spleen is at least 15 cm in length. There is a small
amount of ascites. TIPS shunt is seen extending from the portal
vein to the hepatic vein. The inferior mesenteric vein is
distended. On the T2 fat-saturated images, there is
heterogeneous marrow signal intensity seen in the medial aspect
of the left femoral head. Multiplanar 2D and 3D reformations
delineated the dynamic series with multiple perspectives.
IMPRESSION: 1. Findings of cirrhosis with ascites and
splenomegaly. TIPS shunt is noted. 2. Dilated small bowel,
probably due to ileus. There is edema in the right colon, which
is probably due to portal hypertension. 3. There is increased
signal intensity seen on the T2-weighted images in medial aspect
of the left femoral head. This is nonspecific. If the patient
does not have hip pain, the findings could be due to bone marrow
edema from arthritis. the patient appears to have an osteophyte
extending from the posterior acetabulum. If the patient does
have hip pain, recommend CT to exclude fracture in the hip.
.
CHEST (PORTABLE AP) Study Date of [**2111-4-25**] 11:33 AM CHEST, AP
UPRIGHT PORTABLE: A right IJ central venous catheter terminates
at the cavoatrial junction. A nasogastric tube terminates in the
distal portion of the stomach. A new nasojejunal feeding tube,
placed since the film from the prior day, courses through the
stomach, its tip not visualized. The cardiac and mediastinal
contours are unchanged. There is persistent patchy left lower
lobe and lingular consolidation that is somewhat less extensive
in appearance. There is no pneumothorax or definite effusion.
The patient has been extubated.
.
Brief Hospital Course:
1. Respiratory Failure: The patient was transferred to the ICU
on [**4-23**] for hypoxia and presumed aspiration. She was intubated
upon arrival to the ICU. A Chest Xray showed a new LLL
infiltrate, which likely represented pneumonitis in response to
her aspiration. At the same time, she is at risk for
gram-negative infections given her recent hospitalizations. She
was started on vancomycin and zosyn given this risk for
pneumonia. She was given 5 liters of normal saline for
hypotension and briefly required levophed, likely in the setting
of propofol sedation. On [**4-24**], she underwent IR placement of a
post-pyloric dobhoff for tube feeds and an NG tube for
suction/decompression. A repeat KUB was obtained, which was
unchanged from [**4-17**], thereby decreasing suspicion for small bowel
obstruction. She also underwent bronchoscopy, which showed
largely normal anatomy, and BAL which was sent for gram
stain/culture. Sputum gram stain showed 25+ polys and 2+ yeast.
Following bromchoscopy, sedation was weaned, and the patient had
an excellent spontaneous breathing trial. She was extubated, and
was maintaining good oxygen saturation on nasal cannula and was
normotensive.
.
2. Fever. The patient was febrile prior to aspiration/transfer.
Differential includes pneumonia, infectious diarrhea, UTI, line
infection. Infectious workup, including c. diff, was negative
for diarrhea, and patient had no stools when TFs were stopped.
Per GI, the patient has a combination of gastric dysmotility and
intestinal hypermobility, which is likely the cause of her
diarrhea. Also has had CVL for 6 days so line infection is a
consideration. Plan to d/c CVL when extubated and
hemodynamically stable. Blood and urine cultures were also sent,
and showed no growth. The patient was also given stress dose
steroids.
3. Diarrhea. Per notes, somewhat improved over last couple
days. Initially coffee-ground and guaiac positive; now brown,
guaiac negative. Tube feeds held. Lactulose and [**Month/Day (4) 8005**]
continued. Infectious stool studies negative.
.
4. GI dysmotility. History of SBOs and pSBOs s/p multiple
ex-laps in past. Initially felt to have partial SBO on KUB but
was having diarrhea and flatus. MR enterography [**2111-4-19**] showed
right colonic edema consistent with portal hypertension. The
erythromycin and metoclopramide were stopped. NG and
post-pyloric dobhoff were placed as above. There was not
resolution On [**2111-5-15**] the patient was taken to the OR by Dr
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for lysis of adhesions as SBO was not resolving
with return of GI function. Several enterotomies were made and
an ostomy was created in the R lower quadrant. This is a very
large Ostomy and requires special appliances. Following the
surgery, the ostomy started having outout within a few days. On
occasion, the ostomy output was greater than 1 liter of stool,
octreotide was tried with good result, and towards the end of
the hospitalization, the stool has decreased significantly and
the octreotide has been stopped.
.
5. Cirrhosis: Secondary to sarcoidosis. Complicated by varices,
history of encephalopathy. Lactulose, [**Last Name (NamePattern1) 8005**], ursodiol,
nadolol were continued, but multiple adjustments were made over
the course of the hospitalization, please see the final med list
for current medications.
.
6. Sarcoidosis: Chronic issue. Related to her cirrhosis.
- continue steroids
7. Seizures: Continue phenytoin and keppra. These was some
reoccurence of seizure activity while the patient was in the ICU
following the surgery. Dosing was adjusted, continue to follow
dilantin levels weekly.
.
8 Nutrition: Initially had Dobhoff placed, but secondary to
bowel issues, this was stopped. Patient has been followed by
nutrition services with daily TPN. Caloric intake toward the end
of the hospitalization is not adequete, and TPN via PICC line
will be continued.
.
Long and complicated hospital course with many adjustements to
medications and therapies. Currently the only line is a PICC
line. The patient is devoid of all drains. She has an ostomy
that is well functioning. She will require aggressive PT and
education regarding Ostomy care, and continued nutritional
guidance.
Patient remians on the liver transplant list
Medications on Admission:
1. Erythromycin 250 mg every 6 hours
2. Metoclopramide 10 mg with meals and at bedtime
3. Prednisone 10 mg daily
4. Nadolol 20 mg daily
5. Levothyroxine 100 mcg daily
6. Spironolactone 50 mg daily
7. Omeprazole 20 mg daily
8. Mirtazapine 30 mg at bedtime
9. Ambien 5 mg at bedtime -held
10. Lactulose 30mL (20g) twice a day. Increase for confusion
11. Ursodiol 600mg (2 pills) in the morning and 300mg (1 pill)
in the evening
12. Levetiracetam (Keppra) 500 mg twice a day
13. Albuterol inhaler three time a day
14. Atrovent inhaler three times a day
15. Phenytoin (Dilantin) 100 mg three times a day
16. [**Last Name (NamePattern1) **] 400 mg (2 pills) three times a day
Discharge Medications:
1. [**Last Name (NamePattern1) **] 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily).
4. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**7-20**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for itching.
Disp:*60 Tablet(s)* Refills:*0*
7. Dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Saliva Substitution Combo No.2 Solution Sig: Thirty (30)
ML Mucous membrane QID (4 times a day).
Disp:*3600 ML(s)* Refills:*2*
9. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
13. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*90 Capsule(s)* Refills:*2*
14. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
Disp:*180 Tablet, Chewable(s)* Refills:*2*
17. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
18. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
19. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
20. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
21. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary: hepatic sarcoidosis, small bowel obstruction s/p lysis
of adhesions and enterotomy with ostomy creation
.
Secondary: Depression and anxiety, hypothyroidism, seizure
disorder
Discharge Condition:
Stable/Fair
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever >
101.5, chills, nausea, vomiting, increased diarrhea in the
ostomy, increased abdominal pain, abdominal wound drainage or
redness.
Continue all medications as ordered
Ostomy care per specific wound care guidelines
Ambulate TID
TPN via PICC line. PLease see specific TPN and diet
recommendations
Followup Instructions:
Call Transplant/Hepatology Office at [**Telephone/Fax (1) 673**] for
appointment week of [**7-7**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2111-7-13**] 9:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2111-6-30**]
|
[
"453.42",
"998.2",
"787.01",
"V17.49",
"V15.82",
"530.10",
"787.91",
"135",
"567.9",
"572.3",
"997.39",
"560.81",
"456.21",
"536.8",
"789.59",
"428.0",
"996.74",
"693.0",
"585.9",
"780.39",
"E947.8",
"428.22",
"458.9",
"537.89",
"E879.8",
"V49.83",
"285.29",
"571.5",
"507.0",
"496",
"438.89",
"E870.0",
"300.4",
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"572.8",
"V55.2",
"041.85",
"425.8",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.75",
"46.01",
"33.24",
"96.04",
"54.59",
"45.62",
"45.91",
"54.91",
"96.72",
"99.04",
"99.15",
"96.6",
"38.93",
"38.7",
"96.71",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
16004, 16076
|
8661, 12967
|
361, 473
|
16303, 16317
|
5285, 8638
|
16737, 17128
|
4489, 4538
|
13688, 15981
|
16097, 16282
|
12993, 13665
|
16341, 16714
|
4553, 5266
|
300, 323
|
501, 2774
|
2796, 4229
|
4245, 4473
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,862
| 192,202
|
24320
|
Discharge summary
|
report
|
Admission Date: [**2132-6-3**] Discharge Date: [**2132-6-27**]
Date of Birth: [**2073-2-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Head trauma
Major Surgical or Invasive Procedure:
[**6-3**] craniotomy with evacuation of epidural hemorrhage
[**6-3**] placement of ICP monitor
[**6-9**] percutaneous tracheostomy
[**6-9**] percutaneous endoscopic gastrostomy
[**6-13**] left ankle & toe ORIFs
[**6-15**] T6 vertebrectomy, thoracic spine fusion with iliac crest
bone graft
History of Present Illness:
59M construction worker who had 500 pound steel beam fall on his
head from a height of 3 feet. He seized immediately and was
subsequently intubated at the scene & transported to [**Hospital1 18**] for
further management.
Past Medical History:
unknown
Social History:
noncontrib
Family History:
noncontrib
Physical Exam:
T 99.0 P 110 BP 140/80
GCS 3T
Depressed calvarial fracture
Periorbital ecchymosis, equal pupils but non reactve
+c collar, trachea midline
Bilat BS, no crepitus, + clavicular fracture
Abd: soft
Rectal: decreased tone
Back: no stepoffs or obvious injuries
Not moving extremities
Pertinent Results:
See enclosed DVD for significant images
[**2132-6-26**] 03:32AM BLOOD WBC-11.6* RBC-3.47* Hgb-9.7* Hct-29.8*
MCV-86 MCH-27.9 MCHC-32.6 RDW-14.3 Plt Ct-594*
[**2132-6-25**] 03:15AM BLOOD PT-13.1 PTT-27.6 INR(PT)-1.1
[**2132-6-26**] 03:32AM BLOOD Glucose-116* UreaN-24* Creat-0.5 Na-134
K-3.9 Cl-100 HCO3-28 AnGap-10
Brief Hospital Course:
[**6-3**] craniotomy with evacuation of epidural hemorrhage
[**6-3**] placement of ICP monitor
[**6-9**] percutaneous tracheostomy
[**6-9**] percutaneous endoscopic gastrostomy
[**6-13**] left ankle & toe ORIFs
[**6-15**] T6 vertebrectomy, thoracic spine fusion with iliac crest
bone graft
See Mr. [**Known lastname 61623**] medical record for specific details of his
complicated ICU course. Below is a brief organ-system based
synopsis of his major & current medical issues.
NEURO: Mr [**Known lastname **] was brought emergently to the OR from the
trauma bay, where Dr. [**First Name (STitle) **] drained a substantial epidural
hematoma & repaired of his multiple calvarial fractures. He was
treated with mannitol postop & followed with an ICP monitor,
which was soon DC'd. Kept on dilantin & then keppra to prevent
further seizures. Gradually his mental status improved, to the
point now where he opens his eyes spontaneously, interacts with
nurses & purposefully moves his left side. Inconsistently
follow commands & has intact sensation bilaterally.
CV: His initial pressor requirements stopped, and he was started
on lopressor for perioperative beta blockade.
RESP: After the tracheostomy of [**6-9**], he was gradually weaned
off his [**Last Name (LF) **], [**First Name3 (LF) **] that by discharge, he tolerated trach collar
for about 12 hours per day.
FEN/GI: receiving tube feeds at goal
HEME: receiving iron for his blood loss anemia. Lovenox & P
boots for DVT prophylaxis.
ID: Needs IV access for antibiotics to treat pseudomonal
pneumonia x 10 days. After course complete, please remove CVL.
ENDO: regular insulin sliding scale
DISPO: full code. wife is HCP, [**Telephone/Fax (1) 61624**].
Medications on Admission:
none
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1) syringe
Subcutaneous Q24H (every 24 hours).
Disp:*30 syringes* Refills:*2*
4. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) teaspoon PO
once a day.
Disp:*30 teaspoon* Refills:*2*
5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) dose PO DAILY (Daily).
Disp:*30 doses* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
skull fracture
epidural hemorrhage
subarachnoid hemorrhage
T6 burst fracture
multiple bilateral rib fractures
left clavicular fracture
left ankle fracture s/p ORIF
left 2nd & 3rd toe fractures s/p ORIF
respiratory failure
failure to thrive
pseudomonas pneumonia
enterobacter pneumonia
aspergillus pneumonia
PEG tube site wound infection
postop atelectasis
postop blood loss anemia
Discharge Condition:
improved
Discharge Instructions:
Tube feedings & medications via the PEG tube as precribed. Wear
your TLSO brace while out of bed.
Followup Instructions:
You should arrange a follow up appointment in the Trauma clinic
in [**2-22**] weeks. [**Telephone/Fax (1) 2359**]
Contact Dr.[**Name2 (NI) 12040**] office at [**Telephone/Fax (1) 3573**] to arrange a follow
up spine appointment in [**1-24**] weeks.
Contact Dr.[**Name2 (NI) 4016**] office at [**Telephone/Fax (1) 1228**] to arrange a
follow up orthopedic appointment in 2 weeks.
Contact the neurosurgical office to arrange an appointment in
[**1-24**] weeks.
Completed by:[**2132-6-27**]
|
[
"518.5",
"802.8",
"117.3",
"280.0",
"790.7",
"805.2",
"E916",
"484.6",
"780.39",
"438.20",
"826.0",
"810.00",
"824.0",
"807.03",
"803.16",
"721.7",
"438.19",
"536.41",
"682.2",
"482.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.02",
"38.93",
"31.1",
"96.6",
"81.64",
"43.11",
"03.53",
"81.05",
"03.31",
"01.18",
"77.79",
"99.04",
"79.36",
"02.11",
"79.18"
] |
icd9pcs
|
[
[
[]
]
] |
3986, 4056
|
1612, 3333
|
325, 617
|
4480, 4490
|
1270, 1589
|
4637, 5129
|
943, 955
|
3388, 3963
|
4077, 4459
|
3359, 3365
|
4514, 4614
|
970, 1251
|
274, 287
|
645, 868
|
890, 899
|
915, 927
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,219
| 126,758
|
7029
|
Discharge summary
|
report
|
Admission Date: [**2130-4-20**] Discharge Date: [**2130-5-5**]
Date of Birth: [**2060-3-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Norvasc
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional angina
Major Surgical or Invasive Procedure:
[**2130-4-20**] Four Vessel Coronary artery bypass grafting utilizing
the left internal mammary to left anterior descending, vein
grafts to first and second obtuse marginals and vein graft to
PDA
History of Present Illness:
Mr. [**Known lastname **] is a 70 year old male who recently experienced
exertional chest pain and shortness of breath over the last
several months. He underwent stress testing which was notable
for ischemia. Subsequent cardiac catheterization showed severe
three vessel disease and normal LV function. Angiography
revealed a right dominant system with an 80% stenosis in the
LAD, 90% lesion in the first OM, 80% lesion in the second OM,
and total occlusion in the proximal RCA. Based upon the above
results, he was referred for surgical revascularization.
Past Medical History:
Coronary artery disease, Hypertension, Hypercholesterolemia,
Prostate Cancer - s/p radiation therapy and surgery, Erectile
Dysfunction, Right Shoulder pain, s/p Ear surgery
Social History:
Retired engineer. Lives with his wife. Denies tobacco and ETOH.
Family History:
Denies CAD
Physical Exam:
Vitals: BP 123/86, HR 56, RR 14
General: well developed male in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2130-4-27**] 06:37AM BLOOD WBC-11.9* RBC-3.28* Hgb-10.4* Hct-30.6*
MCV-93 MCH-31.7 MCHC-34.0 RDW-15.3 Plt Ct-289#
[**2130-4-27**] 06:37AM BLOOD Plt Ct-289#
[**2130-4-27**] 06:37AM BLOOD UreaN-34* Creat-1.5* K-4.0
[**2130-4-27**] Abdominal X-Ray
Several air-filled loops of bowel, without evidence of frank
obstruction. This is a nonspecific pattern.
[**2130-4-22**] CXR
There has been removal of various lines and tubes with a right
internal jugular vascular sheath remaining in place in the
superior vena cava. There is no pneumothorax. Cardiac and
mediastinal contours are stable. There is bibasilar atelectasis
with interval improvement in the left retrocardiac area. Small
pleural effusions are noted.
[**2130-4-21**] ECHO
No spontaneous echo contrast or thrombus is seen in the body of
the left
atrium or left atrial appendage. No atrial septal defect is seen
by 2D or
color Doppler. There is mild to moderate regional left
ventricular systolic dysfunction. Resting regional wall motion
abnormalities include moderate inferior wall and inferior septal
hypokinesis. The remaining left ventricular segments contract
normally. There is moderate global right ventricular free wall
hypokinesis. There are simple atheroma in the aortic root. There
are simple atheroma in the ascending aorta. There are simple
atheroma in the descending thoracic aorta. No thoracic aortic
dissection is seen. There are three aortic valve leaflets. The
aortic valve leaflets are mildly thickened. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The branch
pulmonary arteries are dilated. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade. No right ventricular diastolic collapse is seen.
There are bilateral pleural effusions. The right main PA appears
dilated but demonstrates uniform flow on color flow Doppler. As
compared to the study performed on [**2130-4-21**] following changes
are noteworth:
1. Moderate right ventricular free wall hypokinesis.
2. There is trace aortic regurgitation.
3. Bilateral pleural effusions.
4. Pericardial effusion without signs of tamponade.
Brief Hospital Course:
On [**4-20**], Mr. [**Known lastname **] was admitted and underwent four vessel
coronary artery bypass grafting by Dr. [**Last Name (STitle) **]. For surgical
details, please see seperately dictated op note. Following the
operation, he was brought to the CSRU for invasive monitoring.
He was initially kept on inotropic support for low cardiac
indeces. He was also noted to have persistent A-a gradient and
respiratory alkalosis. A bedside TEE was done on postoperative
day one and was compared to the study performed on
[**2130-4-20**](intraop and post bypass). The following changes were
noteworth: moderate right ventricular free wall hypokinesis,
trace aortic regurgitation, bilateral pleural effusions, and a
pericardial effusion without signs of tamponade. Pan cultures
and serial chest x-rays were obtained. There were no signs of
active infection and cultures results remained negative. Over
several days, he eventually weaned from inotropic support and
was extubated on postoperative day three. He was transfused with
packed red blood cells to maintain hematocrit near 30%. He was
noted to have paroxsymal atrial fibrillation/flutter which
resolved with beta blockade. On postoperative day four, he
transferred to the SDU for telemetry and further recovery. He
continued to experience paroxsymal atrial fibrillation/flutter.
Beta blockade was advanced as tolerated and he converted to SR.
He received a single dose of coumadin prior to converting to SR.
Anticoagulation was, therefore, not continued. During the early
morning of [**4-27**], Mr. [**Name13 (STitle) 1764**] became confused and agitated, and
required haldol administration. Unfortunately, he was
physically agressive with the nursing staff during his
confusion, and likely injured his sternum at that time. The
psychiatry team was consulted, and care for his psychiatric
issues was coordinated with them, including continuing him on
his home regimen of klonopin, and also the use of haldol prn.
His confusion passed, however, over the next few days, his
physical exam demonstrated a progressively unstable sternum, and
a CT scan of the chest on [**4-30**] confirmed significant dehiscence
of his sternum at the inferior aspect. He was taken to the
operating room on [**5-1**], and through a combined effort between the
cardiac service and the plastic surgery team (attending: [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]), Mr. [**Last Name (Titles) 11760**] sternum was repaired and stabilized (see Op
Note). He tolerated this procedure well, and was admitted to
the cariac intensive care unit post-operatively for recovery. He
would remain stable throughout the rest of his hospital course.
He was extubated on [**5-2**], which he tolerated well. He had another
episode of a-fib briefly, but converted after 300 mg IV of
amiodarone, and starting an amiodarone drip. He was converted
to PO amiodarone. He was transferred to the floor in stable
condition on [**5-4**], and would remain in sinus rythym. A PICC line
was placed for long-term antibiotic administration. Two JP
drains left in place would only drain minimal serosanguinous
fluid and his wound area wound appear well-healing throughout
the rest of his hospital course. On [**5-5**], Mr. [**Name13 (STitle) 1764**] was
discharged to rehab in stable condition. He will continue IV
Vancomycin for 4 weeks. He will follow-up with Dr. [**First Name (STitle) **] for
further evaluation and treatment within one week, and he will
follow-up with Dr. [**Last Name (STitle) **] within one month.
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. 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*
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. 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*
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 MDI* Refills:*2*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. Metoprolol Tartrate 50 mg Tablet Sig: 2 and 1/2 Tablets PO
twice a day: 125 mg twice daily.
Disp:*150 Tablet(s)* Refills:*2*
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
12. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours) for 4 weeks.
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
17. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Coronary artery disease - s/p CABG, Postoperative Atrial
fibrillation/flutter, Hypertension, Hypercholesterolemia,
Prostate Cancer - s/p radiation therapy and surgery, prior
cellulitis, erectile dysfunction
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
1) You may shower, no baths. No creams, lotions or ointments to
incisions.
2) No driving for at least one month.
3) No lifting more than 10 lbs for at least 10 weeks from the
date of surgery.
4) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
5) Please call with any concerns or questions.
6) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
7) Report any fever greater then 100.5.
Followup Instructions:
- Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Please
call for appointment.
-Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 26259**] within one
week for a follow-up appointment
- Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2130-5-18**] 10:00
- Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2130-9-12**] 9:00
- Provider: [**Name10 (NameIs) **] IMAGING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2130-9-12**]
9:00
|
[
"293.0",
"413.9",
"401.9",
"276.3",
"427.31",
"300.00",
"998.31",
"998.59",
"V10.46",
"414.01",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"36.15",
"88.72",
"34.79",
"83.82",
"99.04",
"38.93",
"39.61",
"77.61"
] |
icd9pcs
|
[
[
[]
]
] |
9447, 9520
|
3963, 7513
|
291, 489
|
9771, 9778
|
1747, 3940
|
10542, 11255
|
1369, 1381
|
7536, 9424
|
9541, 9750
|
9802, 10519
|
1396, 1728
|
234, 253
|
517, 1075
|
1097, 1272
|
1288, 1353
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,342
| 191,931
|
26148
|
Discharge summary
|
report
|
Admission Date: [**2109-11-27**] Discharge Date: [**2109-11-30**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
PCI/DES of RCA
History of Present Illness:
82M w/CAD s/p cath in past who p/w acute onset CP afternoon of
admisson seen in [**Hospital1 **] [**Location (un) 620**] ED noted to have STE in inferior
leads (1mm STE II,III,AVF; depression V2). [**Hospital **]
transferred to [**Hospital1 18**] for cath.
.
Cath showed 3VD, LAD: mid diffuse 80% just after D1; good mid
target and diffuse distal dz; LCx: 80% origin CX; 90% just after
high OM1; RCA: TO mid; PCI of RCA with 3 DES
.
Transferred to CCU, stable, painfree and without arryhtmia.
Transient bradycardia noted in lab.
Past Medical History:
1. temporal arthritis
2. ?prior cath
3. COPD
4. GERD
5. glucose intol [**1-9**] prednisone
6. prior MI?
7. CRI baseline 1.4
Social History:
widowed, lives with son, quit smoking ~15 yrs ago, occasional
alcohol.
Family History:
nc
Physical Exam:
VS 97.1 179/84 82 18 99% 2L NC
Gen pleasant elderly gentleman in NAD lying flat in bed
HEENT NCAT, dry mmm, JVD lying flat
PULM CTA anteriorly and laterally
CV nl S1 S2 RRR II/VI systolic murmur at LUSB
ABD soft nontender +BS
Groin no hematoma or bruit, soft tissue mass in right groin
EXT nonedematous, DPP dopplerable
NEURO AO x3 nonfocal
Pertinent Results:
Na 145 Cl 111 BUN 20 Gluc 267
K 5.7 HCO3 20 Cr 1.5
.
WBC 13.0 Hgb 13.4 Hct 38.1 Plat 183
.
PT 15.5 PTT 150 INR 1.6
CK 65 Trop <0.01
.
imaging:
CHEST (PA & LAT) [**2109-11-28**] 6:31 PM
IMPRESSION: No acute cardiopulmonary process
.
cath [**11-27**] right dominant
PCW 22
RA 13
CO 5.02 CI 2.56
PA 38
LMCA: no significant dz
LAD: mid diffuse 80% just after D1; good mid target and diffuse
distal dz
LCx: 80% origin CX; 90% just after high OM1
RCA: TO mid
PCI of RCA with 3 DES
.
[**11-28**] ECHO
EF 40-45%
1. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is moderately depressed. Lateral and inferior
hypokinesis is present.
3. The aortic valve leaflets (3) are mildly thickened. Mild to
moderate ([**12-9**]+) aortic regurgitation is seen.
4. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**12-9**]+) mitral regurgitation is seen.
.
[**2109-11-28**] CAROTID SERIES COMPLETE - Minor atherosclerotic changes
in the carotid arteries bilaterally. There is no evidence of
carotid stenosis on either side
[**2109-11-28**] R groin ART DUP EXT LO UNI - In the region of the right
groin the common femoral artery, superficial femoral artery,
profunda femoral artery, femoral vein and common femoral veins
are patent. There is no evidence of pseudoaneurysm or
arteriovenous fistula.
Brief Hospital Course:
82 yom w/STEMI s/p PCI of RCA with DES and 3VD.
.
# Ischemia: s/p [**11-27**] PCI of RCA with DES and 3VD.
- cont ASA 325, Plavix, rec'd 18 hrs integrillin, lipitor 80
- cont lopressor 25 PO BID, titrating to BP & HR <70
- cont lisinopril 5
- dc Nitro gtt
- would benefit from two vessel CABG
- apprec CT [**Doctor First Name **] consult, will get pre-op labs and eval (LFTs,
HBAIC, UA, CXR, carotid US, anesthesia consult). pt will
follow-up with CT [**Doctor First Name **] as outpt in [**12-13**] if wishes to proceed
with surgery
.
# Pump: check echo
- follow i/o's
- daily weights
.
# Rhythm: NSR, serial EKGs and cont telemetry
.
# right Groin: preliminary right groin read as negative for
pseudoaneurysm or AVF
- resolving ecchymosis
- Hct stable
.
# Respir: extensive TOB hx & wheezes on exam; sats stable. MDI
prn.
- PFTs show FEV1 is 1.55 at 51%. FVC 2.04 at 51%, with FEV1/FVC
of 76. FEF 25-75 is 1.24 at 42%. MVV is significantly reduced to
28%. TLC is normal. However, increased RV/ TLC ratio of 69% with
normal DLCO of 131%.
.
# FEN: advance to full cardiac diet as tolerated
# Prophyl: PPI, ambulate
# Dispo: likely dc home with follow-up with CT [**Doctor First Name **] [**12-13**].
Medications on Admission:
1. simvastatin
2. ?0.5 prednisone?
3. duoneb
4. pulmocort
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-9**]
Puffs Inhalation Q4H (every 4 hours) as needed.
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*6*
6. 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*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual q5 minutes as needed for chest pain: Please take 1
tablet as needed for chest pain. [**Month (only) 116**] repeat dose after 5 minutes
as needed for total of 3 doses in 15 minutes.
Disp:*1 bottle* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*6*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
1. STEMI s/p PCI/DES of RCA
2, 3 vessel coronary artery disease
Secondary diagnosis:
2. h/o temporal arthritis (no longer on steroids)
3. CAD
4. COPD
5. GERD
6. CRI baseline 1.4
Discharge Condition:
AAOx3
Chest pain free
NOt dyspneic
Discharge Instructions:
1. Please take all medications as prescribed
2. Please make all follow-up appointments
3. If you develop chest pain, shortness of breath,
lightheadedness, or any other concerning signs/symptoms, please
contact your PCP [**Name Initial (PRE) **]/or report to the Emergency Department
immediately.
Followup Instructions:
Please call Dr.[**Name (NI) **] office at [**Telephone/Fax (1) 15550**] for questions
regarding your surgery.
.
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5292**] Date/Time: [**2109-12-4**] 10:30am Phone:
[**Telephone/Fax (1) 5294**] Location: [**Street Address(2) **] [**Apartment Address(1) 64869**] [**Location (un) **],
[**Location (un) 620**]
Please call [**Telephone/Fax (1) 4022**] on Tues [**2109-12-3**] to schedule an
appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in cardiology for the end of
[**2109-12-8**].
Completed by:[**2109-12-6**]
|
[
"585.9",
"530.81",
"446.5",
"496",
"272.0",
"416.8",
"410.41",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.47",
"00.66",
"88.56",
"37.21",
"00.40",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
5392, 5398
|
2871, 4072
|
275, 292
|
5640, 5677
|
1489, 2848
|
6021, 6675
|
1104, 1108
|
4181, 5369
|
5419, 5419
|
4098, 4158
|
5701, 5998
|
1123, 1470
|
225, 237
|
320, 851
|
5524, 5619
|
5438, 5503
|
873, 999
|
1015, 1088
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,059
| 198,502
|
53325
|
Discharge summary
|
report
|
Admission Date: [**2106-2-3**] Discharge Date: [**2106-2-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Bloody diarrhea this morning
Major Surgical or Invasive Procedure:
colonoscopy
ICU monitoring
History of Present Illness:
80 year old female with Hx of Hx of HTN, hypothyroid, OA, spinal
stenosis presents with BRBPR and watery diarrhea x 5 hrs this
morning. Pt states that on Friday she began to feel "sick" with
cough, decreased, appetite, SOB, difficulty swollowing due to
dryness, and muscle aches. She states that she took robitussin
and aspirin at the suggestion of her PCP and experienced some
relief. Syptomes persisted through weekend. Monday night was
"a disaster" as symptoms became progressively worse. Tuesday
morning, at 5 am, pt experienced crampy abd. pain with watery
diarrhea mixed with bright blood. Pt called PCP who told pt to
report to the ED.
.
In [**Name (NI) **] pt received 2LNS, anzemet and compazine. CT abd. showed
Large heterogeneous filling defect of ascending colon,
suspicious for
malignancy. Constrast seen distal to lesion with no small bowel
dilitation. Hypodense liver lesions in right lobe of liver.
Multiple sigmoid diverticuli. No evidence of diverticulitis.
Scoliosis with degenerative changes through out spine and
pelvis. Abnormal focal mixed heterogeneous lesions of fat, soft
tissue, and bone density within mid abdomen--both intra and
extraluminal. In addition chest X-ray showed 7 mm nodule
projecting over the lower left hemithorax, which may represent a
granuloma.
.
Pt denies chest pain, nausea, vomiting, hematemesis, dysuria,
change in bowel or bladder function, no weight loss, or
headaches.
.
PMH:
1. GERD
2. HTN
3. OA
4. Spinal stenosis
5. Cholonic polyps s/p removal 00'reveiled Polyps in the cecum
and sigmoid colon, Diverticulosis of the sigmoid colon, Internal
hemorrhoids, Otherwise normal Colonoscopy to cecum.
6. hypothyroid
.
Allergies: KNDA
.
Medications:
LEVOTHYROXINE SODIUM 50 MCG TABS (LEVOTHYROXINE SODIUM) 1 po qd,
hold one day per week
CALCIUM CARB CHW 500MG (CALCIUM CARBONATE ANTACID) 3 po qd
ASPIRIN TAB 81MG EC (ASPIRIN) 1 qd
FOSAMAX TAB 70 MG ONE PO QAM, ON AN EMPTY STOMACH, once per week
OCUVITE TAB (MULTIPLE VITAMINS-MINERALS) 1 po qd
LISINOPRIL 20 MG TABS (LISINOPRIL) 1 po qd
PRILOSEC CAP 20MG CR (OMEPRAZOLE) ONE PO QD prn
NORVASC TAB 5MG (AMLODIPINE BESYLATE) 1 tab po QD
HYDROCHLOROTHIAZIDE CAPS 12.5 MG (HYDROCHLOROTHIAZIDE) 1 po Q am
AMOXICILLIN CAP 500MG (AMOXICILLIN) 4 tab 1 hr prior to dental
work
DARVOCET-N 100 100-650 MG TABS (PROPOXYPHENE N-APAP) 1 po q4 - 6
hours
PERCOCET TAB 5-325MG (OXYCODONE-ACETAMINOPHEN) 1-2 tabs po q 4-6
hours PRN pain
COSAMIN DS CAPS (NUTRITIONAL SUPPLEMENTS) 1 po qd
RELAFEN 500 MG TABS (NABUMETONE) 1 po qd
.
FHx: Son died of colon ca at 36. Father died of MI at age [**Age over 90 **].
Mother died of stomach Ca at age 78.
.
Social: Retired personel rep for govt. 3 children. Lives alone
in apt. Retired head of [**Doctor First Name **] scholarship fund. No tabacco
since age 30, occasional ETOH.
.
Physical Exam:
Vitals: T:98.6 HR:91 BP:155/68 RR:19 O2:97%RA
Gen: elderly woman layingon left side NAD
HEENT: NCAT, PERRL, EOMI without nystagmus, O/P clear no
exudates
Neck: no lymphadenopathy, no thyromegally
Chest: coarse exp. ronchi at LLB, otherwise CTA
CV: distant S1 and S2, II/VI crescendo/decrescendo systolic
ejection murmur at RUSB w/o radiation, II/VI blowing holosytolic
ejection murmur at apex w/o radiation, +S3, no rubs or heaves.
Abd: Soft, NT/ND, 4x4cm movable nonfluctuant mass at RLQ, +BS.
Ext: w/w/p no c/c/e weak PT bilaterally.
Neuro: A&O x3, no focal deficits moving all fours.
.
Labs: See below.
.
Imaging:
CT abd. and pelvis: IMPRESSION:
1. Large heterogeneous mass within the cecum and ascending colon
along with low-density lesions within the right lobe of the
liver, likely representing malignancy.
2. No evidence of small bowel obstruction.
3. Sigmoid diverticulosis without evidence of diverticulitis.
Marked
hypertrophy of the sigmoid probably secondary to diverticulosis,
however, cannot rule out colitis.
4. Mixed attenuation lesions within the lower abdomen with
questionable attachment to the uterus, likely representing
bilateral dermoids.
5. Small low attenuation filling defect within the small
intestine of unclear etiology.
.
Chest X-Ray:IMPRESSION: 7 mm nodule projecting over the lower
left hemithorax, which may represent a granuloma.
.
Assesment:80 year old female with Hx of Hx of HTN, hypothyroid,
OA, spinal stenosis presents with BRBPR and watery diarrhea x 5
hrs this morning.
.
BRBPR: Likely primary colon malignancy. Pt with 4x4cm movable
nonfluctuant mass at RLQ in addition to CT findings with large
heterogeneous mass within the cecum and ascending colon along
with low-density lesions within the right lobe of the liver,
likely representing malignancy. In addition, pt has an Hx of
colonic polyps and a positive family FHx of colon [**Name (NI) 16641**] son having
died at 36 of colon Ca.
- NPO and NG-tube
- Golytely
- colonoscopy tomorrow
- GI consult tomorrow appreciate recs.
- Surgery consult appreciate recs.
- consider onc. consult
.
UTI: Pt with an active Ua.
- Ciprofloxacin IV x 3 days
.
HTN: Pt with HTN BP in the 150s/60s. pt on lisinopril,
amlodipine, and HCTZ as out pt. Doses not available, will
follow with family or PCP [**Name Initial (PRE) 503**].
- HCTZ 25 IVqd- will follow up with family tomorrow
.
Hypothyroid: pt with hypothyroid on thyroxyl
- Continue thyroxyl NG
.
OA: Pt with OA of right hip. Pt on darvocet as an out pt.
- Will manage pain with morphine sulfate 1-2mg for now
.
Spinal Stenosis/LBP: Pt on darvocet as an out pt.
- Will manage pain with morphine sulfate 1-2mg for now
.
GERD: Pt with Hx of GERD.
- Pantoprazole 40 mg IV
.
PPI: Pantoprazole, pneumo boots.
.
Code: presumed full
.
Dispo: admit to medicine
.
.
LEVOTHYROXINE SODIUM 50 MCG TABS (LEVOTHYROXINE SODIUM) 1 po qd,
hold one day per week
CALCIUM CARB CHW 500MG (CALCIUM CARBONATE ANTACID) 3 po qd
ASPIRIN TAB 81MG EC (ASPIRIN) 1 qd
FOSAMAX TAB 70 MG ONE PO QAM, ON AN EMPTY STOMACH, once per week
OCUVITE TAB (MULTIPLE VITAMINS-MINERALS) 1 po qd
LISINOPRIL 20 MG TABS (LISINOPRIL) 1 po qd
PRILOSEC CAP 20MG CR (OMEPRAZOLE) ONE PO QD prn
NORVASC TAB 5MG (AMLODIPINE BESYLATE) 1 tab po QD
HYDROCHLOROTHIAZIDE CAPS 12.5 MG (HYDROCHLOROTHIAZIDE) 1 po Q am
AMOXICILLIN CAP 500MG (AMOXICILLIN) 4 tab 1 hr prior to dental
work
DARVOCET-N 100 100-650 MG TABS (PROPOXYPHENE N-APAP) 1 po q4 - 6
hours
PERCOCET TAB 5-325MG (OXYCODONE-ACETAMINOPHEN) 1-2 tabs po q 4-6
hours PRN pain
COSAMIN DS CAPS (NUTRITIONAL SUPPLEMENTS) 1 po qd
RELAFEN 500 MG TABS (NABUMETONE) 1 po qd
80 year old female with Hx of Hx of HTN, hypothyroid, OA, spinal
stenosis presents with BRBPR and watery diarrhea x 5 hrs this
morning. Pt states that on Friday she began to feel "sick" with
cough, decreased, appetite, SOB, difficulty swollowing due to
dryness, and muscle aches. She states that she took robitussin
and aspirin at the suggestion of her PCP and experienced some
relief. Syptomes persisted through weekend. Monday night was
"a disaster" as symptoms became progressively worse. Tuesday
morning, at 5 am, pt experienced crampy abd. pain with watery
diarrhea mixed with bright blood. Pt called PCP who told pt to
report to the ED.
.
In [**Name (NI) **] pt received 2LNS, anzemet and compazine. CT abd. showed
Large heterogeneous filling defect of ascending colon,
suspicious for
malignancy. Constrast seen distal to lesion with no small bowel
dilitation. Hypodense liver lesions in right lobe of liver.
Multiple sigmoid diverticuli. No evidence of diverticulitis.
Scoliosis with degenerative changes through out spine and
pelvis. Abnormal focal mixed heterogeneous lesions of fat, soft
tissue, and bone density within mid abdomen--both intra and
extraluminal. In addition chest X-ray showed 7 mm nodule
projecting over the lower left hemithorax, which may represent a
granuloma.
.
Pt denies chest pain, nausea, vomiting, hematemesis, dysuria,
change in bowel or bladder function, no weight loss, or
headaches.
.
Past Medical History:
1. GERD
2. HTN
3. OA
4. Spinal stenosis
5. Cholonic polyps s/p removal 00'reveiled Polyps in the cecum
and sigmoid colon, Diverticulosis of the sigmoid colon, Internal
hemorrhoids, Otherwise normal Colonoscopy to cecum.
6. hypothyroid
Social History:
Retired personel rep for govt. 3 children. Lives alone in apt.
Retired head of [**Doctor First Name **] scholarship fund. No tabacco since age
30, occasional ETOH.
Family History:
Son died of colon ca at 36. Father died of MI at age [**Age over 90 **].
Mother died of stomach Ca at age 78.
Physical Exam:
Vitals: T:98.6 HR:91 BP:155/68 RR:19 O2:97%RA
Gen: elderly woman layingon left side NAD
HEENT: NCAT, PERRL, EOMI without nystagmus, O/P clear no
exudates
Neck: no lymphadenopathy, no thyromegally
Chest: coarse exp. ronchi at LLB, otherwise CTA
CV: distant S1 and S2, II/VI crescendo/decrescendo systolic
ejection murmur at RUSB w/o radiation, II/VI blowing holosytolic
ejection murmur at apex w/o radiation, +S3, no rubs or heaves.
Abd: Soft, NT/ND, 4x4cm movable nonfluctuant mass at RLQ, +BS.
Ext: w/w/p no c/c/e weak PT bilaterally.
Neuro: A&O x3, no focal deficits moving all fours.
Pertinent Results:
Colonoscopy ([**2106-2-4**]): consistent with severe ischemic
colitis
WBC increased from 13 at admission to 50 on day patient was made
CMO
Brief Hospital Course:
80F with Hx of Hx of HTN, hypothyroid, OA, spinal stenosis who
presented with BRBPR. Colonoscopy was consistent with ischemic
colitis.
.
# Ischemic cholitis (ascending, hepatic and splenic flexure): CT
findings with large heterogeneous mass within the cecum and
ascending colon along with low-density lesions within the right
lobe of the liver (concerning for colon cancer) but colonoscopy
showed no mass and was consistent with severe ischemic colitis.
Unclear whether this ischemic colitis is from emboli or
worsening atheromatous disease.
Surgery was consulted and followed the patient throughout
hospitalization. Option of surgical intervention was discussed
but patient and family did not want to pursue surgery, despite
grim prognosis of medical management with such severe ischemic
colitis. Patient was therefore treated conservatively with IV
hydration and was initially kept on antibiotics (Zosyn, Flagyl).
The patient's WBC continued to rise, likely from uncontrolled
bacterial translocation across her ischemic bowel wall. Lactate
was WNL. Culture data did not grow anything (to date).
Given the patients grim prognosis and refusal of surgical
intervention (which would also hold high risks of morbidity and
mortality), patient and family requested comfort measures only
on [**2106-2-8**]. All medications were discontinued except those
for comfort, including morphine prn. The pt expired on [**2106-2-10**]
at 7 am. Family was notified.
# Acute renal failure (baseline around 1.3): The patient's renal
function was worse than her baseline at admission and continued
to deteriorate throughout her hospitalization, possible from
emboli vs sepsis.
# UTI: Positive urinalysis at admission, initially treated wtih
Flagyl/Zosyn. All antibiotics were discontinued on [**2106-2-8**].
# HTN: BP medication
# Hypothyroid: levoxyl was held as pt was NPO
# Code: DNR/DNI; patient was made comfort measures only at
patient and family request on [**2106-2-8**].
# communication: son [**Name (NI) **] [**Name (NI) 452**] [**Telephone/Fax (1) 109721**]
Medications on Admission:
LEVOTHYROXINE SODIUM 50 MCG qd, hold one day per week
CALCIUM CARB CHW 500MG 3 po qd
ASPIRIN TAB 81MG EC qd
FOSAMAX TAB 70 MG ONE PO QAM, ON AN EMPTY STOMACH, once per week
OCUVITE TAB (MULTIPLE VITAMINS-MINERALS) 1 po qd
LISINOPRIL 20 MG TABS po qd
PRILOSEC CAP 20MG CR PO QD prn
NORVASC TAB 5MG po QD
HYDROCHLOROTHIAZIDE CAPS 12.5 MG Qam
AMOXICILLIN CAP 500MG 4 tab 1 hr prior to dental work
DARVOCET-N 100 100-650 MG TABS (PROPOXYPHENE N-APAP) 1 po q4 - 6
hours
PERCOCET TAB 5-325MG (OXYCODONE-ACETAMINOPHEN) 1-2 tabs po q 4-6
hours PRN
COSAMIN DS CAPS (NUTRITIONAL SUPPLEMENTS) 1 po qd
RELAFEN 500 MG TABS (NABUMETONE) 1 po qd
Discharge Medications:
Pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Death due to Ischemic Colitis
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2106-2-10**]
|
[
"276.2",
"599.0",
"584.9",
"244.9",
"401.9",
"557.0",
"530.81",
"038.9",
"995.94"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25"
] |
icd9pcs
|
[
[
[]
]
] |
12360, 12369
|
9588, 11643
|
289, 317
|
12442, 12447
|
9425, 9565
|
12499, 12627
|
8689, 8802
|
12325, 12337
|
12390, 12421
|
11669, 12302
|
12471, 12476
|
8817, 9406
|
221, 251
|
345, 3158
|
8253, 8490
|
8506, 8673
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,154
| 192,437
|
21766
|
Discharge summary
|
report
|
Admission Date: [**2122-1-5**] Discharge Date: [**2122-1-9**]
Date of Birth: [**2066-1-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Worsening dyspnea on exertion
Major Surgical or Invasive Procedure:
Minimally invasive MVR(29mm [**Company 1543**] Porcine valve) [**2122-1-5**]
History of Present Illness:
Mr. [**Known lastname 57189**] is a 55 year old man with known mitral valve
regurgitation and mitral valve prolapse. He has recently had
worsening dyspnea on exertion and worsening mitral valve
regurgitation by echocardiogram. He is admitted for surgical
management.
Past Medical History:
Hypercholesterolemia
Detached retina
Basal cell carcinoma
S/P removal of mass from right foot and groin.
S/P tonsillectomy/adenoidectomy
Social History:
Lives with partner in [**Name (NI) 57190**]. Works in sales. Quit smoking in
[**2091**] and drinks moderately on weekends.
Family History:
Adopted and does not know biological family history
Physical Exam:
VS: HR 60 BP(Right) 108/70 BP(Left) 110/72 Ht 77" Wt 245
GEN: Well developed and well nourished. No acute distress
SKIN: No lesions or rashes
HEENT: PERRL, EOMI, Benign oropharynx
NECK: Supple, no lymphadenopathy
LUNGS: Clear
HEART: RRR, normal S1-S2, III/VI systolic murmur.
ABDOMEN: Soft, Nontender, nondistended.
EXT: Warm, well perfused. No edema
NEURO: Nonfocal
PULSES: 2+ throughout. No bruits
Pertinent Results:
[**2122-1-8**] 06:40AM BLOOD WBC-8.6 RBC-3.50* Hgb-11.2* Hct-32.4*
MCV-93 MCH-32.1* MCHC-34.6 RDW-12.4 Plt Ct-82*
[**2122-1-8**] 06:40AM BLOOD Plt Ct-82*
[**2122-1-8**] 06:40AM BLOOD Glucose-114* UreaN-17 Creat-1.0 Na-138
K-4.3 Cl-101 HCO3-34* AnGap-7*
[**2122-1-5**] 05:36PM BLOOD UreaN-17 Creat-0.8 Cl-111* HCO3-23
[**2122-1-8**] 06:40AM BLOOD ALT-32 AST-44* LD(LDH)-457* AlkPhos-56
Amylase-154* TotBili-0.9
[**2122-1-7**] 03:54AM BLOOD Glucose-140* Lactate-1.0 Na-134* K-4.9
Cl-105 calHCO3-27
[**2122-1-5**] 07:44AM BLOOD Glucose-109* Na-138 K-3.9
CXR [**2122-1-7**]
Increased bilateral pleural effusion with atelectasis. No
pneumothorax.
EKG [**2122-1-5**]
Sinus rhythm and occasional ventricular ectopy. Prior inferior
and posterior myocardial infarction. Compared to the previous
tracing of [**2121-11-26**] ventricular ectopy is no longer recorded and
the rate has increased. Otherwise, no diagnostic interim change.
Brief Hospital Course:
Mr. [**Known lastname 57189**] was admitted to the [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical
Center on [**2122-1-5**] for surgical management of his mitral valve
disease. He was worked-up in the usual preoperative manner. He
was then taken to the operating room where he underwent a
minimally invasive mitral valve replacement utilizing a 29 mm
[**Company 1543**] mosaic porcine valve. Postoperatively he was taken to
the cardiac surgical intensive care unit for monitoring. On
postoperative day one, Mr. [**Known lastname 57189**] [**Last Name (Titles) 5058**] neurologically intact
and was extubated. He developed hyperamylase and lipasemia and
was thus restricted from oral intake. The general surgery
service was consulted and recommended serial labs and exams as
he was asymptomatic. Clear liquids were ultimately started and
advanced as tolerated. On postoperative day three, Mr. [**Known lastname 57189**]
was transferred to the cardiac surgical step down unit for
further recovery. He was gently diuresed towards his
preoperative weight. The physical therapy service was consulted
for assistance with his postoperative strength and mobility. As
Mr. [**Known lastname 57189**] was somewhat thrombocytopenic postoperatively, a
heparin induced thrombocytopenia assay was sent which was
negative. He tolerated advancement of his diet without abdominal
pain or increase in his amylase or lipase. Beta blockade was
titrated for optimal heart rate and blood pressure control. Mr.
[**Known lastname 57189**] continued to make steady progress and was discharged
home on postoperative day four. He will follow-up with Dr. [**Last Name (Prefixes) **], his cardiologist and his primary care physician as an
outpatient.
Medications on Admission:
Lipitor 10mg daily
Atenolol 50mg daily
[**Doctor First Name **] PRN
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
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 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
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. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Mitral regurgitation.
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 4 weeks.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Make an appointment with Dr. [**First Name (STitle) **] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.
Completed by:[**2122-1-30**]
|
[
"424.0",
"272.0",
"V10.83",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"39.61",
"35.23"
] |
icd9pcs
|
[
[
[]
]
] |
5232, 5294
|
2482, 4268
|
348, 427
|
5360, 5367
|
1530, 2459
|
5609, 5783
|
1039, 1092
|
4386, 5209
|
5315, 5339
|
4294, 4363
|
5391, 5586
|
1107, 1511
|
279, 310
|
455, 723
|
745, 883
|
899, 1023
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,965
| 111,315
|
50600
|
Discharge summary
|
report
|
Admission Date: [**2185-6-25**] Discharge Date: [**2185-6-30**]
Date of Birth: [**2117-2-27**] Sex: F
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old
female with a past medical history of chronic renal
insufficiency, diabetes mellitus, paroxysmal atrial
fibrillation on Coumadin at home, who presents with 3 days of
dark red blood per rectum and episodes of lightheadedness.
She subsequently presented to the Emergency Department, where
she was found to have a hematocrit of 18. A NG lavage was
negative for active bleeding. She was sent to the ICU for
hemodynamic monitoring and transfusions and received 6 units
of red blood cells, vitamin K, 4 units of FFP and remained
hemodynamically stable. Her INR slowly trended down and she
was awaiting a colonoscopy and EGD to find the source of
bleeding.
PAST MEDICAL HISTORY:
1. CHF. History of diastolic dysfunction, echo from [**Month (only) 1096**]
[**2184**] with an EF of 60 percent.
2. Type II diabetes mellitus.
3. Chronic renal failure, baseline creatinine 2.2 to 3.3.
4. Paroxysmal atrial fibrillation status post pacer.
5. Hyperlipidemia.
6. Hypertension.
7. History of DVT.
8. Anemia.
9. Peripheral vascular disease, status post bypass.
10. Colonic polyps.
SOCIAL HISTORY: The patient lives alone, single, no tobacco,
or alcohol. She is supported by her sister who lives nearby.
ALLERGIES: SULFA CAUSES HIVES.
MEDICATIONS ON TRANSFER:
1. Imdur 20 mg 3 times a day.
2. Hydralazine 30 mg 4 times a day.
3. Lopressor 50 mg twice a day.
4. Percocet p.r.n.
5. Lipitor 10 mg once a day.
6. Protonix 40 IV q.12.
7. Vitamin K.
PHYSICAL EXAMINATION: Vital signs: Temperature is 98.8,
blood pressure 138/60 to 160/74, heart rate 60 to 72,
respirations 20, O2 saturation 96 to 97 percent on room air,
and fingersticks 93 to 102. General appearance: The patient
appears comfortable in no apparent distress. HEENT exam:
Nonicteric. Mucosa moist. Lungs are clear to auscultation
bilaterally. Cardiac exam: Regular rate and rhythm, 2/6
systolic ejection murmur. Abdomen: Soft, nontender,
nondistended with good bowel sounds, and obese. Extremities:
No lower extremity edema.
LABORATORIES ON TRANSFER: Notable for an initial hematocrit
of 18.2, which slowly trended up to the low 30s. At the time
of transfer, her hematocrit was 30.3. Her INR was initially
and 4.0 trended down to 1.5. Creatinine was initially 3.3
and trended down to 2.7. UA was negative. Chest x-ray
showed cardiomegaly with stable improvement of CHF.
HOSPITAL COURSE:
1. GI bleeding: Her GI bleeding was felt to likely be
related to her INR of 4 on Coumadin and was suspected that
it was related to her previously known colonic polyps as a
source of this bleeding. Her Coumadin was held and her
INR slowly drifted down and her hematocrit remained stable
for the rest her hospital course. She had a colonoscopy
on [**2185-6-28**] showing rectal polyps, ascending colonic
polyp, mid transverse polyp, which were all removed and
she had a biopsy of the distal transverse colon. She also
had an EGD showing mild gastritis. It was presumed that
her bleeding was related to the colonic polyps and her
Coumadin was held at the time of discharge.
1. Renal: Her BUN and creatinine are slightly elevated at
the time of admission, which improved to her baseline
prior to admission.
1. Cardiac: She did not have any episodes of congestive
heart failure during this admission. After discussion
with the attending, Dr. [**Last Name (STitle) **], instructed the patient
they have considered discontinuing Coumadin therapy in the
future because of the future risks of GI bleeding.
DISPOSITION: The patient was felt well for discharge and
Physical Therapy was consulting, felt the patient was safe
for discharge home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Home with services.
DISCHARGE DIAGNOSES: Primary diagnosis: GI bleed.
Secondary diagnoses: Diastolic CHF, diabetes mellitus,
chronic renal failure, paroxysmal atrial fibrillation status
post pacer, hyperlipidemia, anemia, peripheral vascular
disease, and colonic polyps.
DISCHARGE MEDICATIONS:
1. Hydralazine 30 mg p.o. q.i.d.
2. Lasix 60 mg p.o. b.i.d.
3. Glipizide 5 mg p.o. q.d.
4. Isosorbide dinitrate 20 mg p.o. t.i.d.
5. Protonix 40 mg p.o. q.d.
6. Lipitor 10 mg p.o. q.d.
7. Ambien 5 mg p.r.n.
8. Sertraline 50 mg p.o. q.d.
9. PhosLo 667 mg p.o. t.i.d.
10. Lopressor 100 mg p.o. t.i.d.
FOLLOWUP PLANS: The patient was told to weigh herself every
morning and adhere to a low-sodium diet. She was told that
to take all medications as prescribed and to continue
stopping her aspirin for 3 weeks as well as her Coumadin as
discussed with Dr. [**Last Name (STitle) **]. She was told that if she
develops any bloody stools, black tarry stools,
lightheadedness, abdominal pain, chest pain, shortness of
breath, or any other concerning symptoms that she should
notify her PCP immediately and seek immediate medical
attention. She was told to followup with her primary care
doctor, Dr. [**Last Name (STitle) **] who will contact her about the date and
time of her followup appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 105322**], MD [**MD Number(2) 105323**]
Dictated By:[**Last Name (NamePattern1) 2366**]
MEDQUIST36
D: [**2185-12-1**] 11:35:03
T: [**2185-12-2**] 02:02:50
Job#: [**Job Number 105325**]
|
[
"427.31",
"428.30",
"428.0",
"593.9",
"401.9",
"V58.61",
"235.2",
"250.00",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.07",
"45.42",
"45.16",
"99.04",
"48.36",
"45.43"
] |
icd9pcs
|
[
[
[]
]
] |
3964, 3964
|
4220, 5501
|
2570, 3868
|
4016, 4197
|
1670, 2553
|
170, 853
|
3984, 3994
|
1461, 1647
|
875, 1278
|
1295, 1436
|
3893, 3942
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,453
| 107,534
|
28595+57621
|
Discharge summary
|
report+addendum
|
Admission Date: [**2169-8-29**] Discharge Date: [**2169-9-4**]
Date of Birth: [**2117-6-19**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Erythromycin Base
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD on [**2169-8-30**] and [**2169-9-1**] with variceal banding
History of Present Illness:
52 yo F with EtOH cirrhosis complicated by portal hypertension
and recurrent variceal bleeding transferred from [**Hospital 1562**]
hospital for TIPS procedure.
.
The patient states that she began drinking around [**2169-8-22**] after
several months of sobriety. She presented to [**Hospital 1562**] Hospital
ED on [**2169-8-27**] with nausea, vomiting and hematemesis. She had a
total of 3 episodes of vomiting with small amounts of dark
blood in the emesis. She describes this as different than her
past variceal bleeds when the blood "kept coming and coming."
This time she describes "clot-like" emesis. She denies
associated dizziness, lightheadedness or chest pain.
.
On presentation to the OSH ED, hr 120, bp 90/60, Hct 29 (down
from 35 two days prior). Her alcohol level was 434. The patient
was admitted to the ICU. She received a total of 3U PRBC as well
as several liters IV NS. She was also started on an IV protonix
and IV octreotide drip as well as IV vitamin K. The patient was
placed on levofloxacin for prophylaxis due to elevated risk of
sepsis in cirrhotics with GI bleed. The patient's Hct appeared
to stabilize without further transfusion though it did not bump
to the PRBC's. The patient describes no further bleeding since
her day of admission. She notes passing gas but no stool. Her
last bowel movement was on [**2169-8-26**] and was dark, not bloody.
.
The patient was transferred for TIPS procedure as treatment for
recurrent variceal bleeding.
.
ROS: The patient describes several weeks of increasing abdominal
distention. Denies fevers, chills, nightsweats, changes in
weight or appetite, headache, blurry vision, neck stiffness or
pain, chest pain, SOB, abdominal pain, dysuria, rashes, myalgias
or arthralgias.
Past Medical History:
EtOH cirrhosis with portal hypertension, grade 3 esophageal
varices, gastric varices, thrombocytopenia
EtOH abuse. Denies history of seizures or hallucinations.
Upper GI variceal bleeding s/p multiple sclerotherapy and
banding procedures.
Boerrhave's syndrome/[**Doctor First Name **]-[**Doctor Last Name **] tear
Esophagitis and duodenitis
H/o cervical and uterine CA s/p TAH/BSO
Chronic renal insufficiency
Social History:
Left her husband 2 years ago but sees him every day. 3 children,
2 daughters live nearby and 1 son in college. Drinks
approximately 1 pint of vodka per day. No tobacco or illicit
drug use.
Family History:
Mother died at 62 of CHF. ?Liver disease.
Father died at 63 of lymphoma. ?Liver disease.
1 Brother and 2 sisters all healthy.
Physical Exam:
98.9 76 113/75 18 98% RA
Gen: NAD. Somewhat anxious.
HEENT: PERRL. Pink, moist oral mucosa without lesions. No
cervical or clavicular lymphadenopathy.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: Decreased breath sounds over the right mid-lower lung
fields.
Abd: Distended. Dullness to percussion over the flank with
minimal shifting dullness. No palpable hepatosplenomegaly.
Ext: Spider angioma over the chest.
Neuro: A&Ox3. Tremulous. No asterixis. CN's II-XII intact.
Strength and sensation to light touch intact in all fields.
Pertinent Results:
OSH: Na 135->135, K 4.4->4.6, Cr 1.1->1.3, AST 106, ALT 32, Alk
Phos 120, Alb 3.4, T. Bili 5.0, D Bili 2.3, [**Doctor First Name **] 53, Lip 34, WBC
11->7.7, Hct 29->28, MCV 90, platelets 77->30, INR 1.3, PT 14.2,
PTT 27.3, EtOH 434.
.
[**2169-8-29**] 09:17PM GLUCOSE-112* UREA N-21* CREAT-1.3* SODIUM-133
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-23 ANION GAP-10
[**2169-8-29**] 09:17PM ALT(SGPT)-30 AST(SGOT)-100* LD(LDH)-189 ALK
PHOS-104 AMYLASE-99 TOT BILI-6.8*
[**2169-8-29**] 09:17PM LIPASE-149*
[**2169-8-29**] 09:17PM ALBUMIN-3.0* CALCIUM-8.1* PHOSPHATE-1.0*#
MAGNESIUM-2.2
[**2169-8-29**] 09:17PM WBC-5.8# RBC-3.39* HGB-10.6* HCT-30.9* MCV-91
MCH-31.2 MCHC-34.2 RDW-18.3*
[**2169-8-29**] 09:17PM PT-16.1* PTT-29.9 INR(PT)-1.5*
.
EKG ([**2169-8-27**]): Sinus tachycardia. Rate 130. Nomal axis and
intervals. No acute ST or T wave changes. No baseline for
comparison.
.
[**2169-8-30**] CXR:
SINGLE AP PORTABLE VIEW OF THE CHEST: Cardiac size is top
normal. The lungs are clear. There is no pleural effusion.
.
[**2169-8-30**] ABD U/S:
IMPRESSION: Nodular echogenic coarse liver consistent with
cirrhosis without focal lesion identified. There is evidence of
portal hypertension including splenomegaly and ascites. The
portal veins demonstrate slow hepatopetal flow.
.
Brief Hospital Course:
52 yo F with EtOH cirrhosis complicated by portal hypertension
and recurrent variceal bleeding transferred from [**Hospital 1562**]
hospital for considerations of TIPS procedure.
# Hematemesis - The patient was admitted directly to the ICU for
EGD. The GI team was consulted and performed an EGD. She was
found to have a large varix that was likely the source of her
bleeding. She became tachycardic and was unable to be banded at
that time. She was maintained on a protonix and an ocreotide
drip for 72 hours. Her diet was slowly advanced to a soft GI
diet. She was also started on a 5 day course of cipro 500mg
[**Hospital1 **]. She had a repeat EGD on [**2169-9-1**] which showed non bleeding
varices which were banded successfully. She remained HD stable
without any blood transfusions. She was started on carafate,
continued on PPI [**Hospital1 **], put on a soft/dysphagia diet x3 days after
24hours of clear liq diet. She had no further N/V/Hematemesis.
She will need a follow up appointment at Liver Clinic (patient
given the number for the clinic) and a repeat endoscopy in [**1-29**]
weeks (can be arranged at Liver Clinic or with a local GI
physician).
# EtOH abuse - The patient denied any history of DT's. She had
been on a 5 day binge prior to admission. She was started on a
valium CIWA scale. She received a total of 20mg valium on
[**2169-8-30**] but since then has not required any benzos for
withdrawal. She has been receiving thiamine, folic acid, and
MVI supplementation. SW evaluated pt for AA or further addiction
counseling and services.
# EtOH cirrhosis complicated by portal hypertension, esophageal
varices. A Abdominal U/S was consistent with cirrhosis and
portal hypertension. A TIPS was not thought to be necessary at
this time. She will continue medical management with diuretics,
and nadalol for varices. She was restarted on her lactulose
prior to discharge.
# Thrombocytopenia. Likely secondary to liver disease. We
monitored her platelets with a goal for maintaining platelets
>20.
.
#. CODE: FULL
Medications on Admission:
Meds (at home per patient):
Furosemide 40mg twice daily
Spironolactone 50mg twice daily
Prilosec 20-40mg once daily
Centrum
Ca
Vit D
Iron
Mg
.
Meds (on transfer):
Vit K 10mg daily x 3 total days, last on [**2169-8-29**]
MVI
Thiamine
Octreotide 50mcg/hr continuous infusion
Pantoprazole 8mg/hr continuous infusion
Levofloxacin 500mg Daily
Metoprolol 2.5mg q6h IV
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap 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. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
5. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Hematemosis
Secondary Diagnosis:
ETOH Cirrhosis
Thrompcytopenia
Discharge Condition:
Stable; tolerating a regular diet; hct stable
Discharge Instructions:
You were admitted to the hospital because of bleeding from your
esophagous. You had two EGD's while you were in the hospital
and they were able to band the large varices that was the source
of the bleeding. It is very important that you stop drinking
because it is causing severe damage to your liver.
Please refrain from all alcohol.
Followup Instructions:
-- Please follow up with your primary care doctor, Dr [**Last Name (STitle) **],
within the next 1-2 weeks. Call [**Last Name (un) **] tomorrow at [**Telephone/Fax (1) 62067**]
to set up an appointment.
-- You will need to follow up in the Liver Clinic in [**11-29**] weeks
with Dr. [**Name (NI) **], please call the liver center at ([**Telephone/Fax (1) 16686**] for an appointment.
-- You will need another upper endoscopy in [**1-29**] weeks. This can
be arranged at the Liver Clinic or by a local physician
suggested by your PCP.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2169-9-4**] Name: [**Known lastname 11882**],[**Known firstname **] C Unit No: [**Numeric Identifier 11883**]
Admission Date: [**2169-8-29**] Discharge Date: [**2169-9-4**]
Date of Birth: [**2117-6-19**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Erythromycin Base
Attending:[**First Name3 (LF) 4091**]
Addendum:
Copy of d/c summary faxed to PCP ([**Last Name (LF) 11884**],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 875**] phone:
[**Telephone/Fax (1) 11885**] fax: [**Telephone/Fax (1) 11886**]) on [**2169-9-4**]
Discharge Disposition:
Home
[**First Name8 (NamePattern2) 1558**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 2301**]
Completed by:[**2169-9-4**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
]
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10016, 10176
|
4801, 6853
|
312, 378
|
8249, 8297
|
3495, 4778
|
8683, 9993
|
2804, 2931
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7265, 8092
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8142, 8142
|
6879, 7242
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8321, 8660
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2946, 3476
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261, 274
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406, 2149
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8195, 8228
|
8161, 8174
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2171, 2581
|
2597, 2788
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,696
| 191,115
|
52892
|
Discharge summary
|
report
|
Admission Date: [**2177-5-20**] Discharge Date: [**2177-6-4**]
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
none
Sigmoidoscopy
Sigmoid colectomy
Bladder resection
Gastropexy/gastrostomy
Colopexy for hiatal hernia
Sigmoid resection & repair of colovesicular fistula
History of Present Illness:
87M found by his VNA this morning to be confused (this is their
first visit with him), called EMS who noted patient to be "shaky
and weak", Vitals at that time were an HR in the 140s, BP
70/palp. FS 94. The patient was last noted to be normal sometime
last week.
.
On arrival to the ED the patient triggered for hypotension wiht
initial vitals HR afib [**Company 5249**] 102.8 (rectal) 138, BP 99/50, RR 26,
94% 2L. He was noted to be A+O x 2, with a petechial lower
extremity rash with some abdominal tenderness. Bedside
ultrasound was done to r/o pericardial effusion. Lactate was
noted to be 5 and cleared with 4L IVF. A U/A was checked and was
clear, CXR revealed an enlarged R. Hilum. CTA revealed an
increased AA with concenr for a psdeudoaneurysm off the
ascending aorta or a focal dissection with thrombus formation.
CSURG was consulted and felt this was an old pseudoanneurysm. He
had a R. IJ was placed and levofed was starterd. He underwent LP
and received Vanc, Zosyn, CTX. LP was performed and noted to be
clear. Vitals at the time of transfer 82 104/60 on .21 of
levofed, 100% 4L.
Past Medical History:
-MGUS
-CVA in [**2165**] with symptoms of veering to the right and problems
with writing with the right hand
-TIA in [**2169**] with transient clumsiness and dysarthria
-Diabetes
-Hypertension
-History of right bundle-branch block
-History of recurrent pseudomonal UTIs
-History of liver hemangioma
-History of ascending aortic aneurysm measuring 4.3 cm
-History of hypercholesterolemia
-History of moderate AS in [**2174-8-9**] on TTE
-Multifactorial gait disorder secondary to lumbar stenosis
and chronic small vessel disease
-History of right common iliac aneurysm measuring 2.2 cm
-Paroxysmal afib with a RVR, has not been anticoagulated on
warfarin due to an excessively high risk of fall but is on
ASA/plavix
-h/o seizure (hospitalization in [**9-/2175**])
-pericardial effusion and tamponade w/o evident recurrence ([**Month (only) 205**]
[**2175**])
-DJD of the spine
-Basal cell cancer
Social History:
Lives alone with 24 hour health aide. Daughter is an Infectious
Disease physician. [**Name10 (NameIs) **] and son are health care proxys.
[**Name (NI) 1139**]: 10 pack year history, quit >50 years ago. Rare EtoH. No
illicit drug use. Emeritus Professor [**First Name (Titles) **] [**Last Name (Titles) 109046**] at [**University/College **]
Business School.
Family History:
No family history of arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory. [**Name (NI) **] father and
brother died of MI in early 50s. No family history of stroke or
cancer.
Physical Exam:
Admission Exam:
Vitals: T:98 BP:137/74 P:82 R:24 O2: 97%
General: A+O x 2 (Self, daughter, place, [**2150**])
[**Name2 (NI) 4459**]: Sclera anicteric, Dry MMM, oropharynx clear
Neck: supple, JVP assessment not valid lying flat, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Irregular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, non-hyperdynamic
Abdomen: Milld TTP b/l Upper quadrants, mild guarding bowel
sounds present,
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, linear petechial rashes on b/l shins
Pertinent Results:
Admission Labs:
[**2177-5-20**] 08:40AM PLT COUNT-267
[**2177-5-20**] 08:40AM PT-13.0 PTT-22.4 INR(PT)-1.1
[**2177-5-20**] 08:40AM NEUTS-93.7* LYMPHS-3.4* MONOS-0.7* EOS-1.9
BASOS-0.3
[**2177-5-20**] 08:40AM WBC-4.8 RBC-3.06* HGB-8.9* HCT-26.6* MCV-87
MCH-29.2 MCHC-33.6 RDW-20.0*
[**2177-5-20**] 08:40AM CALCIUM-8.4 PHOSPHATE-2.4* MAGNESIUM-1.9
[**2177-5-20**] 08:40AM cTropnT-<0.01
[**2177-5-20**] 08:40AM ALT(SGPT)-17 AST(SGOT)-20 ALK PHOS-76 TOT
BILI-0.6
[**2177-5-20**] 08:40AM estGFR-Using this
[**2177-5-20**] 08:40AM UREA N-24* CREAT-1.2
[**2177-5-20**] 09:04AM freeCa-1.12
[**2177-5-20**] 09:04AM GLUCOSE-91 LACTATE-4.9* NA+-143 K+-3.0*
CL--106 TCO2-24
[**2177-5-20**] 09:04AM PH-7.50*
[**2177-5-20**] 10:06AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2177-5-20**] 10:06AM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.008
[**2177-5-20**] 10:06AM URINE UHOLD-HOLD
[**2177-5-20**] 10:06AM URINE UHOLD-HOLD
[**2177-5-20**] 10:06AM URINE HOURS-RANDOM
[**2177-5-20**] 10:06AM URINE HOURS-RANDOM
[**2177-5-20**] 01:59PM LACTATE-1.3
Discharge Labs:
Notable Labs:
[**2177-5-20**] 03:50PM CEREBROSPINAL FLUID (CSF) PROTEIN-23
GLUCOSE-59
[**2177-5-20**] 03:50PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-1*
POLYS-11 LYMPHS-40 MONOS-49
[**2177-5-20**] 08:40AM BLOOD cTropnT-<0.01
Microbiology:
[**2177-5-20**] 3:50 pm CSF;SPINAL FLUID
GRAM STAIN (Final [**2177-5-20**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): pending
BLOOD CULTURE [**2177-5-20**]: Pending x2
URINE CULTURE [**2177-5-20**]:
[**2177-5-20**] 10:06 am Site: CATHETER
URINE CULTURE (Preliminary):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
Imaging:
CXR [**2177-5-20**]: Abnormal mediastinal and right hilum. This is of
unclear etiology and the margins of the right hilar density are
atypical for mass lesion. I suspect there is a large hiatal
hernia, possibly intrathoracic stomach, which could account for
the relatively atypical appearance, although this is difficult
to confirm given the lack of lateral view and comparison
studies. If clinically feasible, consider PA and lateral views
for further evaluation.
CT TORSO WITH CONTRAST [**2177-5-20**]:
1. There is a focal contrast-filled outpouching off the
anterolateral aspect of the ascending aorta originating
approximately 6 cm from the aortic root. The neck of the
outpouching, in open communication with the aortic lumen, is
approximately 3.7 cm. The entire contrast-filled outpouching
measures 8.4 cm AP x 6.4 cm transverse x 8.8 cm cephalocaudad.
The lesion terminates just prior to the origin of the
brachiocephalic artery. A small focus of adjacent mediastinal
fat is noted laterally. There is no associated stranding or
mesenteric fluid to suggest leak or rupture at this time. These
findings highly suggest a pseudoaneurysm or possibly a very
focal dissection. Although a non-gated study, the gross course
of the right coronary artery, in particular the origin is
approximated and the lesion is remote to it.
2. There is a highly suspicious, circumferential, predominantly
hypoattenuated lesion with relatively sharp transition zones
both proximally and distally in a short segment of the sigmoid
colon, approximately 5 cm in maximal length. Posteroinferiorly,
there is a hypoattenuated outpouching extending inferiorly and
abutting the dome of the thick-walled collapsed bladder. No
intervening fat plane is identified. There is an indwelling
Foley catheter balloon within the thick-walled bladder. It is
unclear whether there is a large right posterolateral bladder
diverticulum or whether the wall thickening of thebladder is
asymmetric and involves the anterior and superior
aspects only. The findings are highly suggestive of carcinoma pf
the sigmoid colon with a possible contained inflammatory
component extending to and possibly locally invading the dome of
the bladder. An underlying fistula, therefore, cannot be
entirely excluded. While the possibility of
diverticulitis is entertained, the overall features of this
lesion are much more consistent with that of colon cancer.
3. There is an irregular geographic area of hypoattenuation
within the anterior right hepatic lobe mostly within segment
VIII but also involving a small component of segment VII with
small eccentric hyperattenuating foci most consistent with a
giant hemangioma. Despite the presence of an apparent sigmoid
cancer, this lesion is not consistent with a metastatic deposit.
4. There is a large hernia anterior to the hiatus involving a
long segment of the transverse colon which is relatively
moderately stool filled. There is no apparent obstruction.
Moderate-to-significant fecal loading is noted
throughout the colon.
5. There is incomplete left lower collapse, predominantly
involving the basal segments with relative sparing of the
superior segment. Subsegmental atelectasis is also noted in the
left upper lobe and right lower lobe. No focal consolidation is
seen. There is no superimposed edema. A small left pleural
effusion is evident.
6. The heart is enlarged with extensive native coronary vessel
calcification. No pericardial effusion is seen. Aside from the
obvious lesion in the ascending aorta detailed in #1 above, the
aorta itself is relatively ectatic throughout its course with
scattered calcified and non-calcified atheromatous plaque. The
right common iliac artery measures 2 cm in maximal diameter.
Severe and extensive vascular calcification of the splenic
artery is incidentally noted.
7. Incidentals: Small lipoma within the paraspinal musculature
of the upper back, reference series 2, image #16, is noted. A
compression fracture of L1 with significant vertebral body
height loss is also noted. Margins are smooth and well
marginated suggesting chronicity. There is no posterior
retropulsion. Degenerative changes are noted diffusely
throughout the thoracolumbar spine with multilevel bridging
osteophytes are seen in the mid thoracic spine. Numerous
hypoattenuating lesions of the kidneys are present which are too
small to further characterize. There is a large exophytic
hypoattenuated lesion off the lateral aspect of the inferior
pole of the right kidney. There is either a tiny focus of
layering milk of calcium or possibly a small rim calcification
noted.
Brief Hospital Course:
The patient is an 87M with long and complicated past medical
history admitted from the ED with new onset confusion,
hypotension, and fever.
HYPOTENSION/SEPTIC SHOCK: He presented with SBP to 70s systolic,
fevers, and eventually mounted a leukocytosis to 22.7 in the
setting of a lactate greater than 5. He was aggressively
resuscitated and cultured. A central venous line was placed in
the ED. A lumbar puncture was performed due to confusion (near
his baseline) and a patechial rash on his shins, though it was
negative for meningitis. A CT torso was done in the setting of
hypotension to evaluate a known aortic dissection, though this
was stable. It did show a sigmoid apple-core lesion consistent
with possible colon cancer. He was started on vanco/zosyn to
cover potential bowel pathogens, with a translocation event
suspected in light of abdominal pain on exam. He briefly
required pressor support with aggressive fluids with
normalization of his blood pressure. Other sources of infection
include a right lower lobe pneumonia which evolved on HD2, as
well as a urinary tract infection growing enterococcus on
culture.
On [**5-25**] the patient was transferred to the surgical service and
taken to the operating room where a sigmoid colectomy and
reduction of type IV hiatal hernia was performed. In order to
completely remove the sigmoid mass, a section of the bladder had
to be removed with the specimen and this was repaired primarily.
The patient tolerated the procedure well and was transferred to
the TSICU for further management. His levophed was weaned to off
and he was extubated without difficulty. Following extubation,
the patients mental status improved and he was transferred to
the floor for further management.
# ALTERED MENTAL STATUS: Delerium is the most likely etiology,
in this setting sepsis is the most likely etiology, though the
patient is quite constipated on CT scan, and this could also
precipitate delerium. There is no evidence of MI, hypo or hyper
glycemia or new pain or pain meds driving this. This resolved
after his operation and was not an issue for the remainder of
his hospitalization.
# COLON CANCER : Apple core lesion seen in sigmoid colon
concerning for colon cancer, especialy with guiac positive
stools and anemia. Specimen from colonscopy by GI demonstrated
adenocarcinoma. This was removed inraoperatively and sent to
pathology. Part of dome of bladder also involved and was
removed. Fistulas repaired surgically. The patient will follow
up with ACS and primary doctor for further management.
# HIATAL HERNIA: Large hiatal hernia seen with stool-filed
colon passing into thorax. Moving bowels without sign of
obstruction. This was repaired in the operating room.
# ATRIAL FIBRILLATION: Patient was in Afib and had episodes of
RVR post-op. These responded to i.v. and PO metoprolol. Cards
consulted and suggested anticoagulation and rate control.
Patient on lovenox and will follow up with PCP.
# BPH:
- hold tamsulosin in the setting of hypotension
# CAD: On aspirin and plavix
# Dementia:
- continue memantine for now
.
Osteoporosis:
- continue vitamin D
.
GERD:
- continue ranitidine
Medications on Admission:
tamsulosin 0.4 mg Capsule, Ext Release 24 hr PO BID
Plavix 75 mg Tablet daily
memantine 10 mg PO BID prn for dementia
Vitamin D 1,000 daily
aspirin 81 mg Tablet daily
ranitidine HCl 150 mg PO BID
ciprofloxacin 500 PO Q12H for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Sepsis
Colon adenocarcinoma
Right IJ thrombus
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to [**Hospital1 18**] initially with septic shock. It
remains unclear where the source of infection was, but you
improved after a course of antibiotics. We did a CT scan which
showed a mass in your colon. You had a sigmoidoscopy to
evaluate it and biopsies were taken. The biopsies showed
evidence of adenocarcinoma.
The mass showed evidence obstruction of bowel, local invasion
into the bladder, and fistulization. Due to this, our general
surgery team was consulted and performed sugery. In the
surgery, part of your sigmoid colon was removed, as well as part
of your bladder. The fistula between your colon and bladder was
then closed. Your stomach was anchored to your abdominal wall,
and a hernia in your diaphragm was repaired.
While in the hospital, you were found to have atrial
fibrillation with fast heart rates (RVR). For this, you
required i.v. and oral beta blocker medications. We consulted
our cardiologists, who agree you should stay on this beta
blocker medication. Due to concern for possible clotting, they
also suggest you be on blood thinners. You were started on
lovenox. Please follow up with your primary doctor to discuss
further management of this.
You also have a thrombus/clot of your internal jugular vessel.
This is another reason why you have been started on blood
thinners. You are scheduled to have another imaging test of
this vessel in 5 weeks. Please keep this appointment.
You required a Foley cathether to help you urinate. You will
need to keep this cathether in until you follow up with us in 2
weeks.
It was a pleasure meeting you and participating in your care.
Followup Instructions:
Dr.[**Name (NI) 75011**] office will contact you for follow up. If you do
not hear from them, please contact them to set up an
appointment.
Please follow up with our general surgery clinic in two weeks by
calling [**Telephone/Fax (1) **]. Please let them know you have to have a
voiding cystogram performed prior to your visit.
Completed by:[**2177-7-9**]
|
[
"995.92",
"293.0",
"041.04",
"038.9",
"600.00",
"599.0",
"733.00",
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"427.31",
"250.00",
"272.4",
"785.52",
"V58.61",
"584.9",
"564.09",
"553.3",
"401.9",
"276.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.76",
"38.93",
"43.19",
"96.6",
"45.24",
"57.6",
"46.63",
"53.72"
] |
icd9pcs
|
[
[
[]
]
] |
13565, 13655
|
10114, 11865
|
262, 421
|
13745, 13745
|
3688, 3688
|
15597, 15958
|
2858, 3066
|
13676, 13724
|
13305, 13542
|
13930, 15574
|
4856, 5253
|
3081, 3669
|
211, 224
|
5443, 10091
|
449, 1546
|
3704, 4839
|
13760, 13906
|
1568, 2465
|
2481, 2842
|
5282, 5410
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,899
| 131,879
|
45282
|
Discharge summary
|
report
|
Admission Date: [**2173-3-8**] Discharge Date: [**2173-3-11**]
Date of Birth: [**2094-4-11**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Penicillins
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Carotid artery stenosis
Major Surgical or Invasive Procedure:
LCEA
History of Present Illness:
The patient is an elderly male with a right- sided stroke
related to a high-grade left carotid stenosis. After appropriate
recovery and repeat CT scan showing no further bleed, he was
scheduled for endarterectomy.
Past Medical History:
1. CAD w/ h/o STEMI [**2171-11-16**] s/p RCA stent (cypher stent x 2 to
RCA w/ TIMI III flow)
2. CHF (diastolic dysfunction) - ECHO '[**69**]: EF > 60%, LA mod
dilated, mild symm LVH w/ normal cavity size, 1+ MR, aortic
valve leaflets mildly thickened
3. NIDDM (>15 years)
4. HTN
5. Osteopenia
6. Hyperlipidemia
7. ? TIA like sx [**2168**] (numb around the mouth, relieved w/ [**Year (4 digits) **])
8. h/o pyonidal cyst
9. gout (last flare 1 1/2 years ago)
10. carpal tunnel syndrome
11. CRI (Cr 1.3 since STEMI [**2171-11-16**], previously 0.9)
12. s/p thyroidectomy
13. s/p appy
14. s/p TKR
15. Anemia
16. L-sided stroke several years ago
17. BPH
18. Erectile dysfunction
Social History:
He was most recently D/C'd to [**Hospital1 5595**] MACU on [**11-2**] for further
care. Prior to that, he was at home with his wife. Further
history limited. Quit smoking 39 years ago but 100 pack-year
history.
Family History:
Mother: heart problems; father: arthritis, brother died at 19 of
Hodgkins disease
Physical Exam:
PE:
AFVSS
[**Month/Year (2) 4459**]:
NCAT
Neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lyphandopathy, supra clavicular nodes
LUNGS: CTA b/l
CARDIAC: RRR without murmers
ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness
EXT:
rle - palp fem, [**Doctor Last Name **], pt, dp
lle - palp fem, [**Doctor Last Name **], pt, dp
Pertinent Results:
[**2173-3-11**] 05:15AM BLOOD WBC-10.6 RBC-3.25* Hgb-9.3* Hct-28.2*
MCV-87 MCH-28.5 MCHC-32.8 RDW-15.4 Plt Ct-136*
[**2173-3-11**] 05:15AM BLOOD Calcium-8.4 Phos-4.1 Mg-2.0
Brief Hospital Course:
Mr. [**Name14 (STitle) 96747**] was admitted on [**2172-3-8**] for an elective carotid
endarectomy . Pre-operatively, he was consented, prepped, and
brought down to the operating room for surgery.
Intra-operatively, he was closely monitored and remained
hemodynamically stable. He tolerated the procedure well without
any difficulty or complication.
Post-operatively, he was extubated and transferred to the PACU
for further stabilization and monitoring.
He was then transferred to the VICU for further recovery. All
lines were DC'd. Pt diod have difficulty swallowing. A speech
and swallow study was performed. Pt pasesed. His diet was
advqanced as tolerated. On Dc he is at baselin, taking good PO.
On the floor, he remained hemodynamically stable with his pain
controlled. He progressed with physical therapy to improve his
strength and mobility. He continues to make steady progress
without any incidents. He was discharged to a rehabilitation
facility in stable condition
Medications on Admission:
Metoprolol 25mg qd, Lasix 60 mg [**Last Name (LF) **], [**First Name3 (LF) **] 325 mg qd, Clopidogrel
75mg qd, Allopurinol 150mg qd, ISDN 60mg qd, Prednisone 10mg qd,
Glyburide 10mg qd, Terazosin 10mg qd, Lipitor 80m qd, Priloset
20mg qd, Senakot 1 qd, Colace 100mg [**Hospital1 **].
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
14. Labetalol 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
15. [**Hospital1 **] 75 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **], Inc.
Discharge Diagnosis:
Left Carotid artery stenosis
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Division of [**Name8 (MD) **] and Endovascular Surgery
Carotid Endarterectomy Surgery Discharge Instructions
What to expect when you go home:
1. Surgical Incision:
?????? It is normal to have some swelling and feel a firm ridge along
the incision
?????? Your incision may be slightly red and raised, it may feel
irritated from the staples
2. You may have a sore throat and/or mild hoarseness
?????? Try warm tea, throat lozenges or cool/cold beverages
3. You may have a mild headache, especially on the side of your
surgery
?????? Try ibuprofen, acetaminophen, or your discharge pain
medication
?????? If headache worsens, is associated with visual changes or
lasts longer than 2 hours- call [**Name8 (MD) 1106**] surgeon??????s office
4. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
5. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? No excessive head turning, lifting, pushing or pulling
(greater than 5 lbs) until your post op visit
?????? You may shower (no direct spray on incision, let the soapy
water run over incision, rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2173-3-23**] 1:00
Provider: [**Name10 (NameIs) 475**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 474**], M.D. Phone:[**Telephone/Fax (1) 1989**]
Date/Time:[**2173-8-25**] 3:40
Completed by:[**2173-3-11**]
|
[
"401.9",
"600.00",
"412",
"272.4",
"733.90",
"274.9",
"428.32",
"250.00",
"V45.82",
"427.89",
"433.10",
"585.9",
"414.01",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.12",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
4722, 4824
|
2178, 3159
|
317, 324
|
4897, 4906
|
1981, 2155
|
7909, 8289
|
1511, 1595
|
3493, 4699
|
4845, 4876
|
3185, 3470
|
4930, 7314
|
7340, 7886
|
1610, 1962
|
254, 279
|
352, 568
|
590, 1267
|
1283, 1495
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,323
| 107,385
|
52378+59424
|
Discharge summary
|
report+addendum
|
Admission Date: [**2130-1-9**] Discharge Date: [**2130-1-20**]
Date of Birth: [**2060-12-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Pericardial effusion
Major Surgical or Invasive Procedure:
[**2130-1-11**] Subxiphoid pericardial window
[**2130-1-11**] IVC filter placement
History of Present Illness:
Mr. [**Known lastname **] is a 69 year old gentlemen with medical history
significant for emphysema and is status-post neoadjuvent
chemoradiation and thoracotomy with left upper lobectomy
[**2129-12-20**] for stage IIIA T2N2 squamous cell carcinoma who
returned to [**Hospital1 18**] with complaint of shortness of breath and CXR
findings at his PCP's demonstrating a left lower lobe infiltrate
concerning for pneumonia. At presentation he described 5 days of
progressively worsening dyspnea.
Patient been discharged home with physical therapy services
after his operation and had been progressing well until 5 days
prior to admission when he began noticing increasing dyspnea
while climbing stairs during the 2
days prior to admission he also experience dyspnea while walking
on flat surfaces and with speech. By the morning of present
admission Mr. [**Known lastname **] was requiring 4L of nasal home oxygen.
He was scheduled to see Dr. [**First Name (STitle) **] in clinic [**2130-1-10**] but due to his
continued worsening dyspnea he presented to his PCP at [**Hospital1 2292**] and was noted on CXR to have a left lower lobe
infiltrate with and elevated WBC count to 19 with left shift, as
well as an INR of 8. (Patient had been discharged from the
hospital on a Lovenox bridge to Coumadin for history of left
lower extremity DVT and pulmonary embolism). He was subsequently
sent to the ED at
[**Hospital1 18**] for further care.
At the time of presentation the patient denied chest pain,
pleuritic pain, headaches, dizziness, fever, chills, nausea,
vomiting, changes in bowel or bladder habits, prolonged
bleeding, easy bruising, or changes in weight did endorse
continued decreased appetite. He had recently completed a course
of Levaquin for suspected hospital-acquired pneumonia.
Past Medical History:
Oncology History:
PET CT [**2129-8-10**]: FDG-avid LULlarge 49x40mm lung lesion is seen
highly concerning for lung cancer. There are FDG-avid
prevascular lymph nodes, as follows: 27 x 19 mm and 18x14mm.
There is a prominent lymph node in the left peritracheal area
measuring 18x12mm (not FDG-avid) and non-specific
Bronchoscopy [**2129-8-22**]: obtained tissue for pathology which
revealed invasive squamous cell carcinoma (stage IIIa)
[**2129-9-9**]: left VATS and lymph node biopsy to complete staging work
up. No pleural metastases were noted but there were bulky level
6 lymph nodes, which were positive for metastatic carcinoma on
frozen sections; final pathology showed poorly differentiated
squamous cell carcinoma with extensive necrosis histologically
similar to the prior lung sample.
[**9-/2129**]: Started cisplatin and VP-16 as well as radiotherapy as
neoadjuvant treatment before a definitive surgery
PMH: Emphyzema, bipolar disorder, patello-femoral syndrome,
squamous cell lung carcinoma
Past Surgical History:
Left VATS with biopsy of peri-aortic lymph node [**2129-9-9**]
Left thoracotomy, left upper lobectomy, mediastinal lymph node
dissection, and buttressing of bronchial staple line with
intercostal muscle [**2129-12-20**]
Subxiphoid pericardial window [**2129-1-11**]
Social History:
Lives with wife at home. 75 pack-year smoking history, quit [**2-10**]
yrs ago, drinks 3 glasses of EtOH/week and denies use of illegal
drugs
Family History:
Mother died of pancreatic cancer, father had Parkinsons. No
other history of cancer or blood clotting disorders
Physical Exam:
GENERAL: No acute distress; alert and fully oriented; pleasant
and cooperative
HEENT: Mucous membranes moist and pink; nasal canula in place;
no ocular or nasal discharge; no scleral icterus; no skin
lesions
CARDIAC: Regular rate and rhythm; normal S1 and S2; no
appreciable murmumurs
CHEST: Left thoracotomy incision healing well; no erythema or
induration
PULMONARY: Crackles at lung bases bilaterally; slightly
diminished breath sounds on left side
ABDOMEN: Soft, non-tender, non-distended; no palpable masses; no
rebound or gaurding; healing vertical incision in sub-xiphoid
region
EXTREMITIES: Moderate bilateral lower extremity edema
bilaterally
Pertinent Results:
[**2130-1-9**] 09:48PM PT-150* PTT-72.9* INR(PT)-15.7*
[**2130-1-9**] 09:37PM LACTATE-2.3*
[**2130-1-9**] 08:13PM TYPE-ART PO2-75* PCO2-27* PH-7.49* TOTAL
CO2-21 BASE XS-0
[**2130-1-9**] 07:20PM PT-150* PTT-74.3* INR(PT)-15.7
[**2130-1-9**] 06:52PM LACTATE-3.5*
[**2130-1-9**] 06:45PM GLUCOSE-123* UREA N-33* CREAT-1.3* SODIUM-134
POTASSIUM-5.4* CHLORIDE-99 TOTAL CO2-21* ANION GAP-19
[**2130-1-9**] 06:45PM estGFR-Using this
[**2130-1-9**] 06:45PM WBC-16.5* RBC-3.31* HGB-9.0* HCT-29.3* MCV-89
MCH-27.2 MCHC-30.7* RDW-16.2*
[**2130-1-9**] 06:45PM NEUTS-88.4* LYMPHS-6.7* MONOS-3.4 EOS-1.4
BASOS-0.2
[**2130-1-9**] 06:45PM PLT COUNT-589
RADIOLOGY:
CT CHEST WITH CONTRAST [**2130-1-10**]:
Findings:
A large pericardial effusion, with attenuation characteristics
of bloody or
exudative fluid has developed, impinging on the right atrium and
right
ventricle, suggesting cardiac tamponade.
Severe consolidation in the post-operative left lung, extending
from the
superior segment to the upper regions of the basal segments has
worsened, and
extensive consolidation in the right lung is largely new, in the
anterior
segment of the right upper lobe, the right middle lobe, and the
right lower
lobe, most pronounced in the superior segment.
Brief Hospital Course:
The patient underwent a CT of the chest in the ED which
demonstrated a large pericardial effusion impairing right
ventricular function. He was transported to the cath lab for
pericardialcentesis and approx 875cc of bloody fluid was
successfully drained. The pericardial fluid was sent for
cytology and a drain was left in place. The patient had
improvement in his dyspnea symptoms, however a TTE performed the
following morning was significant for a continued moderate
pericardial effusion that was reported to be echo-dense and
consistent with blood - despite the minimal output from his
pericardial drain. Cytology results of the pericardial fluid
returned negative for malignant cells.
It was decided at that time that the patient would benefit from
a pericardial window procedure. He was appropriately pre-op'ed
and consented, and underwent a sub-xiphoid pericardial window
procedure with placement of IVC filter for DVT prophylaxis (due
to the importance of discontinuation of his anticoagulation due
to his hemopericardium and drastically supra-therapeutic INR).
The patient was transferred to the ICU post-op for close cardiac
monitoring, and a bedside ECHO did not demonstrate any
significant re-accumulation of fluid on post-operative day 1.
However, the patient's ICU course was complicated by a short
bout of V-tach and two short episodes of atrial fibrillation
with rapid ventricular response which resolved spontaneously
without intervention.
By post-operative day 3 the patient was weaned off all pressors,
and by post-operative day 4 he was stable for transfer out of
the ICU and to the floors following removal of his pericardial
drain.
The patient's post-operative course continued to be complicated
by episodes of atrial fibrillation/ectopy with heart rates in
the 120's while ambulating. His Metoprolol was increased to
3-time daily dosing and a Cardiology consult was obtained. Per
the recommendations of the Cardiology team the patient was begun
on Amiodarone: 400mg [**Hospital1 **] loading dose x1 week to be followed by
200mg [**Hospital1 **] x3 weeks and then decreased to maintenance dose of
200mg daily. Additionally, Cardiology recommended ASA 325mg
(daily) alone for anticoagulation due to his risk of bleeding
and the low likelihood that his (presumed temporary)
post-operative atrial fibrillation would pose a risk for
thrombus formation. Of note, the patient was temporarily placed
on a Lasix regimen of 20mg daily for significant bilateral lower
extremity edema, but had two episodes of mild hypotension on
post-operative days 8 and 10 - both of which responded well to
fluid boluses- after which time the Lasix was discontinued.
Mr. [**Known lastname **] did well after initiation of Amiodarone, with
noticeable decrease in the frequency of his arrythmia episodes.
Staples from his incision were removed on post-operative day 9,
and by post-operative 11 it was determined both medically and
surgically appropriate to discharge the patient home with
physical therapy services, following clearance by both the
Cardiology and Physical Therapy teams.
At the time of discharge the patient was ambulating well with
assistance, was tolerating a regular diet, had no active pain
issues, had been afebrile through-out his hospital course, and
was in normal sinus rhythm. He was discharged with plans to
follow-up in Thoracic Surgery clinic in 2 weeks and to follow-up
with Cardiology clinic in [**4-14**] weeks.
Medications on Admission:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. lithium carbonate 300 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. enoxaparin 100 mg/mL Syringe Sig: One Hundred (100) mg
Subcutaneous Q12H (every 12 hours).
Disp:*14 syringes* Refills:*2*
6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours): thru [**2130-1-1**].
Disp:*18 Tablet(s)* Refills:*0*
10. Coumadin 5 mg Tablet Sig: One (1) Tablet PO as directed.
Disp:*100 Tablet(s)* Refills:*2*
11. Respiratory Therapy
Oxygen at 1-2 liters per minute vis nasal cannula during any
exertional activity or for shortness of breath
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. nystatin-triamcinolone 100,000-0.1 unit/g-% Cream Sig: One
(1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. lithium carbonate 300 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. amiodarone 400 mg Tablet Sig: One (1) Tablet PO twice a day
for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
8. amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 3 weeks: Please begin on [**2130-1-26**].
Disp:*42 Tablet(s)* Refills:*0*
9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Begin on [**2130-2-16**] after completion of 3-week cours of [**Hospital1 **]
scheduling.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Hemopericardium
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 accumulation of fluid
around your heart that resulted in difficulty breathing, and
subsequently underwent a procedure to evacuate this fluid called
a "pericardial window." Post-operatively you were also noted to
have some changes in the pattern of your heartbeats for which
you were evaluated by the cardiologists and prescribed some new
medications. Currently you are recovering well and ready for
discharge home
* Continue to take your new cardiac medications as prescribed
* Your Warfarin was discontinued during your hospital stay due
to concern of bleeding. Do not resume your Warfarin for at least
4-6 weeks or until instructed to do so by your Cardiologist.
Continue taking Aspirin 325mg daily for anticoagulation
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* You may continue to need pain medication once you are home but
you can wean it over a few weeks as any lingering discomfort
resolves. Make sure that you have regular bowel movements while
on narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol 650 mg every 6 hours in between your narcotics.
If your doctor allows you may also take Ibuprofen to help
relieve the pain.
* Continue to stay well hydrated and eat well to heal your
incisions
* 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 and gradually increase your activity as
you can tolerate.
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain, persistent
palpitations, or any other symptoms that concern you
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**]
Date/Time:[**2130-1-31**] 9:00
Please call Dr.[**Name (NI) 17720**] office for a follow-up appointment in
[**4-13**] weeks. Phone: [**Telephone/Fax (1) 56771**]. Address: [**Location (un) 2129**],
[**Location (un) 86**], [**Numeric Identifier 718**]
Completed by:[**2130-1-20**] Name: [**Known lastname 17701**],[**Known firstname 17702**] Unit No: [**Numeric Identifier 17703**]
Admission Date: [**2130-1-9**] Discharge Date: [**2130-1-20**]
Date of Birth: [**2060-12-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1999**]
Addendum:
Clarification to ICU course in earlier discharge summary: the
patient likely had ARDS rather than pneumonia
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 42**] VNA
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2000**] MD [**MD Number(2) 2001**]
Completed by:[**2130-2-9**]
|
[
"453.41",
"V12.55",
"423.0",
"719.46",
"278.00",
"458.9",
"293.0",
"162.3",
"997.49",
"196.1",
"518.52",
"V12.51",
"426.13",
"427.32",
"997.1",
"V15.82",
"296.80",
"285.9",
"427.1",
"E849.7",
"560.1",
"E934.2",
"790.92",
"427.31",
"E878.8",
"492.8",
"423.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"33.24",
"37.12",
"38.97",
"38.91",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
14748, 14961
|
5818, 9262
|
330, 415
|
11646, 11646
|
4538, 5795
|
13849, 14725
|
3736, 3850
|
10478, 11506
|
11607, 11625
|
9288, 10455
|
11797, 13826
|
3291, 3559
|
3865, 4519
|
270, 292
|
443, 2237
|
11661, 11773
|
2259, 3268
|
3575, 3720
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,187
| 160,729
|
53200
|
Discharge summary
|
report
|
Admission Date: [**2194-12-22**] Discharge Date: [**2194-12-30**]
Date of Birth: [**2151-6-14**] Sex: F
Service: Plastic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 43-year-old
female. The patient has a known history of breast cancer and
was admitted on [**2193-12-22**] for planned bilateral
mastectomy with bilateral free transverse rectus abdominis
flaps and bilateral oophorectomies.
PAST MEDICAL HISTORY: The patient's past medical history
includes a previous history of breast cancer (as indicated).
Previous incisional breast surgery for infiltrating carcinoma
with both ductal and lobular features. This breast surgery
was conservative in nature and was followed by radiation
therapy and chemotherapy. Otherwise, her past medical
history was unremarkable.
HOSPITAL COURSE: The patient received prophylactic bilateral
salpingo-oophorectomy because of her personal and family
history of breast cancer.
On the day of admission, the patient was to the operating
room for her bilateral mastectomy done by Dr. [**Last Name (STitle) 11635**]. Her
salpingo-oophorectomy was done by Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 2920**] [**Doctor Last Name 1022**]. Her
reconstructive surgery was performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13797**].
Please see the Operative Report from each of these physicians
for details of the components of this operation.
Immediately after surgery, the patient was transferred to the
Intensive Care Unit for monitoring of her free flap. On
postoperative day two, she was noted to have a swollen left
breast that was felt to be secondary to venous congestion.
On [**2194-12-24**], the patient was started on intravenous
heparin with a goal of maintaining her partial thromboplastin
time between 50 and 70 to prevent thrombosis.
On [**2194-12-26**], the patient was taken to the operating
room for debridement of her left free transverse rectus
abdominis flap. She was closed primarily at that time
without additional attempts at reconstruction.
Her postoperative course was unremarkable. Her first two
drains were removed on the day prior to discharge. Her
second two drains were removed on the day of discharge.
CONDITION AT DISCHARGE: The patient's condition on discharge
was stable.
DISCHARGE STATUS: Her discharge status was to home.
DISCHARGE DIAGNOSES:
1. Breast cancer.
2. Status post bilateral mastectomy.
3. Status post bilateral transverse rectus abdominis flap
reconstruction.
4. Status post bilateral salpingo-oophorectomy.
5. Free transverse rectus abdominis revision.
6. Free transverse rectus abdominis removal.
MEDICATIONS ON DISCHARGE: (Discharge medications included)
1. Keflex 500 mg p.o. q.i.d. (times 10 days).
2. Percocet one to two tablets p.o. q.4-6h. as needed.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow
up with Dr. [**Last Name (STitle) 13797**] in approximately one week. The patient
was instructed to call Dr.[**Name (NI) 109520**] office to obtain an
appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19095**], M.D. [**MD Number(1) 19096**]
Dictated By:[**Last Name (NamePattern1) 1752**]
MEDQUIST36
D: [**2194-12-30**] 15:09
T: [**2194-12-30**] 19:47
JOB#: [**Job Number 109521**]
|
[
"620.0",
"E878.2",
"996.52",
"174.4",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"85.85",
"85.21",
"65.61",
"85.44"
] |
icd9pcs
|
[
[
[]
]
] |
2404, 2679
|
2706, 2843
|
815, 2264
|
2878, 3354
|
2279, 2383
|
175, 417
|
440, 797
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,730
| 157,832
|
49793
|
Discharge summary
|
report
|
Admission Date: [**2118-6-30**] Discharge Date: [**2118-7-5**]
Service: MEDICINE
Allergies:
A.C.E Inhibitors
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
Pacemaker placement
History of Present Illness:
This is a [**Age over 90 **] year-old primarily Russian speaking man with a
history of CAD s/p 5v CABG in [**2111**], AVR, left ventricular
systolic dysfunction with EF 30-40% who presents with dizziness
today and after having episodes recently of awaking on floor
without recall of preceding events. His daughter brought him in
with this concern. Says he did not hit his head.Otherwise
denies chest pain, shortness of breath, orthopnea, pnd. Of note
recent admissions for fall without discovery of obvious
etiology.In emergency room EKG with high degree AV block.
Become asystolic and EP placed temp wire.
Past Medical History:
Hypercalcemia (hyper-PTH)
CAD (followed by Dr. [**Last Name (STitle) 3302**]- s/p MI and 5 vessel CABG [**2111**] at
OSH
Aortic valve replacement
CHF - EF 30% in [**2115**]
SVT s/p cardioversion at OSH
HTN
asthma/COPD
legally blind in L eye
hyperlipidemia
chronic renal insufficiency (baseline Cr 1.3)
chronic abdominal pain with h/o gastritis and esophagitis with
atypia
iron deficiency anemia
depression
anxiety
diverticulosis
h/o positive PPD
steroid-related glucose intolerance
L eye cataract surgery
Social History:
Widowed, holocaust survivor. Has lived in US for 25 years.
Independent in ADLs, does have help from VNA.
No alcohol, tobacco, or illicit drug use.
Family History:
non-contributory
Physical Exam:
VS: Temp:98 BP:144/75 HR:60 RR:21 O2sat:97% on 3 L
.
general: pleasant, comfortable, NAD
HEENT: PERLLA, EOMI, anicteric, MMM, op without lesions,temp
wire in right neck
lungs: minimal bilateral crackles at bases
heart: [**Last Name (un) **], S1 and S2 wnl, no murmurs, rubs or gallops
appreciated
abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
extremities: no edema
skin/nails: no rashes/no jaundice/
neuro: AAOx3. Cn II-XII intact.
Pertinent Results:
[**2118-6-30**] 03:33PM BLOOD K-4.9
[**2118-7-1**] 04:38AM BLOOD CK(CPK)-42
[**2118-7-1**] 04:38AM CK-MB-NotDone cTropnT-0.10*
[**2118-7-1**] 04:38AM CK(CPK)-42
[**2118-7-2**] 05:25AM WBC-8.0 RBC-3.89* Hgb-11.9* Hct-36.0* MCV-93
MCH-30.5 MCHC-32.9 RDW-14.8 Plt Ct-198
[**2118-7-2**] 05:25AM Glucose-93 UreaN-24* Creat-1.4* Na-140 K-4.9
Cl-104 HCO3-31 AnGap-10 Calcium-10.1 Phos-3.7 Mg-2.5
[**2118-7-3**] 06:05AM BLOOD Plt Ct-200
[**2118-7-3**] 06:05AM BLOOD Glucose-84 UreaN-24* Creat-1.3* Na-138
K-4.7 Cl-101 HCO3-30 AnGap-12
[**2118-7-3**] 06:05AM BLOOD Calcium-10.4* Phos-3.2 Mg-2.4
[**2118-7-4**] 06:50PM BLOOD Hct-32.9*
CXR ([**2118-7-3**]):The previously seen density in the right mid lung
is again visualized, but is less opaque. I do not clearly
localize this on the lateral view, but that could be obscured by
the overlying soft tissue of the left upper extremity. There are
bilateral effusions, which appear similar when comparing the
frontal view and basilar atelectasis. Probable scarring at the
right base is again noted. Pulmonary vascular markings,
cardiomegaly and pacemaker hardware/wires are unchanged.
Brief Hospital Course:
This is a [**Age over 90 **] year-old man with history of CAD, CHF, AVR and
unexplained falls presenting with fall found to have Type II
Mobitz degenerating into CHB now with temp pacer wire,
transferred to CCU for further management. Had permanent
pacemaker placed without complication.
1)CV:a)perfusion: known cad, s/p CABG. No evidence of ischemia
now. Enzymes normal. Continued ASA, statin, imdur and beta
blocker
b)pump: known ef of 30%, appeared euvolemic throughout
admission. Continued beta blocker, but did not add ACE as he has
a h/o hyperkalemia.
c)rhythm: Pt had complete heart block and underwent successful
and uneventful permanent pacemaker placement.
d)AVR: bioprothesis, so no anticoagulation was needed.
2)Asthma/COPD: Flovent, inhalers were continued.
3)CRI: at baseline, renally dosed meds
4)Depression: celexa
Medications on Admission:
Acetaminophen prn
Citalopram 20 mg daily
Azmacort 100 mcg/Actuation Aerosol Sig: Two (2) puff
Inhalation three times a day.
Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Senna
Simethicone 80 mg tid
Omeprazole 40 daily
Aspirin 325 mg PO DAILY (Daily).
Atorvastatin 40 mg po daily
Ferrous Sulfate 325 daily
Isosorbide Mononitrate 60 mg daily
Metoprolol Tartrate 25 po bid
Cholecalciferol 400 mg
Acetaminophen-Codeine 300-30 mg
Ibuprofen 600 mg PO Q8H prn
Miralax
Oxazepam 15 mg po hs prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
6. Azmacort Inhalation
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
10. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
14. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed.
15. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Syncope secondary to complete heart block
Discharge Condition:
Good
Discharge Instructions:
1. **KEEP pressure dressing on Left shoulder/arm for two more
days.***
2. Please return to the hospital if you have chest pain, acute
shortness of breath, pass out, have bleeding from the site of
your pacemaker implantation or fever.
Followup Instructions:
1. Please keep your follow up appointment with the PACEMAKER
DEVICE CLINIC on [**2118-7-11**] at 8:30 Please call if you need to
change the appointment (PH:[**Telephone/Fax (1) 59**]).
2. Please keep your follow up appointment with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
(PH:[**Telephone/Fax (1) 250**]) on [**2118-8-9**] at 1:30 pm.
3. Please keep your follow up appointment with Dr [**First Name (STitle) **]
([**Telephone/Fax (1) 253**]) on [**2118-7-27**] at 8:45am.
Completed by:[**2118-7-15**]
|
[
"426.0",
"493.20",
"V45.81",
"280.9",
"412",
"998.12",
"530.81",
"V42.2",
"414.01",
"593.9",
"428.0",
"369.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.72",
"37.83"
] |
icd9pcs
|
[
[
[]
]
] |
5888, 5963
|
3267, 4107
|
232, 253
|
6048, 6054
|
2120, 3244
|
6337, 6872
|
1603, 1621
|
4661, 5865
|
5984, 6027
|
4133, 4638
|
6078, 6314
|
1636, 2101
|
184, 194
|
281, 892
|
914, 1421
|
1437, 1587
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,469
| 157,594
|
14696+14697
|
Discharge summary
|
report+report
|
Admission Date: [**2129-5-30**] Discharge Date: [**2129-6-18**]
Date of Birth: [**2061-7-19**] Sex: F
Service: [**Hospital1 139**]
HISTORY OF PRESENT ILLNESS: This is a patient that was
transferred to the [**Hospital6 **] from the Medical
Intensive Care Unit on [**2129-6-14**].
The patient is a 67-year-old female who had been bed-ridden
for two years who presented to an outside hospital with
hematemesis of bright red blood with a hematocrit drop from
34 to 18. At the outside hospital [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube was
placed. She was started on somatostatin and vasopressin,
given 4 units of packed red blood cells and 2 units of fresh
frozen plasma and transferred to the [**Hospital1 190**].
Here, she got an esophagogastroduodenoscopy which showed
grade III esophageal varices which were banded. Her
hematocrit remained stable after the banding. She has had no
hematemesis since then during her Medical Intensive Care Unit
stay. The patient was intubated on arrival to the Medical
Intensive Care Unit, and she was extubated on [**6-13**] on the
first try and then transferred to the floor on the third.
The patient had been bed-ridden for two and a half years
because she initially had a lower extremity fracture that
caused her increased pain, and she had decided not to walk on
this lower extremity fracture and heal it by remaining in bed
and had remained in bed since for the next two years.
While in the Medical Intensive Care Unit, the patient
complained of pain in her legs that mostly began on ambulance
transfer to the stretcher. She was found to have a distal
right femur fracture and bilateral proximal tibial fractures
that were both impacted and not healed and a question of
their age. The patient began to have atrial fibrillation
during this admission which was well rate controlled on her
propanolol 10 mg p.o. b.i.d. dose for her varices. She was
not anticoagulated because of her bleeding history. The
patient also was found to have a methicillin-susceptible
Staphylococcus aureus pneumonia in the Medical Intensive Care
Unit after bronchoalveolar lavage was done which grew out
this methicillin-susceptible Staphylococcus aureus. She was
also found to have a right-sided lung mass of 5 cm, and
bronchoalveolar lavage of this lung mass did show atypical
cells consistent with non-small-cell lung cancer. She had
initially failed her swallow study in the Medical Intensive
Care Unit and was placed on tube feeds.
PAST MEDICAL HISTORY: The patient has had very little
medical care in the past. She did have non-insulin-dependent
diabetes mellitus and apparently a history of alcohol use;
which she quit 15 years ago.
MEDICATIONS ON ADMISSION: Her medications prior to
admission were a question of large nonsteroidal
antiinflammatory drug use for her lower extremity pain.
MEDICATIONS ON TRANSFER: On transfer from the Medical
Intensive Care Unit, the patient was oxacillin 2 g q.8h.,
albuterol and Atrovent inhalers, heparin subcutaneous,
morphine 2 mg as needed for pain, Protonix 40 mg
intravenously q.12h., propanolol 10 mg per tube b.i.d., and
an insulin sliding-scale with Glargine, Miconazole powder,
Neutra-Phos 2 p.o. b.i.d., calcium carbonate 1 g t.i.d.,
lactulose 30 mL q.4-6h. as needed to make three bowel
movements per day, Nystatin swish-and-swallow,
Aldactone 100 mg q.d., vitamin C 500 mg b.i.d.
SOCIAL HISTORY: As above, the patient had been bed-bound for
about two years. She lives with her daughter and son and has
been widowed for two years as well. She has an 80-pack-year
tobacco history and quit 15 years ago along with a question
of a history of alcohol abuse which came with the patient in
her records, but was denied by the patient and family. She
supposedly quit the alcohol 15 years ago.
PHYSICAL EXAMINATION ON PRESENTATION: Examination on
transfer to the [**Hospital6 **] revealed a blood
pressure of 70/31, pulse was 80, afebrile. The patient was
saturating at 95% on 2 liters via nasal cannula and had made
less than 30 cc of urine over the past two hours. In
general, an obese female who could not speak but tried to
answer questions. Alert, not oriented, and in no acute
distress. Head, eyes, ears, nose, and throat revealed
extraocular movements were intact. Pupils were equal, round,
and reactive to light and accommodation. Sclerae were
anicteric with dry mucous membranes. The neck with
inaccessible jugular venous distention. No lymphadenopathy.
No bruits. The chest revealed poor air movement with wheezes
bilaterally and anteriorly. Cardiovascular examination was
irregularly irregular rhythm. First heart sound and second
heart sound. No murmurs, rubs or gallops. The abdomen was
obese, nontender and nondistended, normal active bowel
sounds. No appreciable ascites and a nonpalpable liver and
spleen. Extremities had 2+ pitting edema in the right lower
extremity and trace pitting edema in the left lower
extremity. Both lower extremities were grossly malformed
with multiple ulcers on her lower extremities. Her pulses
were 2+/4 in the dorsalis pedis and dorsalis pedis
bilaterally. She had a sacral pressure sore noted by
nursing. Neurologically, she had cranial nerves II through
XII which were intact. She had a weak left arm, and her
lower extremity strength was not assessed secondary to her
leg fractures. Her skin showed no rashes.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
transfer revealed sodium was 140, potassium was 3.7, chloride
was 104, bicarbonate was 28, blood urea nitrogen was 15,
creatinine was 0.5, blood glucose was 159. White blood cell
count was 8.8, hematocrit was 31.7, platelets were 304.
Calcium was 7.6, phosphorous was 2.8, magnesium was 2.1. INR
was 1.7, PTT was 35.
RADIOLOGY/IMAGING: Her electrocardiogram from [**6-8**]
showed low voltage and a question of chaotic atrial rhythm.
She had an echocardiogram that showed a normal left
ventricular ejection fraction of greater than 55%, with
moderate pulmonary hypertension.
She had an abdominal CT which showed positive ascites, a
positive cirrhotic liver, and a 7-mm liver mass. Her liver
was small, and shrunken, and cirrhotic.
A chest x-ray on [**6-14**] showed the nasogastric tube placed
post pylorically with a left lower lobe atelectasis.
A chest CT on [**6-3**] showed right lower lobe consolidation,
left basilar atelectasis, and ascites. There was a 5-cm mass
in the right lower lobe.
Hip and femur films from [**6-14**] showed distal right femur
fracture and bilateral proximal tibial fractures.
HOSPITAL COURSE: In summary, This is a 67-year-old woman
with liver cirrhosis with grade III esophageal varices who
had been bed-ridden for two years who presented to an outside
hospital and subsequently transferred for a variceal bleed.
She subsequently got a methicillin-susceptible Staphylococcus
aureus pneumonia and was found to have multiple old and new
lower extremity fractures.
1. GASTROINTESTINAL: The patient had no further episodes
of variceal bleeds up to this point. Question of the cause
of her cirrhosis; alcoholic versus perhaps NAS. Her past
workup consisted of a workup for autoimmune hepatitis that
showed a negative antinuclear antibody. She had a negative
hepatitis serologies as well.
She had a follow-up esophagogastroduodenoscopy on [**6-17**] in
which she had three more bands placed. At that time, her
nasogastric tube was removed and it showed some ulceration,
so another nasogastric tube was not replaced. She continued
on her propanolol 10 mg p.o. b.i.d. for variceal bleed and
portal hypertension prophylaxis. She was continued on her
pantoprazole 40 mg intravenously q.12h., and her lactulose
was increased from 30 mL as needed to 45 mL p.o. q.d. as the
patient had not had a bowel movement since transfer; up until
four days after transfer from the Medical Intensive Care
Unit.
Apparently, there was a question as to whether or not the
patient will be eligible for any transjugular intrahepatic
portosystemic shunt procedure to decrease her portal
hypertension. The Gastroesophageal team has been following
the patient along since admission.
On [**6-17**], it was noted that the patient started to have an
increased abdominal girth and the presence of a fluid wave.
On [**6-18**], she was noted to have gained about three pounds
of weight and had increased abdominal girth and had increased
peripheral edema. This was most likely due to her cirrhosis,
and she was given some diuresis with Lasix with good results.
She was transfused one unit of packed red blood cells to draw
some of the interstitial fluid into her intravascular space.
Her maintenance intravenous fluids were decreased as well.
2. PULMONARY: The patient was extubated on [**6-13**], and
her pulmonary status improved rapidly. She was saturating
well on 1 liter to 2 liters of nasal cannula while on the
Medicine Service. She is currently being weaned off of her
nasal cannula with saturations of 93% on room air. She was
clearing her secretions well at this time from her pneumonia.
She will receive one more day of her oxacillin dose on
[**6-19**], and then her oxacillin should be discontinued. The
patient's nebulizer treatments were also made as needed.
The plan from a pulmonary standpoint was to continue to wean
her from her oxygen and discontinue the oxacillin after her
course was done.
3. ORTHOPAEDIC: The patient had been bed-ridden for two
years after confining herself to the bed because of pain in
her previously fractured leg. Apparently, she has treated
other fractures in this way by treating them herself by bed
rest. The patient is being followed by the Orthopaedic
Service for nonoperative care of her fractures, and her legs
are currently placed in [**Doctor Last Name **] braces for stabilization.
After this two years of bed-rest the patient is severely
osteopenic and osteoporotic and his being given calcium,
phosphate, and vitamin D.
The pain from her fractures is currently managed by morphine.
There is a question whether this is affecting her mental
status. It is considered that calcitonin might be added for
pain control for this osteoporosis, osteomalacia, and
fractures.
4. MENTAL STATUS: The patient's family knows that the
patient's mental status is still somewhat decreased from her
baseline. She was intubated for most of the time in the
Medical Intensive Care Unit and did present with apparently
some degree of hepatic encephalopathy. This improved
throughout her hospitalization, and when she was transferred
to the floor, she did respond to questioning and did not have
fluctuations in her degree of consciousness and did not have
asterixis.
On [**6-17**], this was the first day she began to be able to
speak status post extubation, and this was barely a whisper
and barely intelligible. She was evaluated to be only
oriented to herself at this time. She did not know where she
was and thought that she was at home. She also spoke of a
little girl who watches television in her bedroom. It is
unknown if this is a change in her mental status at this
current time or if this has been her mental status all along
in the recent past, but without her ability to speak it was
just unknown. The patient may be suffering from delirium
secondary to her medications such as morphine or maybe having
increased encephalopathy secondary to cirrhosis, or maybe at
a new baseline status post her prolonged illness and hospital
course. She will be seen by Psychiatry on Monday. The
lactulose will be continued until a good bowel movement
response is seen. This should be three to four bowel
movements per day.
5. CARDIOVASCULAR: The patient has been fairly hypotensive
for this entire admission with her blood pressure mostly in
the 80s to the 60s. She has continued in that range for most
of her floor time; although, in the past day she has
increased her blood pressure to be 120s/60s. During her time
of relative hypotension, she had no symptoms related to the
hypotension and no electrocardiogram changes.
The patient had a new onset of atrial fibrillation on this
admission; question if this was secondary to hypoxia with the
pneumonia. The patient is mostly auto anticoagulated from
her cirrhosis and will not be anticoagulated for embolic
prophylaxis. There is no evidence of ischemia or
cardiomyopathy on the cardiac workup this patient had. She
has been cardiovascularly stable for her time on the floor.
6. ONCOLOGY: The patient was found to have a lung mass at
the right base; which upon workup with bronchoalveolar lavage
was found to most likely a non-small-cell lung cancer. The
patient's family at the current time did not want the patient
to be aware of this diagnosis and does not want any further
workup of her lung cancer. She has not had a biopsy at this
time. She also has a small mass on her cirrhotic liver that
is of unknown etiology. This also will not be worked up at
this time.
7. RENAL: Ms. [**Known lastname 43244**] has had decreased urine output
from her time of transfer from the Medical Intensive Care
Unit. Her blood urea nitrogen and creatinine, however, have
all been within normal limits throughout this
hospitalization. Her urine output has begun to pick up
within the past two to three days; however, it is still much
lower than her input. Her FENa was 1.3% on transfer from the
Medical Intensive Care Unit. It was thought that her renal
function is normal at this time, and her oliguria is most
likely a result of decreased effective circulating volume
from her cirrhosis.
8. FLUIDS/ELECTROLYTES/NUTRITION: The patient initially
could not take orals because of a failed swallow study on
[**6-14**]. She was started on tube feeds at that time which
had been mostly held for the next two to three days because
of planned esophagogastroduodenoscopy procedure.
After her esophagogastroduodenoscopy on [**6-17**], her
nasogastric tube was removed and not replaced. The patient
was started on intravenous fluids at that time for
maintenance. On [**6-18**], she was evaluated by the team for
her swallowing function, and she had shown a good improvement
in her ability to speak. She was given small sips of water
and swallowed these without problems, or aspiration, or
coughing. She was then begun on a clear diet and
nectar-consistent diet. She will be fully advanced on this
diet; hopefully to a normal diet.
Her electrolytes have been stable throughout this admission.
Her volume status has been difficult to control secondary to
her cirrhosis. Most of her intravenous fluids end up being
third-spaced. She is more recently, with her continued lower
urine output than input from intravenous fluids and oral
intake, began to be having increased ascites and lower
extremity edema. It was at this time she was given Lasix
with a good response, as she put out one liter after one
120-mg intravenous treatment with Lasix. She was also given
a packed red blood cell transfusion to keep her fluid
intravascularly and give her more osmolar pull. She can be
continued on Lasix 20 mg b.i.d. as her blood pressure
tolerates.
9. WOUND CARE: The patient has small ulcers on her legs
which are healing well. She is currently being seen by Wound
Care for sacral pressure sores.
10. HEMATOLOGY: The patient has a anemia which is likely
secondary to her loss of blood that was not fully replaced
during her gastrointestinal bleed, and she also has anemia of
chronic disease. With her lower extremity edema, she was
evaluated for deep venous thrombosis; and lower extremity
Doppler tests were found to be negative.
11. ENDOCRINE: The patient's diabetes and blood sugars have
been well controlled on Glargine long-term and an insulin
sliding-scale.
12. SOCIAL: The patient had been bed-ridden for two years,
and this has caused consequences for her health. She will be
seen by Elder Services and Social Services on Monday,
[**6-20**].
13. PROPHYLAXIS: The patient is on subcutaneous heparin for
deep venous thrombosis prophylaxis, proton pump inhibitor for
ulcer, and variceal prophylaxis. She will be on incentive
spirometry when she can understand the directions.
14. DISCHARGE DISPOSITION: The patient should be discharged
to rehabilitation when a bed is found for her.
15. CODE STATUS: She is a full code.
CONDITION AT DISCHARGE: Her condition on discharge will be
determined at the time of discharge.
DISCHARGE STATUS: Her discharge status will be determined at
the time of discharge.
DISCHARGE DIAGNOSES:
1. Variceal bleed.
2. Cirrhosis.
3. Likely non-small-cell lung cancer.
4. Osteopenia.
5. Multiple lower extremity fractures.
6. Atrial fibrillation.
NOTE: The remainder of her Discharge Summary will be
completed at her time of discharge.
DR.[**First Name (STitle) **],[**First Name3 (LF) 569**] 12-328
Dictated By:[**Last Name (NamePattern1) 9352**]
MEDQUIST36
D: [**2129-6-18**] 20:48
T: [**2129-6-23**] 15:40
JOB#: [**Job Number 43245**]
Admission Date: [**2129-5-30**] Discharge Date: [**2129-6-24**]
Date of Birth: Sex:
Service: MEDICINE-[**Hospital1 **] FIRM.
HISTORY OF THE PRESENT ILLNESS: The patient is a 67-year-old
female with the past medical history of type 2 diabetes
mellitus and osteoporosis. Two years ago she had a CT of the
chest and abdomen showing liver metastasis and lung lesions.
She declined further workup. She has been bedridden for the
past two years after a number of falls during which time she
injured her lower extremities. She presented to [**Hospital 1474**]
Hospital with hematemesis on [**2129-5-29**]. EGD showed a
grade 3 esophageal varices, not bleeding, therefore, no
therapy was done. After being transferred to [**Hospital1 346**] the patient re-bled, had a second
endoscopy. According to the report, the bleeding was perfuse
and could not be treated endoscopically, therefore, the
patient was intubated with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube placed. The
patient bled with hematocrit dropping from 40% to 18%. She
received 74 units of packed red blood cells and two units of
fresh frozen plasma.
PHYSICAL EXAMINATION: Examination on admission revealed the
following: VITAL SIGNS: 140/60 blood pressure, pulse 86.
General appearance: The patient is an obese, sedated,
paralyzed female. SKIN: No jaundice. She has palmar
erythema. HEENT: Pupils equal, round, and reactive to light
and accommodation. No scleral icterus, no jaundice.
RESPIRATORY: Lungs were clear anteriorly. CARDIOVASCULAR:
The patient had irregularly irregular heart rate with no
murmurs, rubs, or gallops, distant heart sounds. ABDOMEN:
Examination revealed the patient to be obese, distended,
without hepatomegaly, with marked splenomegaly and decreased
bowel sounds. EXTREMITIES: 1+ edema.
LABORATORY DATA: Laboratory data revealed the following:
White count of 9.2, hematocrit 40.9, platelet count 209,000,
sodium 130, potassium 4.2, chloride 104, BUN 25, creatinine
0.5, glucose 248, magnesium 1.7, calcium 7.9, phosphorus 3.5,
bilirubin 1.5, AST 33, ALT 19, alkaline phosphatase 118,
albumin 3.0, amylase 31, total protein 6.5.
HOSPITAL COURSE: Hospital course was subsequently
complicated by pneumonia requiring tracheal intubation and
treated with Oxicillin. The patient has mental status
changes, which were thought to be secondary to
encephalopathy. The patient was diagnosed with cirrhosis of
unknown origin. Hepatitis serologies returned negative. The
[**Doctor First Name **] workup, rheumatologic workup returned negative. The
ammonia level remained normal despite her mental status
changes. The CT examination of the head showed chronic mild
atrophy with chronic vascular microinfarction. Therefore, at
discharge, the patient's main issues were history of
cirrhosis, status post esophageal bleed, status post
encephalopathy, and status post pneumonia and intubation.
She also had a history of nonsmall cell lung cancer, which
was not treated for the past two years.
GASTROINTESTINAL: The patient is to followup with a repeat
endoscopy in 30 days. She has been advised by speech and
swallow to eat pureed foods and thick liquids.
PULMONARY: The patient has been weaned off oxygen. She is
actively using incentive spirometry and increased upper body
activity to decrease atelectasis.
RENAL: The patient is being aggressively diuresed with 40 mg
PO b.i.d. Lasix to decrease the ascites and swelling in her
lower extremities.
CONDITION ON DISCHARGE: Fair.
The patient is being discharged to a nursing home on the
following medications:
DISCHARGE MEDICATIONS:
1. Percocet elixir 5 ml PO q.8 p.r.n. for rheumatoid
arthritis and lower extremity fracture pain.
2. Lasix 40 mg PO b.i.d. for diuresis.
3. Pantoprazole 40 mg PO q.12 prophylaxis for GI bleeding.
4. Ergocalciferol 800 units PO q.d.
5. Albuterol nebulizer solution, one nebulizer q.6.p.r.n.
6. Ipratropium bromide nebulizer, one nebulizer q.8.p.r.n.
7. Lactulose 45 ml PO q.i.d. to improve GI motility and
mental status.
8. Insulin sliding scale for history of diabetes mellitus.
9. Propanolol 10 mg PO b.i.d. hold for systolic blood
pressure less than 85, heart rate less than 55.
10. Heparin 5000 units subcutaneously q.12 for prophylaxis.
11. Albuterol sulfate/ipratropium four to twelve puffs per
hour p.r.n.
12. Zinc sulfate 220 mg PO q.d.
13. Ascorbic acid 500 mg PO b.i.d.
14. Spironolactone 100 mg PO q.d.
15. Desitin one application as directed p.r.n.
16. Nystatin oral suspension 5 ml PO q.i.d.p.r.n.
17. Calcium carbonate 1000 mg PO t.i.d.
18. Neutra-Phos two packets PO b.i.d.
19. Miconazole powder 2%, one application t.i.d p.r.n. to
areas of breakdown.
20. Lidocaine jelly 2% one application skin near pannus.
The patient also must followup with the Department of
Podiatry to cut her toenails secondary to diabetes mellitus.
She must be encouraged to use the incentive spirometer to
prevent atelectasis. She must be encouraged to eat
adequately to maintain her potassium and magnesium levels.
She must be encouraged to move her upper torso and extremity
to prevent atelectasis. Diet is to consist of pureed foods
and thick liquids.
DISCHARGE STATUS: Stable.
FINAL DIAGNOSIS: Cirrhosis. Complications including
esophageal-variceal bleed, diabetes mellitus, osteoporosis
leading to multiple lower extremity fractures. Nonsmall cell
cancer, pneumonia encephalopathy.
[**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Name (STitle) 43246**]
MEDQUIST36
D: [**2129-6-23**] 17:11
T: [**2129-6-23**] 17:47
JOB#: [**Job Number 43247**]
cc:[**Name13 (STitle) 43248**]
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29,951
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32280
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Discharge summary
|
report
|
Admission Date: [**2123-12-21**] Discharge Date: [**2123-12-30**]
Date of Birth: [**2055-4-8**] Sex: F
Service: MEDICINE
Allergies:
Lipitor / Sulfa (Sulfonamides) / Clarithromycin / Epinephrine /
Thiopental / Tetanus / Shellfish / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Transferred from OSH for Trach + PEG
MICU Transfer: Pneumonia on vent
Major Surgical or Invasive Procedure:
-tracheostomy
-G-tube placement
-right thoracentesis
History of Present Illness:
68F h/o 02-dependent COPD, chronic hypercapneia, s/p mult admits
in last 6mo's COPD exacerbations, though never intubated until
current admission, who was transferred to [**Hospital1 18**] for trach and
PEG on [**2123-12-22**]. On arrival to [**Hospital1 18**], pt spiked fever to 103.
Workup of the fever revealed severe RLL as well as large,
loculated R pl. effusion (see full report below). Trach and PEG
postponed to treat these issues. Pt being transferred to MICU
service for management and tx of PNA.
.
Relevant recent hx includes admission to [**Hospital6 **] on
[**2123-12-12**] w/ hypercarbic resp failure & MS changes. Admission
ABG on [**2123-12-12**] was 7.13/>115/64 on [**1-5**] of BiPAP. She was
treated w/ IV steroids, abx, and lasix. She was thought to have
COPD exacerbation & PNA, as well as possible CHF exacerbation.
Pt failed BiPAP & required intubation. A triple lumen R-IJ was
placed on [**2123-12-14**] in the setting of hypotension: she reportedly
had SBP into the 80s & required pressors for a short
period--dopamine initially (which made her tachycardic) then
vasopressin. Cause for her hypotension is unclear. [**Name2 (NI) **] sputum
from [**12-13**] grew pseudomonas (sensitive to gent, tobra, cefepime,
imipenem, and zosyn). Because of this cx data, her abx were
changed from levoflox to cefepime. Bld cx's there were w/o
growth. Pt was started on TF via NGT.
.
Despite tx, pt was unable to be weaned off of vent. ABG on
[**2123-12-21**] was 7.36/83/78 on AC [**1-5**], TV 450, Fi02 45%. Given
overall picture, pt evaluated for trach & PEG at OSH; however,
it was felt that she would be high risk for procedure given her
kyphosis & body habitus, so she was transferred here for
intervention.
.
On arrival to [**Hospital1 18**], pt was con't on cefepime for tx of PNA as
well as IV steroids & nebs for COPD and dilt gtt for rapid afib.
The day following admission, [**2123-12-22**], WBC 20 (up from 15 day
prior) and pt febrile to 103. She was started on vanc in
addition to cefepime. She underwent chest CT which showed PNA
w/ large, complex effusion. Additionally, CT showed possible
filling defect in pulm artery, for which CTA was recommended to
further eval. However, b/c of pt's allergy to iodine, she did
not undergo CTA.
Pt underwent flex bronch on [**12-23**], which showed small white
exophytic playw in RML (likely aspirated food). Biopy x2 of RML
orifice and BAL of LLL performed. PPD performed--result
pending.
.
Pt currently c/o dyspnea--stable since admission. She has had
moderate amount of secretions. Her afib has improved w/ regard
to rate control. She was transitioned off dilt gtt and
controlled with dilt PO.
.
ROS: Pt notes no pain, including CP. Fever y'day. Feels
"scared" about all that is going on medically. This is her
first time being intubated. She feels like she needs lasix. No
LE swelling, She notes that she only has diabetes while on
steroids.
Past Medical History:
-COPD 02 dependent, chronic hypercapnia, never intubated prior
to current admission
-mild CHF-->LVED 40-45% on OSH echo
-mild pulm HTN w/ PA pressure of 35mmhg by OSH echo
-P-Afib-->not on coumadin, unclear why not
-[**Name (NI) 15764**]>pt reports this is only present while on steroids
-kyphosis
-PVD w/ LE ulcers
Physical Exam:
VS: T: HR: 87 (70-110s) BP: 130/50 RR: 19 Sat: 96 on AC 15/8,
0.45
Gen: awake, alert, oriented x3, mouthing words/writing to
communicate, sl uncomfortable appearing
HEENT: NCAT, PERRL, sclera anicteric
Neck: Supple, no LAD, no JVD
CV: RRR S1/S2, no m/r/g
Resp: Roncherus w/ exp wheezes throughout anterior fields
Abdomen: Soft, NTND, BS+
Ext: Trace LE edema DP pulses are 2+ bilaterally
Neuro: A + O x 3, CN II-XII grossly intact, Motor [**6-5**] both upper
and lower extremities
Skin: B/l LE healed scars from old wounds/ulcers; scattered
ecchymoses on b/l feet. Skin warm.
Pertinent Results:
[**2123-12-21**] 08:21PM WBC-15.7* RBC-3.96* HGB-11.4* HCT-34.7*
MCV-88 MCH-28.8 MCHC-32.9 RDW-16.3*
[**2123-12-21**] 08:21PM NEUTS-88* BANDS-0 LYMPHS-5* MONOS-7 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2123-12-21**] 08:21PM GLUCOSE-295* UREA N-18 CREAT-0.4 SODIUM-134
POTASSIUM-4.6 CHLORIDE-88* TOTAL CO2-42* ANION GAP-9
[**2123-12-21**] 08:21PM CALCIUM-8.9 PHOSPHATE-2.2* MAGNESIUM-2.0
[**2123-12-21**] 08:47PM TYPE-ART PO2-58* PCO2-47* PH-7.52* TOTAL
CO2-40* BASE XS-13
Brief Hospital Course:
68F h/o severe COPD, vent-dependent, planned for trach & PEG on
admission deferred after finding MRSA LLL PNA + B pleural
effusions (L>R), treated with vanc/cefepime, also on heparin gtt
for PE.
.
# MRSA Pneumonia: Pt was found to have LLL pneumonia, initially
considered CAP vs. nosocomial as pt had been transferred from
[**Hospital6 **] after being admitted there from home w/ PNA,
and because pt had been vented for over a week before transfer.
Pt received cefepime for pseudomonal coverage per OSH cultures,
and was started on vancomycin for MRSA in sputum. She should be
continued on vancomycin and cefepime until [**1-1**].
.
# Respiratory distress: Pt originally intubated at OSH because
of hypercarbic failure related to severe COPD, PNA, and pleural
effusions. Pt found to have bilateral pleural effusions likely
[**3-5**] chronic process, and possibly related to previous infection
(considered unlikely acute empyema). Because of PNA, pt
initially continued on vent. A right-sided thoracentesis was
performed on [**2123-12-27**] seeking to drain an effusion; this was
complicated by the development of a pneumothorax which required
the placement of a chest tube. Bedside tracheostomy was
subsequently performed by interventional pulmonology on
[**2123-12-28**].
.
# Pulmonary embolism: CT w/o contrast demonstrated filling
defect in pulmonary artery. Pt administered heparin gtt and to
r/o possible future PE source, bilateral lower extremity
ultrasounds were obtained and confirmed no DVTs. Pt's
outpatient mgt will require long-term anticoagulation.
Anticoagulation was held briefly in anticipation of her multple
procedures; warfarin was re-started on [**2123-12-29**]. INR 1.3 on
[**2123-12-30**].
.
# COPD, possible exacerbation: Pt's baseline pulmonary function
marked by severe COPD with hypercarbia & baseline 02
requirement. Pt was therefore maintained on nebulizers and
guaifenesin, and was started on methylprednisolone (Solumedrol)
IV at 40mg IV q8h, which was tapered to 20mg q8h. Before [**12-27**]
procedure, pt was maintained on stress-dose steroids. On
[**2123-12-29**], she was transitioned to 15 mg daily of PO prednisone.
This dose may be tapered as follows: 15mg on [**12-31**], 10mg on
[**1-1**], 5mg on [**1-2**], 3mg on [**1-3**] mg on [**1-3**] and then
discontinue.
.
# CHF: Pt uses furosemide 60mg daily as home regimen for
baseline CHF, and was restarted on furosemide 60mg QOD to
maximize respiratory capacity and was increased to 60mg PO
daily. She should continue on lasix 60mg PO daily.
.
# Type II DM: Per pt, elevated glucose only when steroids used.
Pt was initially placed on insulin gtt, which was then changed
to NPH 30units x1 dose AM after MICU transfer. NPH was titrated
to control sugars Fs<150, and as of [**12-29**], was 20 units [**Hospital1 **].
This may require adjustment as steroids are tapered and
eventually discontinued.
.
# AFib: Patient was rate-controlled initially on diltiazem gtt
and later on diltiazem PO. Anticoagulation was held in the
setting of surgial procedures but restarted on [**2123-12-29**].
Continue warfarin and titrate to INR 2.0-3.0.
.
# Nutrition: Nutrition was consulted and recommended tube feeds
as follows: Half strength Nutren 2.0 at 50ml/hour with 15g
Benepro, 1251kcal, 61g protein.
Medications on Admission:
Medications on Transfer:
Diltiazem 10 mg/hr IV DRIP INFUSION
Docusate Sodium (Liquid) 100 mg NG [**Hospital1 **]
Ipratropium Bromide MDI 8 PUFF IH QID
Miconazole Powder 2% 1 Appl TP [**Hospital1 **]
Acetaminophen 650 mg PO/PR Q6H:PRN
Albuterol 8 PUFF IH Q6H:PRN
Lorazepam 2-4 mg PO/IV Q4H:PRN
Morphine Sulfate 2-4 mg IV Q1H:PRN
Insulin SC
Heparin 5000 UNIT SC TID
Famotidine 20 mg PO BID
CefePIME 1 gm IV Q8H
Dexamethasone 4 mg IV Q6H
Tobramycin-Dexamethasone Ophth Oint 1 Appl BOTH EYES QID
Digoxin 0.25 mg IV DAILY
Metoprolol 5 mg IV Q2-3H PRN
Ibuprofen Suspension 400 mg NG Q6H:PRN pain
Vancomycin 1000 mg IV Q 12H
Ibuprofen Suspension 400 mg NG Q6H:PRN pain
Discharge Medications:
1. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-2**] Sprays Nasal
TID (3 times a day) as needed.
3. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
4. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please monitor INR until stable.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Tobramycin-Dexamethasone 0.3-0.1 % Ointment Sig: One (1) Appl
Ophthalmic QID (4 times a day).
7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day): Hold for loose stools.
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
10. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1) ML
Inhalation q6hr prn () as needed for SOB, wheezing.
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO WITH DRESSING
CHANGES () as needed for Administer 30 min prior to dressing
changes.
12. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection four times a day: Per sliding scale.
13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Five (25) units Subcutaneous twice a day: [**Month (only) 116**] require titration
as prednisone is tapered.
14. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
15. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours).
16. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
17. Prednisone 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily)
for 1 days: To be followed by 10mg daily for 1 day then 5 mg
daily for 1 day then 3mg daily for 2 days then discontinue.
18. Cefepime 1 gram Recon Soln Sig: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for 2 days: TO be completed on
[**2124-1-1**].
19. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours): To be completed on [**2124-1-1**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital
Discharge Diagnosis:
Primary Diagnoses
-ventilator dependent COPD
-MRSA LLL PNA and bilateral pleural effusions
-tension pneumothorax
-question of PE
Secondary Diagnoses
-CHF
-diabetes
-atrial fibrillation
Discharge Condition:
Good;
Discharge Instructions:
You are being transferred to a rehabilitation facility for
further care and treatment to improve your breathing over the
long-term. While at the rehab, be sure to alert your caregivers
should you experience any fever, chills, chest pain or pressure,
shortness of breath, nausea, vomiting or change in your bowel or
urinary functions.
Followup Instructions:
Schedule a follow-up appointment with Dr. [**Last Name (STitle) 1693**] when you are
discharged from your rehabilitation facility.
.
You were given the number for pulmonology clinic at [**Hospital1 771**]. Call ([**Telephone/Fax (1) 513**] to make an
appointment.
|
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"482.41",
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"E878.8",
"250.00",
"428.0",
"737.10",
"491.21",
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icd9cm
|
[
[
[]
]
] |
[
"31.1",
"34.04",
"33.24",
"96.6",
"43.11",
"96.72",
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icd9pcs
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10978, 11049
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4940, 8228
|
456, 511
|
11278, 11286
|
4432, 4917
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11668, 11935
|
8940, 10955
|
11070, 11257
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8254, 8254
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11310, 11645
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3835, 4413
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347, 418
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539, 3481
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8279, 8917
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3503, 3820
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,612
| 193,089
|
54797
|
Discharge summary
|
report
|
Admission Date: [**2184-5-19**] Discharge Date: [**2184-5-29**]
Date of Birth: [**2130-11-16**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
Chief Complaint: UGIB
Reason for MICU transfer: active UGIB
Major Surgical or Invasive Procedure:
Upper Endoscopy
Intubation
History of Present Illness:
53 year old woman with ETOH and HCV (untreated) cirrhosis,
actively drinking ETOH, polysubstance abuse, history of PUD
[**2179**], presented with hematemesis and melena since [**2184-5-16**]. She
initially presented to [**Hospital 8**] Hospital on [**2184-5-18**] where she
was hemodynamically stable, but had witnessed hematemesis of
200cc of bright red blood in the OSH ED. She had associated
lightheadedness and was confused compared to baseline (per
family). She denied abdominal pain, fever, SOB or chest pain.
She had been taking Nabumetone prior to admission, denies other
NSAIDS. At the OSH she received 2U PRBC, 3U FFP, 1 unit
platelets, 10mg vit K, and ceftriaxone. EGD showed oozing
portal gastropathy and non-bleeding esophageal varices. She was
placed on octreotide and PPI drips. She had signs of alcohol
withdrawl and received ~100mg of IV valium. She was transferred
to [**Hospital1 18**] on [**2184-5-19**] for possible TIPS. Labs prior to transfer
from OSH include HCT 28.8, Plt 48, INR 1.6, Tbili 9.9, AST 117,
ALT 36, Cr 0.4. ETOH level on [**5-18**] at 19:28 was 36. Last drink
was reportedly [**2184-5-16**].
On arrival to the MICU, vitals were HR 118, BP 140/100 and 95%
RA. She was encephalopathic and not answering questions, barely
opening eyes to sternal rub. Her NGT was draining maroon blood.
She was continued on octreotide drip, transitioned to IV PPI
[**Hospital1 **] given lack of ulcer disease seen on OSH ED, and given
ceftriaxone. She was intubated for airway protection for repeat
EGD and ongoing encephalopathy, sedated with propofol. GI was
consulted for urgent EGD.
Review of systems:
unable to obtain
Past Medical History:
ETOH abuse
HCV untreated -seen at [**Hospital1 1774**] and [**Hospital1 2177**]
Cirrhosis due to above issues
HTN
Peptic ulcer disease with hematemesis [**2179**]
Gastric antrum vascular ectasias
Left ankle fracture
Social History:
Currently drinking, history of alcohol abuse.
Family History:
Noncontributory
Physical Exam:
Admission exam:
Vitals: 99.6 122 152/84 21 94%
General: obtunded, barely opening eyes to sternal rub
HEENT: Sclera icteric, oropharynx clear, PERRL
Neck: supple
CV: Sinus tachycardia, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, distended, ascites
GU: foley
Ext: warm, well perfused, 2+ pulses
Neuro: obtunded, withdraws to pain bilaterally, PERRL
.
Discharge exam:
General: AOx3, appropriate, no asterixis
HEENT: icteric sclera
Abd: soft, distended, +ttp over upper quadrants
Neuro: grossly intact
otherwise as above
Pertinent Results:
Admission labs:
[**2184-5-19**] 10:47AM BLOOD WBC-4.9 RBC-3.15* Hgb-10.9* Hct-33.9*
MCV-107* MCH-34.7* MCHC-32.3 RDW-17.1* Plt Ct-52*
[**2184-5-19**] 10:47AM BLOOD Neuts-84.3* Lymphs-8.7* Monos-5.2 Eos-0.7
Baso-1.0
[**2184-5-19**] 10:47AM BLOOD PT-16.7* PTT-32.7 INR(PT)-1.6*
[**2184-5-19**] 10:47AM BLOOD Glucose-138* UreaN-11 Creat-0.5 Na-142
K-3.3 Cl-104 HCO3-27 AnGap-14
[**2184-5-19**] 10:47AM BLOOD ALT-27 AST-99* LD(LDH)-461* AlkPhos-70
TotBili-7.6*
[**2184-5-19**] 10:47AM BLOOD Albumin-3.4* Calcium-8.0* Phos-1.9*
Mg-2.4
[**2184-5-20**] 08:27PM BLOOD Type-ART pO2-122* pCO2-39 pH-7.48*
calTCO2-30 Base XS-6
Discharge labs:
[**2184-5-29**] 08:30AM BLOOD WBC-9.7 RBC-3.41* Hgb-11.7* Hct-36.7
MCV-108* MCH-34.3* MCHC-31.9 RDW-16.9* Plt Ct-181
[**2184-5-29**] 08:30AM BLOOD PT-22.4* PTT-34.7 INR(PT)-2.1*
[**2184-5-29**] 08:30AM BLOOD Glucose-134* UreaN-4* Creat-0.4 Na-132*
K-3.2* Cl-99 HCO3-26 AnGap-10
[**2184-5-29**] 08:30AM BLOOD ALT-40 AST-87* AlkPhos-99 TotBili-16.9*
[**2184-5-29**] 08:30AM BLOOD Albumin-2.6* Calcium-8.9 Phos-3.2 Mg-1.6
Micro:
Blood: no growth
Urine: S.bovis, no growth
HCV VL 88,614
HCV genotype pending
[**2184-5-19**] EGD:
Impression: Esophageal varices (ligation)
Abnormal mucosa in the stomach
Blood in the whole stomach
A lesion most consistent with a dieulafoy lesion was seen in the
body of the stomach. There was an adherent clot. (endoclip)
Blood in the whole examined duodenum
Otherwise normal EGD to third part of the duodenum
Liver ultrasound:
IMPRESSION:
1. Hepatopetal flow seen in the main and right portal veins.
Slow flow which is possibly bidirectional is seen in the left
portal vein on limited views. The hepatic veins and IVC are
patent.
2. Cirrhotic appearing liver with no focal liver lesion
identified.
3. Splenomegaly. A scant trace ascites in the right upper
quadrant.
[**2184-5-19**] CXR:
IMPRESSION:
1. ETT in standard position, with overinflated cuff.
2. NGT in proximal stomach, and could be advanced a few
centimeters.
3. Mild pulmonary edema.
[**2184-5-20**] ECHO;
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Normal left ventricular cavity size and wall
thickness with preserved global and regional biventricular
systolic function. No clinically significant valvular disease.
Moderate pulmonary artery systolic pressure.
[**2184-5-28**] EGD
Findings: Esophagus:
Excavated Lesions A single non-bleeding 9 mm clean base ulcer
with white exudates on top from prior banding was found in the
lower third of the esophagus .
Other No evidence of Barretts ro active bleeding was identified
Stomach:
Contents: White liquid fluid was seen in the entire stomach. A
hemoclip was found in the fundus. where the Dielofoy lesion was
identified. No active signs of bleeding
Mucosa: Localized discontinuous mosaic appearance of the mucosa
with no bleeding was noted in the stomach body. These findings
are compatible with mild portal gastropathy.
Other No evidence of active bleeding, ulcers or polyps
Duodenum:
Protruding Lesions A sub-mucosal non-bleeding 1.5 cm mass of
benign appearance was found at the second part of the duodenum.
The scope traversed the lesion.
Other No active bleeding was identified in the duodenum
Brief Hospital Course:
53 year old woman with ETOH, HCV cirrhosis, actively drinking
ETOH with evidence of Alcoholic hepatitis on labs who presented
with hematemesis and melena, s/p banding grade 3 esophageal
varices and dieulafoy clipping. Patient was admitted to ICU for
UGIB. Following EGD patient remained hemodynamically stable,
was sucessfully extubated and was transferred to medical floor.
# Upper GI bleeding: Patient presented with UGIB. Received a
total of 3 units pRBCs and FFP at OSH. Bleeding resolved after
dieulafoy clipping and variceal banding. TIPS is an option
should bleeding recur. Hct has been stable since
clipping/banding. Patient was continued on octreotide gtt for 72
hours after bleeding stopped. She received protonix 40 mg IV
BID. She was started on ceftriaxone 1 g Q24 for 5 days after
bleed for SBP prophylaxis. Patient was started on carafate
slurry and nadolol 48 hrs after cessation of bleeding. She
remained hemodynamically stable and was called out to medicine
floor where she had no recurrence of her bleed. She was
discharged on a PPI, nadolol and a fourteen day course of
carafate.
# Encephalopathy: Etiology likely hepatic encephalopathy
triggered by GI bleed or Alcoholic Hepatitis although could be
medication effect vs UTI. No evidence of PVT/Budd Chiari or
liver mass on RUQ US. Mental status improved with extubation and
lactulose. Patient was continued on lactulose and rifaxaimin
with improvement in encephalopathy. She was oriented,
appropriate and without asterixis at discharge.
# Alcoholic Hepatitis: Patient was actively drinking leading up
to this admission and labs show evidence of Alcoholic Hep with
elevated AST, Tbili, INR. Following extubation, encouraged
aggressive nutrition with Dobhoff tube but patient refused so
she was encouraged to drink six Ensures a day in addition to her
regular meals. Pentoxyfylline was started and her liver enzymes
initially continued to trend up with discriminant factors > 50.
Repeat EGD was performed to determine whether it would be safe
to start steroids but this showed prominent ulceration and
gastropathy that seemed susceptible to bleeding so steroids were
not started. At discharge her LFTs were stabilizing so she was
discharged on a 28 day course of pentoxyfylline. She was
encouraged to follow-up with her outpatient hepatologist. Social
work and the team expressed to her the importance of abstaining
from alcohol and entering relapse prevention.
# Decompensated cirrhosis with encephalopathy: MELD is 22.
Secondary to ETOH and untreated hepatitis C. Viral load was
88,000 and genotype was pending at discharge. Patient continued
on lactulose, rifaxamin, nadolol as above.
# ETOH abuse: Patient had withdrawal at OSH treated with IV
diazepam. She was intubated on arrival as she was
obtuned/required airway protection prior to procedures. Patient
was continued on CIWA scale, but this was discontinued in ICU as
she had no further withdrawal symptoms. Patient was continued
on multivitamin, thiamine, folate. Social work was consulted
and patient was given information regarding relapse prevention.
.
TRANSITIONAL ISSUES
- Patient will require EUS to biopsy submucosal mass in the
duodenum found on repeat EGD
- HCV genotype was pending at discharge
Medications on Admission:
Medications home:
Nabumetone
Medications on transfer:
Ocretotide drip
Pantoprazole drip
Ceftriaxone
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg daily Disp #*30 Tablet Refills:*2
2. Lactulose 30 mL PO TID
Titrate to [**2-29**] bowel movements/day
RX *lactulose 20 gram/30 mL three times a day Disp #*2700
Milliliter Refills:*2
3. Multivitamins 1 TAB PO DAILY
RX *multivitamin daily Disp #*30 Tablet Refills:*2
4. Nadolol 40 mg PO DAILY
hold if sys BP < 90
RX *nadolol 40 mg daily Disp #*30 Tablet Refills:*2
5. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg twice daily Disp #*60 Tablet Refills:*2
6. Pentoxifylline 400 mg PO TID
RX *pentoxifylline 400 mg three times a day Disp #*63 Tablet
Refills:*0
7. Rifaximin 550 mg PO BID
RX *Xifaxan 550 mg twice a day Disp #*60 Tablet Refills:*2
8. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram/10 mL four times a day Disp #*280
Milliliter Refills:*0
9. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg daily Disp #*30 Tablet Refills:*2
10. Outpatient Lab Work
Please have CBC, INR, LFTs, albumin drawn on [**5-31**] and every
Monday for the next 3 weeks. Please fax results to
Dr. [**Last Name (STitle) 111993**] at [**Telephone/Fax (1) 111994**].
Discharge Disposition:
Home
Discharge Diagnosis:
Alcoholic cirrhosis
Alcoholic hepatitis
Variceal bleed
Dieulafoy lesion
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 GI bleeding and confusion
that was related to your liver cirrhosis. We performed an EGD
that isolated and treated the source of bleeding. You were
transferred out to the medicine floor, where we continued
treating your liver disease.
Your bilirubin continued to rise and we started a medicine
called pentoxyphylline to decrease the inflammation in the liver
which you will need to continue taking for the next month. This
inflammation was due to your recent alcohol use. A repeat
endoscopy showed no active bleeding but you still have ulcers
that are very susceptible to bleeding. As our team and our
social worker discussed with you, you must refrain from any
future alcohol intake, otherwise you will get even more sick and
may even die. Since you refused to have a feeding tube placed,
please remember to try to drink [**2-29**] Ensures a day to help with
your nutrition as this will also help your liver heal.
You will need to have your blood tests and liver function tests
monitored each week to make sure you are doing well.
Followup Instructions:
-Please call your PCP's office at [**Telephone/Fax (1) 72816**] on Monday to set
up an appointment in the next week. You should also get your
blood counts and liver function tests performed every Monday
starting on [**5-31**] and have these faxed to Dr.[**Name (NI) 111995**] office.
-Please call your liver doctor Dr.[**Name (NI) 111996**] office at ([**Telephone/Fax (1) 111997**] on Monday to schedule a follow-up appointment with him
this week to discuss this hospitalization and your liver disease
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
|
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icd9cm
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9,454
| 157,067
|
47685
|
Discharge summary
|
report
|
Admission Date: [**2134-12-4**] Discharge Date: [**2134-12-9**]
Service: MEDICINE
Allergies:
Pronestyl / Quinidine / Clonidine / A.C.E Inhibitors
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
cold blue hand
Major Surgical or Invasive Procedure:
Left axillary thrombectomy and right neck exploration [**2134-12-5**].
History of Present Illness:
85 yo F with multiple medical problems including CAD s/p stent,
CHF (EF 25%), AF on coumadin, temporal arteritis, who was
recently admitted ot [**Hospital1 18**] for CHF. During that admission, she
was given IV lasix and diuresed. She was seen in [**Company 191**] for f/u and
was noted to be less attentive and tired per her family. An
albuterol IH was rx for dyspnea. She was also seen in
rheumatology where her steroids were stopped.
.
Hx was obtained from pt's daughter and family. The pt 24hr care
attendant foudn the pt c/o pain in her left hand at 7 am this
morning and noted it to be cold. She tried taking her pulse ox
and it did not read. She called the pt's daughter who then
called 911. She had one episode of emesis and diaphoresis on her
way to [**Hospital1 **].
.
Over the last several days, the daughter state's that she has
been SOB with minimal activity ([**2-20**] steps); however was able to
walk some distance yesterday. Her appetite has been poor but her
wt has been stable. She has stable 5 pillow orthopnea. The
daughter feels that the pt is "getting better but is way too
sleepy." She is maintained on a low Na diet per the family.
.
In the ED, the patient's VS were T97.1 HR 70 BP 195/69 RR 17
O2sat 100RA. Right subclavian central line was placed. Vascular
surgery saw her and started her on heparin and brought her to
the OR; per report the anestesthia team in consultation with Dr
[**Last Name (STitle) 1391**] did not feel this to be urgent and wanted her admitted
to be optimized from a cardiac stand point. The decision was
made to evaluate her limb overnight and admit her to medicine.
.
In the PACU the patient was not oriented (thought she was in Fl,
it was 1900s). She did not have any complaints including no pain
in her hand, chest pain or SOB.
.
ROS: +constipation, mild "cold", "inflammed eyes", mild cough
since 2:30 pm
Past Medical History:
1. Coronary artery disease: MI in [**2128**]. Last cath [**4-19**]
demonstrated: LMCA appeared angiographically normal. LAD had 80%
lesion in the mid segment - stented with 3.5 x 18 and 3.5 x 13
Hepacoat stents with 0% residual. LCX had a 30% proximal lesion.
RCA was a small, non-dominant vessel with minimal blood supply
to LV, stenosed to 80%.
2. Rheumatic Heart Disease: moderate AS, moderate to severe AR,
moderate MR
3. Atrial fibrillation: rate controlled, anticoagulated
4. Bradycardia: s/p pacemaker
5. HTN
6. Dyslipidemia
7. Dementia
8. Diabetes mellitus-on insulin
9. h/o GI bleed
10. Hypothyroidism
11. CHF: last echo [**9-24**]-severe global hypokinesis, LV systolic
function severely depressed-EF 25%
12. Temporal arteritis: [**2134-4-19**], on steroid taper. With
residual left upper visual field defect. Followed by Dr.
[**Last Name (STitle) 3057**] and Dr. [**Last Name (STitle) **] (Neuro-Opth at Mass Eye/Ear)
Social History:
Pt grew up in [**Location (un) 86**] with both parents and siblings. She
graduated from HS and worked as a secretary until becoming a
homemaker after her kids were born. Has 2 grown daughters. Was
married to her 1 husband for many years, he passed away in [**2131**].
Now lives at home with a 24-hour health aides. No tobacco or
alcohol use.
Family History:
unknown.
Physical Exam:
VS: T: 96.5; HR: 97; BP: 137/49; RR 24; 100O2 % 2L NC
Gen: pleasant elderly female, nad, demented, answers direct
questions appropriately
HEENT: OP clear, temporal arteries-nontender, PERRL, EOMI
Neck: no LAD, JVP 8cm, no thyromegaly
Resp: bibasilar crackles 2/3 up posteriorly, no E->A egophany,
no wheezes or ronchi
CV: RRR, III/VI SM heard best at apex (but heard throughout),
radiating to axilla
Abd: soft, NT, + BS, ND, no masses
Ext: left arm cool non-palp pulses, non-dopplerable. 2+ DP
pulses B
Neuro: somnolent, oriented to person, but not place or time.
Pertinent Results:
Admission Labs:
143 100 23
-------------<306
4.3 31 1.4
estGFR: 36/43 (click for details)
.
CK: 30 MB: Notdone Trop-*T*: 0.17-->CK: 95 MB: Notdone
Trop-*T*: 0.55-->CK: 75 MB: not done Trop-T: 0.61-->CK 197 MB: 4
Trop-T: 0.38
.
Ca: 9.6 Mg: 2.0 P: 3.6
ALT: 13 AP: 52 Tbili: 0.4 Alb: 3.6
AST: 18 LDH:
[**Doctor First Name **]: 33 Lip: 37
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
Comments: 80 (These Units) = 0.08 (% By Weight)
.
12.7
13.6>---<229
36.0
N:87.2 Band:0 L:8.4 M:2.6 E:1.6 Bas:0.3
Anisocy: 1+ Microcy: 2+ Polychr: OCCASIONAL
.
PT: 25.6 PTT: 36.0 INR: 2.6
.
CTA [**2134-12-4**]: IMPRESSION: 1) Occluded left proximal axillary
artery.
2) 3cm hematoma in the right inferior neck, presumably from
traumatic central line placement. There is a small amount of
arterial contrast just medial to it, originating from the right
subclavian artery, suspicious for active extravasation. Close
clinical monitoring of this region is recommended. 3) Pulmonary
edema. 4) Cardiomegaly with dense coronary artery and aortic
valvular calcification. 5)Mediastinal lymphadenopathy, possibly
reactive. 6) Small pericardial effusion.
.
CXR [**2134-12-4**]: No significant change in pulmonary edema, small
right pleural effusion, and cardiomegaly. Aortic stenosis as
seen on previous CT scans may relate to patient's left arm
symptoms.
.
CT [**2134-12-5**]: IMPRESSION:
1. Comparison is very limited. However, extensive infiltration
of fat and muscle in the right neck and upper chest is likely
consistent with bloody infiltration. Of note, although the
airway is not compressed, infiltration of paratracheal fat and
muscle is identified within the neck. Therefore, close clinical
monitoring is advised.
.
CXR [**2134-12-5**]: Previous interstitial edema has cleared but the
heart is larger, particularly the left atrium. Tip of the ET
tube is less than 2 cm from the carina, and the chin is not
visible suggesting this position is at least 2 cm too low.
Pleural effusion, if any, is on the right and minimal. Left
transvenous right ventricular pacer lead is in standard
placement. A right subclavian vascular line ends in the upper
SVC. There is no pneumothorax.
.
Micro:
URINE CULTURE: PROBABLE GARDNERELLA VAGINALIS. >100,000
ORGANISMS
Brief Hospital Course:
85yo woman with CAD, CHF, a.fib, temporal arteritis, dementia
with axillary thrombosis s/p thrombectomy [**12-5**] with neck
hematoma after CVC attempt, acute renal failure and gardnerella
in urine.
.
1) left axillary artery thrombosis: s/p thrombectomy [**12-5**].
Patient was therapeutic on coumadin with INR of 2.6 on admission
though subtheraputic INR (1.4) on [**12-2**] per coumadin clinic with
no intervention in terms of coumadin dose. Rheumatology (Dr.
[**Last Name (STitle) **] doubts related to TA, ? thromboembolic event given
a.fib/potentially subtheraputic inr. Cardiology (Dr. [**Last Name (STitle) 696**]
recommended tighter INR control with goal 2.0-3.0 but no further
imaging at this time. She was bridged post-opperatively on a
heparin gtt to coumadin to theraputic INR (2.2) and coumadin was
restarted, however INR fell to 1.8 so she was covered with
lovenox injection, 60mg (based on 1mg/kg) dosed qdaily based on
renal function. She should continue lovenox until INR 2.0-3.0,
and is discharged on coumadin 3mg po qhs, to be titrated to
maintain INR at goal. She will follow-up with vascular surgery
[**2134-12-22**] to have wounds checked and staples removed,
additionally should have dry gauze to cover these wounds changed
daily.
.
2) Neck Hematoma: Secondary to carotid puncture during CVC
placement in the ED on admission. This wound was explored by
vascular surgery [**12-5**] when in surgery for thrombectomy and
noted to have no active bleeding. This site was closed with
staples and had no further swelling or bleeding, but has marked
ecchymosis and edema. Wound care and staple removal as above.
.
3) Respiratory failure: Patient was intubated for general
anesthesia and weaned/extubated with relative ease [**12-6**], oxygen
has been steadily titrated down to 1L by nasal canula and will
need to be further titrated with diuresis to prevent pulmonary
edema as postopperative edeam revascularizes. She should
continue oxygen to maintain sat >90%, albuterol/ipratropium
nebulizers as needed, chest pt, and incentive spirometry.
.
4) Cardiomyopathy/CHF: Patient has EF of 25% by Echo [**9-24**],
severe AS, [**12-21**]+ AR, [**12-21**]+ MR and mod PAH. pro-BNP 31K on
admission. Has pulm edema on exam and in CXR but improved on
[**12-5**] CXR. CVP is currently flat, she required gentle IVF and
diuresis in the ICU and further diuresis on the general medicine
floor. She is total body volume overload by weight (142, up from
dry weight of 136) likely related to edema at her surgical sites
and may require additional diursis with IV lasix as that edema
revascularizes. She was given 40mg IV lasix [**2134-12-9**] priro to
discharge with good effect. She was continued on carvedilol,
losartan was held during renal failure but restarted on
discharge, aspirin and lipitor. She is to restart her home lasix
regimen of 40mg by mouth twice daily, with IV as needed
depending on her respiratory and volume status, and weight.
.
5) Atrial fibrialation: on coumadin outpt, recently had coumadin
increased for subtherapeutic level, to be discharged on 3mg po
qhs, to be titrated as an outpatient to INR 2.0-3.0. On
discharge INR 1.9 and likely will be theraputic soon as this
medication was recently restarted after being held for surgery.
She is on lovenox 60mg qd as a bridge to theraputic INR (based
on renal function). This lovenox should be stopped once she
reaches theraputic INR. She is also restarted on digoxin, which
was held while she was in acute renal failure, at the time of
discharge. She was continued on rate control with carvedilol.
.
6) CAD: Troponin rose (peak 0.61, now trending down), but in the
setting of renal failure and flat CK's unlikely to be acute
ischemia. She was continued on aspirin, carvedilol, statin, and
restarted on cozaar once renal failure improved.
.
7) Acute renal failure: baseline Cr 1.1, peak in house 1.7, fell
to 1.2 by time of discharge. This could have been secondary to
overdiuresis vs poor forward flow, given FeUREA 8.4% and urine
sodium undetectable indicates prerenal etiology rather than
renal. By discharge improved, able to restart cozaar, digoxin,
tolerated lasix with renal improvement.
.
8) Leukocytosis: w/ left shift initially ? stress reaction,
trending down, resolved to 9.8 by the time of discharge,
possibly related to gardnerella vaginalis in urine though less
likely, treated with metronidazole for 5 days, afebrile.
.
9) Hypertension: controlled with carvedilol, restarted cozaar on
discharge.
.
10) History of bradycardia: s/p pacemaker, V paced.
.
11) Temporal arteritis: Followed by Dr. [**Last Name (STitle) **] outpatient.
Was on a 6-8month long taper (initally high dose) but it was
stopped [**2134-11-24**], he noted angiography, he feels, would be
low-yeild, favors not restarting prednisone given CNS
side-effects.
.
12) Diabetes Mellitus: Poor PO intake post-operatively initially
but improved, restarted on NPH at 16units though home dose 18
units so will need to be uptitrated at rehab depending on PO
intake and blood glucose, also with Humolog per sliding scale.
.
13) Dementia/Delirium: She was continued on home dose of
aricept.
.
14) Hyperlipidemia: continued on atorvastatin.
.
15) Hypothyroid: continued on synthroid, repeat TSH 0.32.
.
16) Depression: continued on home dose of zoloft.
.
17) Contact: [**Name (NI) **] [**Name (NI) 100724**] cell [**Telephone/Fax (1) 100725**](HCP)
.
18) FEN: Diabetic diet, low salt diet, electrolytes prn
.
19) Prophylaxis: PPI, theraputic coumadin/lovenox, bowel regimen
.
20) Code: FULL
In brief this 85 yo woamn with multiple medical problems
including CAD s/p stent, CHF (EF 25%), AF on coumadin, temporal
arteritis (stopped [**6-26**] month prednisone taper [**2134-11-24**]), was
admitted on [**12-4**] with a cold left hand and found to have left
proximal axillary artery thrombosis by CTA. Vascular surgery
followed her and she went to the OR [**12-5**] for thrombectomy. Her
hospital course was complicated by carotid artery perforation
with hematoma after CVC atttempt in the ED. This was explored at
the time of surgery and found not to be bleeding. She received
100cc NS, [**12-21**] unit PRBC in OR, and about 1L of fluid on [**12-6**].
She was intubated for the surgery and brought to the ICU for
further management. Patient remained intubated because of
multiple medical problems, even though her ABG and hemodynamics
had been stable. Patient was given multiple lasix doses
overnight for decreased urine output. She was successfully
extubated [**2134-12-6**]. She was also noted to have Gardnerella in
her urine so was started on metronidazole iv [**2134-12-6**].
.
Currently she feels well, has little recolection of surgery,
denies pain at surgical sites, dizziness, lightheadedness,
fevers, chills, nausea, vomitting, constipation, abdominal pain,
diarrhea, shortness of breath, cough, chest pain or pressure.
She does note a sensation of having to go to the bathroom (has
foley catheter in). Her daughter notes she has been more
somnolent since her discharge in early Decemeber, with DOE that
seems more severe.
.
Medications on Admission:
Furosemide 40 QAM, 20/40QPM (alternating with extra if SOB by
VNA)
Aricept 10 QAM
coreg 6.25 [**Hospital1 **]
Protonix 40
synthroid 0.125mcg QD
potassium 20mg
calcitonin 200 spray
cozaar 25mg QD
calcium and vit D 500mg tid
ECASA 81mg
Digoxin 0.0625
iron
Coumadin 2 (TTSS) and 3mg(MWF) QHS
Atorvastatin 10 QHS
zoloft 75mg
tylenol PRN
NPH 18u QD
HISS 100-140 6U, 141-180 8U, 181+ 10U
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: [**12-21**] Tablet PO once a day.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Potassium Chloride Granules Sig: One (1) Miscell. once
a day: HOLD if potassium >40 MeQ.
5. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
6. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO once a day:
please give 0830 in am.
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO QHS (once a day
(at bedtime)).
9. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal DAILY (Daily): please give 0830.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily): please give at 1300.
13. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q3-4H (Every 3 to 4 Hours) as needed for wheezing, dyspnea.
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for dyspnea, wheezing.
15. Coumadin 3 mg Tablet Sig: One (1) Tablet PO at bedtime:
please adjust coumadin dose to INR 2.0-3.0. Tablet(s)
16. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily): please continue this medication until INR
2.0-3.0, then stop.
17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day:
Please give at 0830 and 1630. She normally takes 40mg in the am
and either 20 or 40 in the pm so as lungs become more clear may
need to change pm dose.
18. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Sixteen
(16) units Subcutaneous once a day: please give at 0830. Home
dose 18 units, may need to be increased once eating better.
19. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: 1-10 units
Subcutaneous four times a day as needed for per sliding scale:
with meals:
see attached sliding scale.
20. Cozaar 25 mg Tablet Sig: One (1) Tablet PO once a day.
21. CALCIUM 500+D 500-200 mg-unit Tablet Sig: One (1) Tablet PO
three times a day. Tablet(s)
22. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
twice a day.
23. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain: not to exceed 4gm/day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Left axillary thrombus, s/p thrombectomy, right carotid puncture
.
Coronary artery disease, Rheumatic Heart Disease with aortic
stenosis, Atrial fibrillation, history of bradycardia: s/p
pacemaker, hypertension, dyslipidemia, dementia, diabetes
mellitus-on insulin, history of GI bleed, hypothyroidism,
congestive heart failure, ejection fraction 25%.
12. Temporal arteritis
Discharge Condition:
Stable.
Discharge Instructions:
Please take all medications as prescribed. Please keep all
follow-up appointments. Please notify your doctor if you
experience fevers, chills, lightheadedness, shortness of breath,
chest pain, arm pain, numbness, weakness, or any symptoms
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 665**] within 1-2 weeks after release
from rehab. Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] of vascular
surgery, on [**2134-12-22**] at 1:00pm. Please call ([**Telephone/Fax (1) 29063**] if questions for Dr. [**Last Name (STitle) 1391**].
|
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"998.2",
"446.5",
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"396.8",
"250.00",
"414.01",
"444.21",
"V58.67",
"E878.8",
"398.91",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"06.09",
"38.03"
] |
icd9pcs
|
[
[
[]
]
] |
16424, 16490
|
6460, 13543
|
275, 348
|
16909, 16919
|
4182, 4182
|
17206, 17550
|
3572, 3582
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13976, 16401
|
16511, 16888
|
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|
16943, 17183
|
3597, 4163
|
221, 237
|
376, 2239
|
4198, 6437
|
2261, 3196
|
3212, 3556
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,935
| 119,178
|
8870
|
Discharge summary
|
report
|
Admission Date: [**2182-8-23**] Discharge Date: [**2182-9-5**]
Date of Birth: [**2105-5-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname 30896**] is a 77 year old female with history of RCC,
Metastatic colon CA, pulmonary embolus and metabolic syndrome
presenting with failure to thrive. Patient states, through her
daughter serving as interpreter, that she was visited by one of
her physicians at rehab who became very concerned about her.
Patient however states that she has been having vomiting, leg
pain and lower extremity swelling for days. She states emesis
was gastric contents only and was not bilious. She denies any
chest pain, shortness of breath or diarrhea.
Past Medical History:
IDDM
HTN
DJD
RCC s/p L nephrectomy 3 years ago
s/p cataract surgery
? hx of benign pancreatic cyst
Social History:
Denies smoking/ETOH/Drugs
Lives at home, alone in [**Location (un) 686**], has home health aids and
VNA, children live close by.
Family History:
Diabetes, grandfather with "cancer"
Physical Exam:
Tmax 97.6 BP: 115/72 RR:20 97%@2L BG: 201
GEN: Patient resting comfortably in bed, accompanied by daughter
who is translating. Patient has very flat affect and does not
make eye contact with us.
HEENT: Anicteric sclera, no nystagmus, no cervical
lymphadenopathy
CV: Distant heart sounds, no murmurs, S1S2 auscultated.
LUNGS: Crackles heard over both lower lung fields. No wheezes or
rales
ABD: Epigastric tenderness to deep palpation, bowel sounds
slightly decreased. No palpable organomegaly
Pertinent Results:
[**2182-8-23**]
WBC-13.9* RBC-0*# Hgb-9.4* Hct-34.5* MCV-0*# MCH-0*# MCHC-29.4*
RDW-0* Plt Ct-325
PT-14.9* PTT-25.1 INR(PT)-1.3*
Glucose-238* UreaN-53* Creat-1.7* Na-142 K-5.4* Cl-107 HCO3-24
AnGap-16
CK(CPK)-101
cTropnT-0.04*
CK-MB-3 proBNP-3198*
Calcium-8.7 Phos-4.1 Mg-2.1
Lactate-3.9*
Head CT:
CT HEAD WITHOUT IV CONTRAST: There is no evidence of
intracranial hemorrhage, hydrocephalus, shift of normally
midline structures or edema. The [**Doctor Last Name 352**]-white matter
differentiation is intact throughout. Periventricular white
matter hypoattenuation is consistent with chronic small vessel
infarction. Atherosclerotic calcifications involving the
vertebral arteries and the cavernous portions of the internal
carotid arteries are redemonstrated. The paranasal sinuses are
well aerated.
IMPRESSION: No evidence of intracranial hemorrhage or edema.
Brief Hospital Course:
Patient exhibited recurrent atrial fibrillation with hypotension
in the ICU. Treatment with nodal agents was limited by sustained
hypotension. Treatment of hypotension by fluid resuscitation was
limited due to poor nutritional status and large anasarca.
Digoxin was added for rate control but was not effective.
Given the fact that the patient expressed several times her wish
not be in the intensive care unit, as well as the very poor
prognosis of her advanced malignancy and the refractory nature
of her cardiovascular disease the decision was made after a
family meeting to pursue comfort measures only . Patient passed
on [**2182-9-5**]. Family was notified and declined post-mortem
examination.
Medications on Admission:
Capecitabine [**2175**] mg po b.i.d. started on [**2182-8-16**],
Cozaar 50 mg b.i.d.,
Megace oral suspension 400 mg daily,
Compazine 10 mg q4-6h given this morning,
Compazine 25 mg per rectum q6h not given,
Lasix 20 mg daily
Verapamil 20 mg b.i.d.
Humulin N100 5 units subcutaneously b.i.d.
Humalog sliding scale,
Lovenox 100 mg subcutaneously [**Hospital1 **]
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2182-10-1**]
|
[
"197.7",
"458.9",
"276.51",
"288.60",
"787.91",
"V58.67",
"599.0",
"783.7",
"584.9",
"276.7",
"V10.51",
"250.00",
"401.9",
"276.2",
"427.89",
"V10.05",
"041.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
3770, 3779
|
2657, 3359
|
322, 328
|
3830, 3839
|
1769, 2059
|
3891, 3925
|
1199, 1236
|
3800, 3809
|
3385, 3747
|
3863, 3868
|
1251, 1750
|
274, 284
|
356, 913
|
2068, 2634
|
935, 1036
|
1052, 1183
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,485
| 146,432
|
6334
|
Discharge summary
|
report
|
Admission Date: [**2193-1-24**] Discharge Date: [**2193-2-2**]
Date of Birth: [**2114-11-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2193-1-24**] Four Vessel Coronary Artery Bypass Grafting utilizing the
left internal mammary to left anterior descending, saphenous
vein grafts to ramus, obtuse marginal and posterior descending
artery.
History of Present Illness:
Mr. [**Known lastname 23203**] is a 78 year old male with multiple cardiac risk
factors. Since the [**2192**] summer, he has complained of increasing
dyspnea on exertion and increasing claudication. Prior to this
admission, he was admitted two weeks prior with angina and ruled
in for a NSTEMI. He underwent stress test which was positive for
ischemia. Subsequent cardiac catheterization showed calcified
coronary arteries and severe three vessel disease. Angiography
revealed a 40% stenosis of the left main; totally occluded left
anterior descending; 90% lesions in the first obtuse marginal
and right coronary artery; and 80% stenosis in the first
diagonal. An echocardiogram in [**2192-12-20**] showed normal left
ventricular function with minimal valvular abnormalities. Based
on the above results, he was referred for cardiac surgical
intervention.
Past Medical History:
Coronary Artery Disease, Hypertension, Insulin Dependent
Diabetes Mellitus, Hyperlipidemia, Chronic Renal Insufficiency,
Peripheral [**Year (4 digits) **] Disease with claudication, Anemia,
Osteoarthritis, BPH, Diabetic Neuropathy, Diabetic Retinopathy,
s/p Cataract Surgery, s/p Vitrectomies, s/p Tonsillectomy
Social History:
No current tobacco x past 45 years. Used to smoke 1ppd x 17
years. Drinks 2-3 beers/day. Lives at home with his wife, works
as an insurance broker.
Family History:
Father had a stroke at age 89. Mother died of cancer. No known
heart disease in the family.
Physical Exam:
Vitals: BP 138/62, HR 87, RR 14, SAT 96% on room air
General: elderly male in no acute distress
HEENT: oropharynx benign, slight droop right upper eyelid, EOMI
Neck: supple, no JVD
Heart: regular rate, normal s1s2, 2/6 systolic ejection murmur
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, 1+ pretibial edema, no varicosities
Pulses: 2+ distally
Neuro: alert and oriented, CN2-12 grossly intact, MAE, [**4-24**]
strenght, no focal deficits noted, decreased sensation in feet
Brief Hospital Course:
Mr. [**Known lastname 23203**] was admitted and underwent four vessel coronary artery
bypass grafting. For surgical details, please see seperate
dictated operative note. Following the operation, he was brought
to the CSRU on minimal inotropic support. Within 24 hours, he
awoke neurologically intact and was extubated without incident.
He weaned from inotropic support without difficulty. He was
initially maintained on an Insulin drip for glycemic control.
The [**Last Name (un) **] center was consulted to assist in the management of
his diabetes mellitus. Lantus therapy was resumed, and his
sliding scale insulin titrated for tight glucose control. His
CSRU course was complicated by postoperative atrial fibrillation
which was treated with Amiodarone. His rhythm alternated between
sinus rhythm/bradycardia and atrial fibrillation. Frequent
pauses were noted on telemetry - all asymptomatic. Occasional
periods of junctional rhythm were also noted. The EP service was
consulted, and recommended to continue low dose Amiodarone,
metoprolol and observation. He otherwise maintained stable
hemodynamics, and remained asymptomatic. He eventually
transferred to the telemetry floor. Given persistent atrial
dysrhythmias, Warfarin anticoagulation was initiated and dosed
for a goal INR between 2.0 - 3.0. He will have his Amiodarone
tapered per ER service recommendations to 200mg a day. Mr.
[**Known lastname 23203**] also had two episodes of urinary retention in which he
failed trials of void. He was discharged with a 16fr Foley
catheter and leg bag. His PCP will arrange referral for urology
follow up after discharge. He further had an episode of
probable acute ATN secondary to this surgery which was resolving
upon discharge. He was discharged home on POD 9 with services
in good condition, cardiac/diabetic diet, sternal precautions,
and instructed to follow up with his PCP and cardiologist in [**1-21**]
weeks. He will follow up with Dr. [**Last Name (STitle) **] in four weeks.
Outpatient VNA services will draw PT/INR on [**2193-2-4**] and fax
results to Dr. [**Last Name (STitle) 24522**], PCP [**Telephone/Fax (1) 18684**], office phone number
[**Telephone/Fax (1) 24523**].
Medications on Admission:
Diovan 80 qam, 160 qpm
Terazosin 5 [**Hospital1 **]
Hctz 25 [**Hospital1 **]
Imdur 30 qd
Aspirin 325 qd
Humalog TID with meals
Lantus qpm
Lipitor 80 qd
Norvasc 5 qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 5 days: then one tablet 200mg daily thereafter.
Disp:*40 Tablet(s)* Refills:*2*
6. 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*
7. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
Disp:*15 Tablet(s)* Refills:*2*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
11. Insulin Lispro (Human) 100 unit/mL Solution Sig: [**5-29**]
Subcutaneous four times a day: give per sliding scale.
Disp:*qs 6* Refills:*2*
12. Insulin Glargine 100 unit/mL Solution Sig: Twenty Six (26)
Subcutaneous at bedtime.
Disp:*26 8* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary Artery Disease, Hypertension, Insulin Dependent
Diabetes Mellitus, Hyperlipidemia, Chronic Renal Insufficiency,
Peripheral [**Hospital1 **] Disease with claudication, Anemia,
Osteoarthritis, BPH, Diabetic Neuropathy, Diabetic Retinopathy,
Postoperative Atrial Fibrillation
Discharge Condition:
Good
Discharge Instructions:
You can take shower. Do not bath. Wash incisions with water and
gentle soap. Gently pat dry. Do not apply lotions, creams,
ointments, or powders to incisions. Do not lift greater than 10
pounds for 2 months. Do not drive for 1 month. If you notice
redness, drainage from incisions, or experience fever greater
than 101, please contact office immediately.
Followup Instructions:
Follow-up in wound clinic in 3 weeks for staple removal
Follow-up with cardiac surgeon, Dr. [**Last Name (STitle) **] in 4 weeks
Follow-up with Cardiologist, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**2-22**] weeks
Follow-up with PCP, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 24522**] in [**1-21**] weeks
Completed by:[**2193-2-2**]
|
[
"V58.67",
"410.72",
"443.9",
"414.01",
"362.01",
"272.0",
"250.50",
"250.60",
"357.2",
"401.9",
"411.1",
"427.31",
"715.98",
"593.9",
"600.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
6507, 6562
|
2598, 4795
|
340, 548
|
6888, 6895
|
7299, 7684
|
1949, 2042
|
5010, 6484
|
6583, 6867
|
4821, 4987
|
6919, 7276
|
2057, 2575
|
281, 302
|
576, 1432
|
1454, 1767
|
1783, 1933
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,286
| 187,882
|
29711
|
Discharge summary
|
report
|
Admission Date: [**2152-12-27**] Discharge Date: [**2153-1-10**]
Date of Birth: [**2073-6-26**] Sex: M
Service: MEDICINE
Allergies:
Nitrofurantoin / Alpha-2 Receptor Antagonst Antidepresnts
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Fever, confusion
Major Surgical or Invasive Procedure:
s/p L3/4 discectomy and fusion
PICC line placement
History of Present Illness:
79 year old man PMH significant for MRSA osteomyelitis and
bacteremia, DJD/back pain, diet controlled DM, anxiety disorder,
and BPH. He underwent TURP in [**2151-12-19**] c/b ~ 6 months of
recurrent MRSA UTI??????s, cachexia, low grade fevers, anorexia. Was
rx with intermittent courses of abx (duration not known), but
continued to be ill.
.
[**7-23**] was readmitted to [**Hospital 1727**] Medical Center with intractable
back pain, found to have MRSA and pseudomonal bacteremia. MRI
with L3-L4 osteo/discitis/paraspinal mass. No surgery or biopsy,
TTE negative, TEE done [**2152-8-11**], showed no evidence of
endocarditis, EF 45%. He was treated for 6 weeks with Vanco
(changed to Linezolid) and Cipro for pseudomonas, sent to rehab
and was doing better; starting to walk, had PEG for weight-loss.
.
[**12-24**] admitted to [**Hospital 66189**] hospital with weakness, fever,
confusion, pain, started on levaquin, then changed Vancomycin
and Bactrim for when multiple blood cultures grew MRSA, urine
culture with Klebsiella pneumoniae. Repeat MRI shows partial
resolution of paraspinal mass, improved Discitis, but ? small
epidural abscess (question minor nerve root impingement). [**Name8 (MD) **] MD
neuro exam is significant for ??????generalized weakness,?????? but
non-focal.
.
Yesterday afternoon had a 15 minute bout of chills, hypotension
and SOB - SBP 70/ HR 70. Transferred to ICU, CXR normal, ABG
normal, buffed up to 120/ with IVF. Comfortable on 2L O2, but
still with severe back pain. WBC 10, Plts 500, HCT 35, NA 133,
BUN/ Cr 20/1.1, Alb: 2.6. Should be OK for floor as he is in ICU
because it is a small hospital.
.
On arrival to the floor, he was awake, alert, very conversant.
Does not remember much of the details of his most recent
hospitalization he states [**1-19**] to paim medications he is on. His
pain is well controlled, no dysuria. Denies chest pain. He has
not ambulated since arrival. No changes in sensation in hands or
feet.
.
On review of systems, the patient denies any chest pain,
shortness of breath, night sweats, fevers, chills, night sweats,
fatigue, headaches, dizziness, blurred vision, sore throat,
nausea, vomiting, abdominal pain, any new rashes, denies
dysuria, hematuria, increased urgency, diarrhea, constipation,
hematochezia, melena, epistaxis. All other systems reviewed in
detail and negative except for what has been mentioned above.
Past Medical History:
- L3-L4 osteomyelitis/discitis/paraspinal mass likely MRSA
- DJD/back pain
- DM II, diet controlled
- CAD s/p PTCA [**10/2146**], stent to RCA and left Circ. NSTEMI in [**2144**]
with PTCA of RCA.
- BPH, s/p TURP [**12-23**]
- Recurrent MRSA UTIs
- s/p PEG tube placement
- Anxiety disorder
Social History:
Married, lives with wife at home. Retired from making plastic
windows at company in [**Location (un) 20180**]. Previously healthy prior to TURP
in [**6-22**]. PReviously active, now with difficuty walking from
pain. Denies alcohol, remote history of tobacco.
Family History:
NC
Physical Exam:
VS: T:98.2 HR:92 BP:120/70 RR:16 Sat:97 on RA
Gen: Appears well dressed, well nourished, in no acute distress
HEENT: NCAT, PERRL, Sclera anicteric, No ulcers, oropharynx
otherwise clear, throat with no erythema or exudates, no thrush,
no cervical lymphadenopathy, JVP is flat
CV: normal S1/S2, RRR, systolic flow murmur, no r/g, no
tenderness to palpation of precordium, PMI non-displaced
Lungs: Clear to auscultation bilaterally, No w/r/rh
Abdomen: Soft, nontender, nondistended, normoactive bowel
sounds, no hepatosplenomegaly, no ascites
Ext: No peripheral edema, no clubbing, cyanosis, no calf pain,
DP pulses are 2+ bilaterally
Neuro: A + O x 3, CN II-XII grossly intact, Motor [**4-21**] both upper
and lower extremities, Sensation grossly intact to light touch,
DTR 2+ throughout, Toes downgoing
Skin: pink, warm, no rashes
Pertinent Results:
[**2152-12-28**] 05:15AM BLOOD WBC-9.1 RBC-3.78* Hgb-11.7* Hct-35.3*
MCV-94 MCH-30.9 MCHC-33.1 RDW-14.9 Plt Ct-481*
[**2153-1-4**] 05:04PM BLOOD WBC-14.5* RBC-3.28* Hgb-10.2* Hct-29.7*
MCV-91 MCH-31.0 MCHC-34.1 RDW-16.1* Plt Ct-536*
[**2153-1-10**] 06:56AM BLOOD WBC-8.5 RBC-3.25* Hgb-10.4* Hct-29.0*
MCV-89 MCH-31.9 MCHC-35.7* RDW-15.6* Plt Ct-226
[**2153-1-1**] 05:07AM BLOOD Neuts-75.4* Lymphs-15.7* Monos-5.0
Eos-3.7 Baso-0.2
[**2153-1-9**] 06:47AM BLOOD PT-13.7* PTT-35.7* INR(PT)-1.2*
[**2153-1-10**] 06:56AM BLOOD PT-13.3* PTT-33.3 INR(PT)-1.2*
[**2152-12-29**] 05:44AM BLOOD ESR-110*
[**2152-12-30**] 05:36AM BLOOD Ret Aut-1.4
[**2153-1-5**] 06:34AM BLOOD Glucose-169* UreaN-15 Creat-0.8 Na-130*
K-4.7 Cl-95* HCO3-30 AnGap-10
[**2153-1-10**] 06:56AM BLOOD Glucose-174* UreaN-10 Creat-0.5 Na-132*
K-3.7 Cl-96 HCO3-26 AnGap-14
[**2152-12-28**] 05:15AM BLOOD ALT-28 AST-26 LD(LDH)-152 AlkPhos-113
TotBili-0.2
[**2153-1-7**] 02:08AM BLOOD ALT-32 AST-52* AlkPhos-141* TotBili-0.5
[**2152-12-28**] 05:15AM BLOOD Albumin-3.2* Calcium-9.0 Phos-3.6 Mg-2.2
[**2153-1-5**] 06:34AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.7
[**2153-1-10**] 06:56AM BLOOD Calcium-8.0* Phos-1.6* Mg-1.7
[**2152-12-30**] 05:36AM BLOOD calTIBC-233* Ferritn-480* TRF-179*
[**2153-1-7**] 02:08AM BLOOD Triglyc-91
[**2152-12-28**] 05:15AM BLOOD CRP-39.8*
[**2152-12-29**] 05:44AM BLOOD Vanco-22.9*
[**2153-1-10**] 06:56AM BLOOD Vanco-8.1*
[**2153-1-4**] 02:59PM BLOOD Type-ART pO2-182* pCO2-45 pH-7.42
calTCO2-30 Base XS-4
[**2153-1-6**] 04:57PM BLOOD Type-ART pO2-281* pCO2-34* pH-7.49*
calTCO2-27 Base XS-3 Intubat-INTUBATED
[**2153-1-4**] 02:59PM BLOOD Glucose-130* Lactate-1.3 Na-131* K-4.3
Cl-97* calHCO3-29
[**2153-1-6**] 04:57PM BLOOD Hgb-11.5* calcHCT-35 O2 Sat-99
[**2153-1-6**] 04:57PM BLOOD freeCa-1.05*
.
[**2152-12-29**]: Transesophageal echo
Conclusions:
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 to moderate regional left
ventricular systolic dysfunction with anterior hypokinesis
(segmental wall motion was not fully assessed). There are simple
atheroma in the aortic arch and in the descending thoracic
aorta. The aortic valve leaflets (3) are mildly thickened. No
masses or vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Trace mitral regurgitation is seen.
.
[**2152-12-28**]: MRI of C/T/L Spine
IMPRESSION:
1. Discitis-osteomyelitis at L3-4 with pre- paravertebral
inflammatory change with no evidence of epidural abscess at this
location. Clumping of the cauda equina nerve roots suggests
arachnoiditis.
2. STIR signal hyperintensity and enhancement at the T10-11
intervertebral disc and superior endplate of T11, also
suspicious for discitis-osteomyelitis, also with no evidence of
epidural abscess at this location.
.
ECHO Study Date of [**2152-12-29**]
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 to moderate regional left ventricular
systolic dysfunction with anterior hypokinesis (segmental wall
motion was not fully assessed). There are simple atheroma in the
aortic arch and in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Trace mitral regurgitation is seen.
No vegetation or abscess seen.
.
PROSTATE U.S. [**2153-1-2**] 1:44 PM
Mild BPH. No son[**Name (NI) 493**] evidence of mass or abscess.
.
PERSANTINE MIBI [**2153-1-2**]
No definite reversible perfusion defects identified. 2. Slight
apical
hypokinesis with low-normal calculated LVEF of 49%.
.
STRESS Study Date of [**2153-1-2**]
No anginal type symptoms or ischemic EKG changes. Nuclear report
sent separately.
.
L-SPINE (AP & LAT) IN O.R. [**2153-1-4**] 2:30 PM
A series of four intraoperative radiographs of the lumbar spine
were obtained. These demonstrate an anterior interbody fusion
device placed in the lumbar spine at L3-L4. Severe multilevel
degenerative changes in lumbar spine are seen. Evaluation of
osseous structures is obscured by overlying bowel contents.
Retractors are seen anteriorly. Please refer to operative report
for full details.
.
L-SPINE (AP & LAT) [**2153-1-6**] 3:00 PM
Post-surgical changes as described. Limited study.
Brief Hospital Course:
79 y/o man with PMH significant for MRSA osteomyelitis and
bacteremia, DJD/back pain, diet controlled DM, anxiety disorder,
and BPH, p/w with persistent MRSA bacteremia and disc
osteomyelitis, s/p discectomy with fusion.
.
# MRSA bacteremia/osteomyelitis/epidural abscess:
Bacteremia most likely from chronic osteomyelitis/disc abscess.
Blood cultures growing MRSA, last positive blood culture was on
[**2152-12-20**]. Patient does not have any focal neurologic findings.
Repeat MRI on [**12-28**] showed L3/L4 and T11 discitis without any
evidence of epidural abscess (based on prior MRI from OSH). TEE
on [**12-29**] negative for vegetations/abscess. Rectal ultrasound to
r/o prostatic abscess/fluid collection was negative.
Leukocytosis, likely from intermittent bacteremia. CRP 40, ESR
110. Orthopedic spine surgeons were consulted and pt had
resection of infected disc abscess with subsequent rod fixation
on [**1-5**]. Bone tissue culture from [**1-4**] grew coag+ staph,
sensitivities pending. Pt remains afebrile, hemodynamically
stable, without leukocytosis. Surveillance blood cultures
negative, last positive blood culture on [**12-20**]. Vancomycin 1g qday
(started [**12-26**]) via PICC line, to continue for 8 week course. Pt
will need weekly vancomycin level troughs. Vancomycin level
therapeutic on [**1-3**], then sub-therapeutic on [**1-10**] and vancomycin
dose was increased to 1g q12H as GFR had improved.
.
# Klebsiella UTI:
Pan-sensitive, on Bactrim DS. Treated with 10 day course,
completed on [**1-6**].
.
# CAD:
No evidence of chest pain. pMIBI and stress test normal, done
prior to surgery for risk stratification. Continue aspirin.
.
# Anemia:
Pt with Hct of 24 on transfer back to medicine service.
Transfused 1u pRBC with appropriate increase in Hct, however,
Hct decreased again on [**1-9**]. Orthopedics notified, not concerned
about this post-op Hct drop and no need to do imaging studies.
Transfused again with 1u pRBC with appropriate increase in Hct.
Hemolysis labs normal. Iron panel
.
# Back pain:
Secondary to osteomyelitis.
- continue oxycodone and morphine prn, tylenol q6h
- titrate up pain medications as needed
.
# Epistaxis:
Secondary to trauma s/p cautery by ENT. Continue Afrin, allow
nasal packing to dissolve. Avoid O2 NC, use humidified shovel
mask if needed. Bacitracin to nose qdaily. Saline nasal spray as
needed.
.
# DM II:
Diet controlled. Covered with RISS while inpatient.
.
# Anxiety/Depression:
Continue remeron, ativan prn.
.
# FEN:
Pt with hyponatremia and low phos on [**1-9**]. Low sodium from
appears to be from dehydration as looked dry on exam, will
replete with NS IVF. Check urine Na if level not improving.
Continue PO diabetic/cardiac diet. Replete lytes PRN.
.
# Prophylaxis:
Heparin SQ, bowel regimen
.
# ACCESS:
1 PIV, PICC line
- manage per protocol care
.
# CODE:
Full, no "heroic" measures
.
# Communication: With patient
.
# Dispo:
DC to rehab in [**Location (un) 24402**], [**State 1727**]. He will followup with orthopedic
spine clinic and ID both at [**Hospital1 18**] outpatient. Send weekly safety
labs (CBC, chem 7, LFTs, vancomycin level) to [**Hospital 18**] [**Hospital **] Clinic.
Medications on Admission:
Medications at home:
ASA 81 mg daily
Klonopin 0.5mg po daily
Colace 100mg po bid
Senna 2 po bid
Omeprazole 20mg po daily
Remeron 15mg po qhs
Vicodin [**12-19**] po q4h prn
Fentanyl patch 25mg q72h
Tube feeds
.
Medications on transfer:
Vancomycin 1000mg [**Hospital1 **] (started [**12-26**])
Vitamin C 500mg [**Hospital1 **]
Zinc Sulfate 220mg daily
Multivitamin
Tylenol q6h
Protonix 80mg daily
Aspirin 81mg daily
Colace 100mg daily
Bactrim DS 1 po bid (started [**12-23**])
Remeron 15mg
Lortab 10/650mg prn
Roxanol 5mg prn pain
MOM 30ml prn constipation
Maalox 30mL q6h prn
Ambien 5mg po qhs
Discharge Medications:
1. Ascorbic Acid 500 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO BID (2
times a day).
2. Zinc Sulfate 220 (50) mg Capsule [**Month/Day (4) **]: One (1) Capsule PO
DAILY (Daily).
3. Hexavitamin Tablet [**Month/Day (4) **]: One (1) Cap PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable [**Month/Day (4) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Mirtazapine 15 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO HS (at
bedtime).
6. Magnesium Hydroxide 400 mg/5 mL Suspension [**Month/Day (4) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
7. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension [**Month/Day (4) **]:
15-30 MLs PO QID (4 times a day) as needed.
8. Zolpidem 5 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO HS (at bedtime).
9. Sodium Chloride 0.65 % Aerosol, Spray [**Month/Day (4) **]: Two (2) Spray
Nasal QID (4 times a day) as needed.
10. Bacitracin Zinc 500 unit/g Ointment [**Month/Day (4) **]: One (1) Appl
Topical QHS (once a day (at bedtime)).
11. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (4) **]: One (1) PO TID (3
times a day).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (4) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
13. Lactulose 10 g/15 mL Syrup [**Month/Day (4) **]: Thirty (30) ML PO Q4H (every
4 hours).
14. Senna 8.6 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily).
15. Metoprolol Tartrate 25 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO BID
(2 times a day).
16. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
17. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain.
18. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical TID
(3 times a day) as needed.
19. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
20. Lorazepam 0.5-1 mg IV Q4H:PRN
21. Insulin Lispro (Human) 100 unit/mL Solution [**Last Name (STitle) **]: SLIDING
SCALE Subcutaneous ASDIR (AS DIRECTED).
22. Vancomycin HCl 1000 mg IV Q 12H Duration: 7 Weeks Start: In
am
23. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever, pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 24402**], ME
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1. s/p L3/4 discectomy and fusion
2. L3-L4 osteomyelitis/discitis/paraspinal mass likely MRSA
3. DJD/back pain
4. DM II, diet controlled
5. BPH
.
SECONDARY DIAGNOSES:
1. CAD s/p PTCA [**10/2146**], stent to RCA and left Circ. NSTEMI in
[**2144**] with PTCA of RCA.
2. Recurrent MRSA UTIs
3. s/p PEG tube placement
4. Anxiety disorder
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted for bacterial infection in your blood and
spine. You were treated with antibiotics. You had orthopedic
spine surgery to remove the source of infection and had the
lower part of your spinal cord fused. You did not suffer any
complications.
.
You will be discharged on 7 more weeks of vancomycin. Please
call your PCP or return to the ED if you experience fevers,
chills, back pain, nausea/vomiting, shortness of breath, chest
pain.
.
Please take all medications as prescribed.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name 9406**] @ [**Hospital 18**] [**Hospital **] Clinic
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2153-2-6**] 10:30
.
You should followup with your PCP [**Name Initial (PRE) 176**] 1 week of discharge for
further medical management. Call number below to make an
appointment.
PCP: [**Name10 (NameIs) 21496**],[**Name11 (NameIs) 65954**] [**Telephone/Fax (1) 71171**]
.
Dr. [**Last Name (STitle) 363**] @[**Hospital1 18**] Orthopedics
Time: 2:30pm on [**2153-1-24**]
.
Please have weekly labs (CBC, chem 7, liver function tests,
vancomycin level) faxed to [**Hospital 18**] [**Hospital **] Clinic c/o Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**]:
Fax Number [**Telephone/Fax (1) 71172**]
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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"038.11",
"599.0",
"250.00",
"V09.0",
"730.28",
"285.9",
"041.3",
"276.1",
"414.01",
"722.93"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.89",
"38.93",
"81.08",
"81.06",
"88.72",
"96.6",
"03.90",
"84.51",
"80.51",
"84.52",
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icd9pcs
|
[
[
[]
]
] |
15307, 15385
|
9035, 12204
|
335, 388
|
15782, 15792
|
4285, 9012
|
16334, 17263
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3414, 3418
|
12847, 15284
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15406, 15571
|
12230, 12230
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15816, 16311
|
12251, 12440
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3433, 4266
|
15592, 15761
|
279, 297
|
416, 2808
|
12465, 12824
|
2830, 3122
|
3138, 3398
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,482
| 135,583
|
35103
|
Discharge summary
|
report
|
Admission Date: [**2123-10-6**] Discharge Date: [**2123-10-8**]
Date of Birth: [**2072-6-6**] Sex: F
Service: NEUROSURGERY
Allergies:
Codeine / Penicillins / Augmentin
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
[**First Name9 (NamePattern2) 80171**] [**Last Name (un) **] aneuyrsm
Major Surgical or Invasive Procedure:
[**Last Name (un) 80171**] artery aneurysm stent placement
Past Medical History:
PMHx:
HTN
ischemic colitis ([**2121**], no sx)
Social History:
Social Hx:
(+) tobacco, 30 pack-yr hx (1 ppd x 30 yrs)
no EtOH
no drugs
works as a nurse's aid at a nursing home
Family History:
nc
Physical Exam:
Afebrile. VSS per nursing record.Pt underwent placement of
Basilar aneurysm stent. She initially had oozing from the right
groin site as it was difficult for pt to lay flat for the
specified length of time. She has been progressing well,
tolerating all po food and fluid with no residual nausea or
vomiting. She has warm bil. LE's with palpable pulses.
Pertinent Results:
[**2123-10-6**] 05:35PM GLUCOSE-108* UREA N-10 CREAT-0.9 SODIUM-141
POTASSIUM-3.8 CHLORIDE-111* TOTAL CO2-21* ANION GAP-13
[**2123-10-6**] 05:35PM CALCIUM-8.7 PHOSPHATE-3.9 MAGNESIUM-1.7
[**2123-10-6**] 05:35PM WBC-6.1 RBC-3.54* HGB-10.8* HCT-31.5* MCV-89
MCH-30.4 MCHC-34.1 RDW-15.1
[**2123-10-6**] 05:35PM PLT COUNT-530*
[**2123-10-6**] 05:35PM PT-13.7* PTT-122.8* INR(PT)-1.2*
Brief Hospital Course:
To O.R. as expected for placement of the Basilar aneurysm stent.
No post procedure complications. Progressing well. To be d/c'd
back to the prior rehabilitation institution.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6hrs PRN as
needed.
2. Aspirin 325 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. Verapamil 120 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
5. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO BID
(2 times a day) as needed.
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 30 days.
9. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**12-23**]
Tablets PO Q6H (every 6 hours) as needed for headache.
10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
11. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Sub arachnoid hemorrhage
[**Hospital1 80171**] artery aneurysm
Discharge Condition:
Stable
Completed by:[**2123-10-8**]
|
[
"331.3",
"E878.8",
"437.3",
"401.9",
"997.2",
"442.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.72",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
2606, 2686
|
1451, 1626
|
365, 426
|
2793, 2831
|
1037, 1428
|
645, 649
|
1649, 2583
|
2707, 2772
|
664, 1018
|
256, 327
|
448, 496
|
512, 629
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,552
| 156,674
|
31202+57735
|
Discharge summary
|
report+addendum
|
Admission Date: [**2111-10-1**] Discharge Date: [**2111-10-19**]
Date of Birth: [**2064-2-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4282**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
T12 transpedicular decompression and posterior instrumented
fusion T10 to L2
History of Present Illness:
47 yo male with renal cell cancer with intrahepatic and
paraspinal metastasis treated with stereotactic body
radiotherapy, completed on [**2111-8-5**], who is admitted
for pain control. He was doing well after completion of
radiotherapy but within a few weeks developed severe left leg
pain as well as muscular spasms and areas of numbness. Since
this weekend, he has developed severe left leg and back pain.
However, he denied fecal or urinary incontinence and focalized
weakness.
Because of the pain, on [**2111-9-28**], pt was admitted to local
hospital where he received pain medications and MRI under
anesthesia because of inability to lie flat. The MRI revealed "
a large mass over the right renal fossa extending to the
paraspinal muscle and also there was a tumor involving the
thoracic 11 and thoracic 12 vertebral body extending into the
spinal canal, cord compression, and also a tumor involving the
paraspinous muscle. Possible metastatic lesion of cervical 2
vertebral body with possible cord compression.
After discussing with his own [**Date Range 5564**] in [**Hospital1 18**], he was
transferred to here for further management.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies
cough, shortness of breath, or wheezes. Denies nausea, vomiting,
diarrhea, constipation. He admitted right side abd pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rashes or skin breakdown. No
numbness/tingling in extremities. No feelings of depression or
anxiety. All other review of systems negative.
Past Medical History:
ONCOLOGIC HISTORY:
1. Partial right nephrectomy in [**1-/2107**] after the patient
presented with hematuria and flank pain to [**Hospital1 14579**] and was found on CT scan to have a 5.1 x 5.8 right
renal mass.
2. Resection of recurrent renal cell carcinoma in the right
subcostal region and rib in 11/[**2106**]. The pathology of the
resected tumor was consistent with the previously resected clear
cell primary.
3. Posterior cervical fusion, occiput to C5 and left-sided C2
laminectomy and decompression in [**4-/2108**] because of the finding
on MRI of a 2.5 x 3.2 cm destructive soft tissue mass. This mass
had replaced the left side of the C2 vertebral body and extended
into the pedicle and neural foramen on the left at the C2-C3
level.
4. Postoperative radiation therapy to the cervical spine.
5. One cycle of IL-2 as part of the IL-2 select trial in
08/[**2107**].
6. Hospitalization in [**9-/2108**] for hypercalcemia.
7. Enrolled in sorafenib/bevacizumab phase II trial on
[**2108-11-14**] - discontinued as of [**2109-1-4**] with development of
colonic perforation.
8. Readmitted to [**2109-1-10**] with contrast nephropathy. Status
post diverting ileostomy on [**2108-1-17**].
9. Begin Sutent 37.5 mg on [**2109-3-31**]. Stopped Sutent on [**1-/2110**]
(tired of taking it).
10. Consideration for the RAD-001 biomarker trial. The patient,
however, had a nondiagnostic tumor biopsy, and was therefore
ineligible.
11. Resection of right retroperitoneal tumor, right colectomy,
partial liver resection, and ileal transverse colostomy
anastomosis on [**2110-11-14**] for recurrent renal cell carcinoma in
previous right nephrectomy bed with involvement of the liver,
right colon and right psoas muscle.
12. [**2111-4-20**] started PKI-587 (PI3K/mTOR inhibitor) on protocol
09-215
13. [**2111-6-15**] taken off protocol 09-215 because of disease
progression including T11-T12 paraspinal lesion invading spinal
canal
14. [**2111-7-2**] last zometa
15. [**Date range (3) 64795**] SRS to right infrahepatic metastasis;
[**Date range (2) 73646**] SRS to paraspinal metastasis
PAST MEDICAL HISTORY:
- Renal Cell Carcinoma (please see below)
- h/o RLE DVT [**8-/2107**]
- Colonic perforation
- Hyponatremia
- Anemia
- Cervical surgery with rod-placement due to C2 met
-[**2110-11-14**] Right colectomy, Segment VI partial liver
resection, resection of retroperitoneal tumor mass; ileal
transverse colostomy anastomosis (side to side).
Social History:
Married. Quit drinking alcohol. [**Doctor First Name **] tobacco and illicit drug
use. Not currently emplyed, but worked as an electrician. 2
Healthy children.
Family History:
Mother died of a brain tumor. Father diagnosed with prostate
cancer in his 70s and is still living. He has 3 siblings and 2
children without medical concerns. Maternal aunt with lymphoma.
Father and sister have had h/o "blood clots."
Physical Exam:
VS: T 98, BP 120/80, P 91, R 18, saO2 98 @ RA
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, tender in his right flank and RUQ area, +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: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL. sensation intact to LT, cerebellar fxn intact (FTN,
HTS). gait WNL.
Upon discharge:
T 97.8 120/70 75 16 96RA
GEN: NAD,
HEENT: sclera anicteric. no oral lesions.
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: CTAB
Abd: soft, NT, +BS. no rebound/guarding.
Extremities: no edema
Neuro: A&Ox3, 5/5 strength in lower extremities
Back: clean dressing in place, staples, non erythematous
Pertinent Results:
CT of abd ([**2111-9-22**])
1. The paraspinal mass which originates at the lytic lesion of
right 12th
rib, invades into the spinal canal, is more prominent as
compared to the prior studies. Spinal cord compression at the
level of D12, D11, and D10, mostly from the right side but
crossing anteriorly to the left at the level of D11. Findings
are consistent with spinal cord compression and can be further
evaluated by MRI.
2. The overall size of the paraspinal lesion is mildly
increased, as compared to the prior study.
3. The mass in the right lateral posterior abdominal wall
adjacent to the
liver now demonstrates small amount of air in it with possible
tract into
adjacent small bowel loop, suggesting a fistula.
4. Increase in size and number of numerous bilateral pulmonary
metastases and one of them in the right middle lobe with a
cavitation.
5. New small right pleural effusion.
CT L spine [**10-16**]:
IMPRESSION:
1. Extensive fluid surrounding the surgical bed, without
definite
organization or rim to suggest abscess formation.
2. Large, peripherally enhancing fluid collection centered in
the right
paraspinal location near the level of the liver. This is
concerning for a
paraspinal abscess. However, given the presence of a lesion near
this
location on a previous MRI, it is unclear if there is also a
component of
necrotic neoplastic disease. Correlation to prior studies, if
available,
would be helpful.
3. Small, rim-enhancing collection in the left paraspinal
musculature on the
left, also concerning for a paraspinal abscess.
4. Numerous pulmonary nodules, the largest of which are
described above.
.
[**2111-10-19**] 06:45AM BLOOD WBC-10.6 RBC-3.03* Hgb-8.5* Hct-26.7*
MCV-88 MCH-28.1 MCHC-32.0 RDW-16.7* Plt Ct-388
[**2111-10-2**] 05:15AM BLOOD WBC-5.8 RBC-4.08* Hgb-10.5* Hct-33.4*
MCV-82 MCH-25.7* MCHC-31.3 RDW-15.2 Plt Ct-281
[**2111-10-19**] 06:45AM BLOOD Neuts-87.5* Lymphs-6.0* Monos-4.7 Eos-1.6
Baso-0.3
[**2111-10-2**] 05:15AM BLOOD Neuts-74.7* Lymphs-12.5* Monos-9.6
Eos-2.8 Baso-0.2
[**2111-10-13**] 03:50AM BLOOD PT-14.1* PTT-25.5 INR(PT)-1.2*
[**2111-10-2**] 05:15AM BLOOD PT-13.0 PTT-25.2 INR(PT)-1.1
[**2111-10-18**] 06:10AM BLOOD Glucose-100 UreaN-10 Creat-0.9 Na-143
K-5.7* Cl-103 HCO3-32 AnGap-14
[**2111-10-2**] 05:15AM BLOOD Glucose-89 UreaN-10 Creat-1.0 Na-136
K-4.8 Cl-101 HCO3-31 AnGap-9
[**2111-10-11**] 01:03AM BLOOD ALT-10 AST-14 AlkPhos-94 Amylase-27
TotBili-0.3
[**2111-10-2**] 05:15AM BLOOD ALT-16 AST-19 AlkPhos-109 TotBili-0.3
[**2111-10-18**] 06:10AM BLOOD Calcium-9.6 Phos-4.3 Mg-2.2
[**2111-10-2**] 05:15AM BLOOD Albumin-3.5 Calcium-9.7 Phos-3.5 Mg-2.2
Brief Hospital Course:
47 yo male with renal cell cancer with intrahepatic and
paraspinal metastasis treated with stereotactic body
radiotherapy, completed on [**2111-8-5**], admitted for pain control
s/p T10-L2 fusion and removal of 12th vertebrae.
.
#Back/leg pain: Secondary to known spinal mets. Radiation
oncology and Neurosurgery were consulted and decided that a
surgical approach was best for his management. Pain was
controlled prior to surgery with fentanyl patch 400 mcg/hr,
hydromorphone 1-3 mg every 2-3 hrs IV prn, and gabapentin 300 mg
q8. Patient underwent surgical decompression on [**10-8**]-> he
underwent T12 transpedicular decompression and posterior fusion
T10 to L2 under general anesthesia. Had 1500cc EBL. During
procedure he was transfused with 2 units of PRBC and his POD#1
hematocrit was 32. Went to SICU post op and remained intubated
overnight as he required nasal intubation. He was extubated
POD#1 without difficulty. Given his long history of chronic
pain, the pain managment team was consulted and recommended a
ketamine drip for pain control and dilaudid IV as needed. They
continued to follow him post operatively and his ketamine drip
was dc'd on POD#4. His JP drain drain was DC'd on POD#4 without
difficulties. His HCT continued to trend down and on [**2111-10-12**] he
received 2 units of PRBC's for a HCT of 21.7. His hematocrits
remained stable for the rest of his hospital course. He was
transferred to the floor in stable condition although he
suffered [**2111-4-9**] back pain and intense headache. The pain team
continued to follow him on the floor and his pain regimen was
optimized. The IV dilaudid was changed to PO dilaudid and
slowly decreased as tolerated. He was started on methadone 5 mg
[**Hospital1 **] which was decreased to 2.5 mg [**Hospital1 **]. He was given IV caffeine
and benadryl for his headache with minimal improvement.
Indomethacin 25 mg tid in combination with the methadone seemed
to help his headache tremendously and he denied headache on day
of discharge. He will be discharged on fentanyl patch 400
mcg/hr q72 hrs, gabapentin 300 mg q8, indomethacin 25 mg tid,
tylenol 1000mg tid, methadone 2.5 mg [**Hospital1 **], and prn dilaudid [**3-23**]
mg po as needed for breakthrough pain. He should f/u with his
PCP, [**Name10 (NameIs) 5564**], and neurosurgery, and his pain regimen should
be adjusted and decreased as tolerated. Of note, a CT L-spine
[**10-16**] was read as concerning for possible paraspinal abscess.
This was not clinically correlated as the patient was afebrile
without leukocytosis. The neurosurgery team reviewed the CT
films and reported that the changes seen were most consistent
with post-op surgical changes rather than infection. He will be
seen as an outpatient by neurosurgery to follow-up.
.
#TSH: elevated at 5.5. No symptoms. [**Month (only) 116**] be elevated due to
general illness/hospital stay. Will not pursue further workup
at this time. Consider outpatient work-up after discharge.
Medications on Admission:
Transfer meds:
Duragesic patch 400mcg Q3 days
Lidoderm patch for 12 hours
ativan 1mg daily
Miralax 17g daily
Dilaudid 2-3 mg Q 2hours PRN
Flexeril 5mg tid
Ativan 1mg QHS
Zofran 2mg IV Q 6hours PRN
Home meds:
ativan prn
fentanyl for pain
Discharge Medications:
1. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
2. acetaminophen 650 mg/20.3 mL Solution Sig: 1000 (1000) mg PO
TID (3 times a day) as needed for fever or pain: Please do not
exceed 4 g in 24 hours.
Disp:*60 solution* Refills:*2*
3. gabapentin 250 mg/5 mL Solution Sig: Three Hundred (300) mg
PO Q8H (every 8 hours).
Disp:*100 ml* Refills:*2*
4. indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
5. fentanyl 100 mcg/hr Patch 72 hr Sig: Four (4) Patch 72 hr
Transdermal Q72H (every 72 hours): Please do not combine with
alcohol or drive while taking this medication.
Disp:*40 Patch 72 hr(s)* Refills:*2*
6. hydromorphone 4 mg Tablet Sig: 1-4 Tablets PO Q3H (every 3
hours) as needed for pain: Please do not combine with alcohol or
drive while taking this medication.
Disp:*30 Tablet(s)* Refills:*2*
7. methadone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day):
Please do not combine with alcohol or drive while taking this
medication.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**University/College **]
Discharge Diagnosis:
Epidural spinal cord compression from T 12 Spinal metastasis
Metastatic renal cell cancer
Severe postoperative headache ? dural tear with subsequenc
spinal fluid leak
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 73639**],
It was a pleasure participating in your health care. You were
admitted to [**Hospital1 69**] for pain
control. Your pain was managed with a fentanyl patch,
intravenous dilaudid, and gabapentin prior to your operation.
After surgery, your pain was controlled with a fentanyl patch,
oral dilaudid, gabapentin, indomethacin, tylenol, and methadone.
Please make the following changes to your medications:
STOP flexeril 5mg three times daily
START Fentanyl patch 400 mcg/hr every 72 hours
START Gabapentin 300 mg every 8 hours
START Indomethacin 25 mg three times a day
START Methadone 2.5 m twice a day
START HYDROmorphone (Dilaudid) 4-8 mg every 3 hours as needed
for uncontrolled pain.
START Acetaminophen (Tylenol) 1000 mg three times a day
Please work with your physician to reduce the amount of pain
medications that you are taking as your pain improves.
Please continue your other home medications.
In addition, please follow the instructions below:
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in
follow up/ begin daily showers [**2111-10-12**]
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for
signs of infection
?????? Take pain medication as instructed above;
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
?????? Clearance to drive and return to work will be addressed
at your post-operative office visit
Followup Instructions:
The following appointments have been made for you:
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2111-10-14**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], 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
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2111-10-14**] at 4:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6575**], 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
* PLEASE RETURN TO Dr[**Name (NI) 2845**] OFFICE IN [**4-13**] DAYS FOR REMOVAL OF
YOUR STAPLES/SUTURE(CLINIC DAYS TUES OR FRI). PLEASE CALL
[**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT.
* PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.YOU WILL NEED XRAYS PRIOR TO THIS
APPOINTMENT
* Please arrange an appointment with your primary care physician
[**Name9 (PRE) **] [**Last Name (NamePattern4) 73647**],MD for 2-3 weeks after discharge. Please call
[**Telephone/Fax (1) 73645**] to arrange an appointment.
Name: [**Known lastname 12204**],[**Known firstname **] Unit No: [**Numeric Identifier 12205**]
Admission Date: [**2111-10-1**] Discharge Date: [**2111-10-19**]
Date of Birth: [**2064-2-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12206**]
Addendum:
Allergies
Patient recorded as having No Known Allergies to Drugs
Attending
[**Last Name (LF) **],[**First Name3 (LF) **] M.F.
Service
MEDICINE
Chief Complaint
back pain
Major Surgical or Invasive Procedure
T12 transpedicular decompression and posterior instrumented
fusion T10 to L2
History of Present Illness
47 yo male with renal cell cancer with intrahepatic and
paraspinal metastasis treated with stereotactic body
radiotherapy, completed on [**2111-8-5**], who is admitted
for pain control. He was doing well after completion of
radiotherapy but within a few weeks developed severe left leg
pain as well as muscular spasms and areas of numbness. Since
this weekend, he has developed severe left leg and back pain.
However, he denied fecal or urinary incontinence and focalized
weakness.
Because of the pain, on [**2111-9-28**], pt was admitted to local
hospital where he received pain medications and MRI under
anesthesia because of inability to lie flat. The MRI revealed "
a large mass over the right renal fossa extending to the
paraspinal muscle and also there was a tumor involving the
thoracic 11 and thoracic 12 vertebral body extending into the
spinal canal, cord compression, and also a tumor involving the
paraspinous muscle. Possible metastatic lesion of cervical 2
vertebral body with possible cord compression.
After discussing with his own [**Date Range 12207**] in [**Hospital1 8**], he was
transferred to here for further management.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies
cough, shortness of breath, or wheezes. Denies nausea, vomiting,
diarrhea, constipation. He admitted right side abd pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rashes or skin breakdown. No
numbness/tingling in extremities. No feelings of depression or
anxiety. All other review of systems negative.
Past Medical History
ONCOLOGIC HISTORY:
1. Partial right nephrectomy in [**1-/2107**] after the patient
presented with hematuria and flank pain to [**Hospital1 **]
Hospital and was found on CT scan to have a 5.1 x 5.8 right
renal mass.
2. Resection of recurrent renal cell carcinoma in the right
subcostal region and rib in 11/[**2106**]. The pathology of the
resected tumor was consistent with the previously resected clear
cell primary.
3. Posterior cervical fusion, occiput to C5 and left-sided C2
laminectomy and decompression in [**4-/2108**] because of the finding
on MRI of a 2.5 x 3.2 cm destructive soft tissue mass. This mass
had replaced the left side of the C2 vertebral body and extended
into the pedicle and neural foramen on the left at the C2-C3
level.
4. Postoperative radiation therapy to the cervical spine.
5. One cycle of IL-2 as part of the IL-2 select trial in
08/[**2107**].
6. Hospitalization in [**9-/2108**] for hypercalcemia.
7. Enrolled in sorafenib/bevacizumab phase II trial on
[**2108-11-14**] - discontinued as of [**2109-1-4**] with development of
colonic perforation.
8. Readmitted to [**2109-1-10**] with contrast nephropathy. Status
post diverting ileostomy on [**2108-1-17**].
9. Begin Sutent 37.5 mg on [**2109-3-31**]. Stopped Sutent on [**1-/2110**]
(tired of taking it).
10. Consideration for the RAD-001 biomarker trial. The patient,
however, had a nondiagnostic tumor biopsy, and was therefore
ineligible.
11. Resection of right retroperitoneal tumor, right colectomy,
partial liver resection, and ileal transverse colostomy
anastomosis on [**2110-11-14**] for recurrent renal cell carcinoma in
previous right nephrectomy bed with involvement of the liver,
right colon and right psoas muscle.
12. [**2111-4-20**] started PKI-587 (PI3K/mTOR inhibitor) on protocol
09-215
13. [**2111-6-15**] taken off protocol 09-215 because of disease
progression including T11-T12 paraspinal lesion invading spinal
canal
14. [**2111-7-2**] last zometa
15. [**Date range (3) 12208**] SRS to right infrahepatic metastasis;
[**Date range (2) 12209**] SRS to paraspinal metastasis
PAST MEDICAL HISTORY:
- Renal Cell Carcinoma (please see below)
- h/o RLE DVT [**8-/2107**]
- Colonic perforation
- Hyponatremia
- Anemia
- Cervical surgery with rod-placement due to C2 met
-[**2110-11-14**] Right colectomy, Segment VI partial liver
resection, resection of retroperitoneal tumor mass; ileal
transverse colostomy anastomosis (side to side).
Social History
Married. Quit drinking alcohol. [**Doctor First Name **] tobacco and illicit drug
use. Not currently emplyed, but worked as an electrician. 2
Healthy children.
Family History
Mother died of a brain tumor. Father diagnosed with prostate
cancer in his 70s and is still living. He has 3 siblings and 2
children without medical concerns. Maternal aunt with lymphoma.
Father and sister have had h/o "blood clots."
Physical Exam
VS: T 98, BP 120/80, P 91, R 18, saO2 98 @ RA
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, tender in his right flank and RUQ area, +BS. no
rebound/guarding. neg HSM. neg [**Doctor Last Name **] sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL. sensation intact to LT, cerebellar fxn intact (FTN,
HTS). gait WNL.
Upon discharge:
T 97.8 120/70 75 16 96RA
GEN: NAD,
HEENT: sclera anicteric. no oral lesions.
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: CTAB
Abd: soft, NT, +BS. no rebound/guarding.
Extremities: no edema
Neuro: A&Ox3, 5/5 strength in lower extremities
Back: clean dressing in place, staples, non erythematous
Pertinent Results
CT of abd ([**2111-9-22**])
1. The paraspinal mass which originates at the lytic lesion of
right 12th
rib, invades into the spinal canal, is more prominent as
compared to the prior studies. Spinal cord compression at the
level of D12, D11, and D10, mostly from the right side but
crossing anteriorly to the left at the level of D11. Findings
are consistent with spinal cord compression and can be further
evaluated by MRI.
2. The overall size of the paraspinal lesion is mildly
increased, as compared to the prior study.
3. The mass in the right lateral posterior abdominal wall
adjacent to the
liver now demonstrates small amount of air in it with possible
tract into
adjacent small bowel loop, suggesting a fistula.
4. Increase in size and number of numerous bilateral pulmonary
metastases and one of them in the right middle lobe with a
cavitation.
5. New small right pleural effusion.
CT L spine [**10-16**]:
IMPRESSION:
1. Extensive fluid surrounding the surgical bed, without
definite
organization or rim to suggest abscess formation.
2. Large, peripherally enhancing fluid collection centered in
the right
paraspinal location near the level of the liver. This is
concerning for a
paraspinal abscess. However, given the presence of a lesion near
this
location on a previous MRI, it is unclear if there is also a
component of
necrotic neoplastic disease. Correlation to prior studies, if
available,
would be helpful.
3. Small, rim-enhancing collection in the left paraspinal
musculature on the
left, also concerning for a paraspinal abscess.
4. Numerous pulmonary nodules, the largest of which are
described above.
.
[**2111-10-19**] 06:45AM BLOOD WBC-10.6 RBC-3.03* Hgb-8.5* Hct-26.7*
MCV-88 MCH-28.1 MCHC-32.0 RDW-16.7* Plt Ct-388
[**2111-10-2**] 05:15AM BLOOD WBC-5.8 RBC-4.08* Hgb-10.5* Hct-33.4*
MCV-82 MCH-25.7* MCHC-31.3 RDW-15.2 Plt Ct-281
[**2111-10-19**] 06:45AM BLOOD Neuts-87.5* Lymphs-6.0* Monos-4.7 Eos-1.6
Baso-0.3
[**2111-10-2**] 05:15AM BLOOD Neuts-74.7* Lymphs-12.5* Monos-9.6
Eos-2.8 Baso-0.2
[**2111-10-13**] 03:50AM BLOOD PT-14.1* PTT-25.5 INR(PT)-1.2*
[**2111-10-2**] 05:15AM BLOOD PT-13.0 PTT-25.2 INR(PT)-1.1
[**2111-10-18**] 06:10AM BLOOD Glucose-100 UreaN-10 Creat-0.9 Na-143
K-5.7* Cl-103 HCO3-32 AnGap-14
[**2111-10-2**] 05:15AM BLOOD Glucose-89 UreaN-10 Creat-1.0 Na-136
K-4.8 Cl-101 HCO3-31 AnGap-9
[**2111-10-11**] 01:03AM BLOOD ALT-10 AST-14 AlkPhos-94 Amylase-27
TotBili-0.3
[**2111-10-2**] 05:15AM BLOOD ALT-16 AST-19 AlkPhos-109 TotBili-0.3
[**2111-10-18**] 06:10AM BLOOD Calcium-9.6 Phos-4.3 Mg-2.2
[**2111-10-2**] 05:15AM BLOOD Albumin-3.5 Calcium-9.7 Phos-3.5 Mg-2.2
Brief Hospital Course
47 yo male with renal cell cancer with intrahepatic and
paraspinal metastasis treated with stereotactic body
radiotherapy, completed on [**2111-8-5**], admitted for pain control
s/p T10-L2 fusion and removal of 12th vertebrae.
.
#Back/leg pain secondary to known spinal mets and cord
compression seen on imaging without neurological deficits:
Radiation oncology and Neurosurgery were consulted and decided
that a
surgical approach was best for his management. Pain was
controlled prior to surgery with fentanyl patch 400 mcg/hr,
hydromorphone 1-3 mg every 2-3 hrs IV prn, and gabapentin 300 mg
q8. Patient underwent surgical decompression on [**10-8**]-> he
underwent T12 transpedicular decompression and posterior fusion
T10 to L2 under general anesthesia. Had 1500cc EBL. During
procedure he was transfused with 2 units of PRBC and his POD#1
hematocrit was 32. Went to SICU post op and remained intubated
overnight as he required nasal intubation. He was extubated
POD#1 without difficulty. Given his long history of chronic
pain, the pain managment team was consulted and recommended a
ketamine drip for pain control and dilaudid IV as needed. They
continued to follow him post operatively and his ketamine drip
was dc'd on POD#4. His JP drain drain was DC'd on POD#4 without
difficulties. His HCT continued to trend down and on [**2111-10-12**] he
received 2 units of PRBC's for a HCT of 21.7. His hematocrits
remained stable for the rest of his hospital course. He was
transferred to the floor in stable condition although he
suffered [**2111-4-9**] back pain and intense headache. The pain team
continued to follow him on the floor and his pain regimen was
optimized. The IV dilaudid was changed to PO dilaudid and
slowly decreased as tolerated. He was started on methadone 5 mg
[**Hospital1 **] which was decreased to 2.5 mg [**Hospital1 **]. He was given IV caffeine
and benadryl for his headache with minimal improvement.
Indomethacin 25 mg tid in combination with the methadone seemed
to help his headache tremendously and he denied headache on day
of discharge. He will be discharged on fentanyl patch 400
mcg/hr q72 hrs, gabapentin 300 mg q8, indomethacin 25 mg tid,
tylenol 1000mg tid, methadone 2.5 mg [**Hospital1 **], and prn dilaudid [**3-23**]
mg po as needed for breakthrough pain. He should f/u with his
PCP, [**Name10 (NameIs) 12207**], and neurosurgery, and his pain regimen should
be adjusted and decreased as tolerated. Of note, a CT L-spine
[**10-16**] was read as concerning for possible paraspinal abscess.
This was not clinically correlated as the patient was afebrile
without leukocytosis. The neurosurgery team reviewed the CT
films and reported that the changes seen were most consistent
with post-op surgical changes rather than infection. He will be
seen as an outpatient by neurosurgery to follow-up.
.
#asymptomatic elevated TSH: elevated at 5.5. No symptoms. [**Month (only) 412**]
be elevated due to
general illness/hospital stay. Will not pursue further workup
at this time. Consider outpatient work-up after discharge.
Medications on Admission
Transfer meds:
Duragesic patch 400mcg Q3 days
Lidoderm patch for 12 hours
ativan 1mg daily
Miralax 17g daily
Dilaudid 2-3 mg Q 2hours PRN
Flexeril 5mg tid
Ativan 1mg QHS
Zofran 2mg IV Q 6hours PRN
Home meds:
ativan prn
fentanyl for pain
Discharge Medications
1. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
2. acetaminophen 650 mg/20.3 mL Solution Sig: 1000 (1000) mg PO
TID (3 times a day) as needed for fever or pain: Please do not
exceed 4 g in 24 hours.
Disp:*60 solution* Refills:*2*
3. gabapentin 250 mg/5 mL Solution Sig: Three Hundred (300) mg
PO Q8H (every 8 hours).
Disp:*100 ml* Refills:*2*
4. indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
5. fentanyl 100 mcg/hr Patch 72 hr Sig: Four (4) Patch 72 hr
Transdermal Q72H (every 72 hours): Please do not combine with
alcohol or drive while taking this medication.
Disp:*40 Patch 72 hr(s)* Refills:*2*
6. hydromorphone 4 mg Tablet Sig: 1-4 Tablets PO Q3H (every 3
hours) as needed for pain: Please do not combine with alcohol or
drive while taking this medication.
Disp:*30 Tablet(s)* Refills:*2*
7. methadone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day):
Please do not combine with alcohol or drive while taking this
medication.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition
Home with Service
Discharge Diagnosis
T 12 Spinal metastasis
epidural spinal cord compression seen on imaging with no
neurological deficits
metastatic renal cell carcinoma, mets to spine, liver, and with
pulmonary nodules
back/leg pain
elevated TSH, asymptomatic
Discharge Condition
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions
Dear Mr. [**Known lastname **],
It was a pleasure participating in your health care. You were
admitted to [**Hospital1 536**] for pain
control. Your pain was managed with a fentanyl patch,
intravenous dilaudid, and gabapentin prior to your operation.
After surgery, your pain was controlled with a fentanyl patch,
oral dilaudid, gabapentin, indomethacin, tylenol, and methadone.
Please make the following changes to your medications:
STOP flexeril 5mg three times daily
START Fentanyl patch 400 mcg/hr every 72 hours
START Gabapentin 300 mg every 8 hours
START Indomethacin 25 mg three times a day
START Methadone 2.5 m twice a day
START HYDROmorphone (Dilaudid) 4-8 mg every 3 hours as needed
for uncontrolled pain.
START Acetaminophen (Tylenol) 1000 mg three times a day
Please work with your physician to reduce the amount of pain
medications that you are taking as your pain improves.
Please continue your other home medications.
In addition, please follow the instructions below:
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in
follow up/ begin daily showers [**2111-10-12**]
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for
signs of infection
?????? Take pain medication as instructed above;
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
?????? Clearance to drive and return to work will be addressed
at your post-operative office visit
Followup Instructions
The following appointments have been made for you:
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2111-10-14**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5637**], MD [**Telephone/Fax (1) 1578**]
Building: SC [**Hospital Ward Name **] Clinical Ctr [**Location (un) 1579**]
Campus: EAST Best Parking: [**Hospital Ward Name **] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2111-10-14**] at 4:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12210**], MD [**Telephone/Fax (1) 1578**]
Building: SC [**Hospital Ward Name **] Clinical Ctr [**Location (un) 1579**]
Campus: EAST Best Parking: [**Hospital Ward Name **] Garage
* PLEASE RETURN TO Dr[**Name (NI) 12211**] OFFICE IN [**4-13**] DAYS FOR REMOVAL OF
YOUR STAPLES/SUTURE(CLINIC DAYS TUES OR FRI). PLEASE CALL
[**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT.
* PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Doctor Last Name **] TO BE SEEN IN 6 WEEKS.YOU WILL NEED XRAYS PRIOR TO THIS
APPOINTMENT
* Please arrange an appointment with your primary care physician
[**Doctor Last Name **] [**Last Name (NamePattern4) 12212**],MD for 2-3 weeks after discharge. Please call
[**Telephone/Fax (1) 12213**] to arrange an appointment.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
T12 transpedicular decompression and posterior instrumented
fusion T10 to L2
History of Present Illness:
47 yo male with renal cell cancer with intrahepatic and
paraspinal metastasis treated with stereotactic body
radiotherapy, completed on [**2111-8-5**], who is admitted
for pain control. He was doing well after completion of
radiotherapy but within a few weeks developed severe left leg
pain as well as muscular spasms and areas of numbness. Since
this weekend, he has developed severe left leg and back pain.
However, he denied fecal or urinary incontinence and focalized
weakness.
Because of the pain, on [**2111-9-28**], pt was admitted to local
hospital where he received pain medications and MRI under
anesthesia because of inability to lie flat. The MRI revealed "
a large mass over the right renal fossa extending to the
paraspinal muscle and also there was a tumor involving the
thoracic 11 and thoracic 12 vertebral body extending into the
spinal canal, cord compression, and also a tumor involving the
paraspinous muscle. Possible metastatic lesion of cervical 2
vertebral body with possible cord compression.
After discussing with his own [**Date Range 12207**] in [**Hospital1 8**], he was
transferred to here for further management.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies
cough, shortness of breath, or wheezes. Denies nausea, vomiting,
diarrhea, constipation. He admitted right side abd pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rashes or skin breakdown. No
numbness/tingling in extremities. No feelings of depression or
anxiety. All other review of systems negative.
Past Medical History:
ONCOLOGIC HISTORY:
1. Partial right nephrectomy in [**1-/2107**] after the patient
presented with hematuria and flank pain to [**Hospital1 12214**] and was found on CT scan to have a 5.1 x 5.8 right
renal mass.
2. Resection of recurrent renal cell carcinoma in the right
subcostal region and rib in 11/[**2106**]. The pathology of the
resected tumor was consistent with the previously resected clear
cell primary.
3. Posterior cervical fusion, occiput to C5 and left-sided C2
laminectomy and decompression in [**4-/2108**] because of the finding
on MRI of a 2.5 x 3.2 cm destructive soft tissue mass. This mass
had replaced the left side of the C2 vertebral body and extended
into the pedicle and neural foramen on the left at the C2-C3
level.
4. Postoperative radiation therapy to the cervical spine.
5. One cycle of IL-2 as part of the IL-2 select trial in
08/[**2107**].
6. Hospitalization in [**9-/2108**] for hypercalcemia.
7. Enrolled in sorafenib/bevacizumab phase II trial on
[**2108-11-14**] - discontinued as of [**2109-1-4**] with development of
colonic perforation.
8. Readmitted to [**2109-1-10**] with contrast nephropathy. Status
post diverting ileostomy on [**2108-1-17**].
9. Begin Sutent 37.5 mg on [**2109-3-31**]. Stopped Sutent on [**1-/2110**]
(tired of taking it).
10. Consideration for the RAD-001 biomarker trial. The patient,
however, had a nondiagnostic tumor biopsy, and was therefore
ineligible.
11. Resection of right retroperitoneal tumor, right colectomy,
partial liver resection, and ileal transverse colostomy
anastomosis on [**2110-11-14**] for recurrent renal cell carcinoma in
previous right nephrectomy bed with involvement of the liver,
right colon and right psoas muscle.
12. [**2111-4-20**] started PKI-587 (PI3K/mTOR inhibitor) on protocol
09-215
13. [**2111-6-15**] taken off protocol 09-215 because of disease
progression including T11-T12 paraspinal lesion invading spinal
canal
14. [**2111-7-2**] last zometa
15. [**Date range (3) 12208**] SRS to right infrahepatic metastasis;
[**Date range (2) 12209**] SRS to paraspinal metastasis
PAST MEDICAL HISTORY:
- Renal Cell Carcinoma (please see below)
- h/o RLE DVT [**8-/2107**]
- Colonic perforation
- Hyponatremia
- Anemia
- Cervical surgery with rod-placement due to C2 met
-[**2110-11-14**] Right colectomy, Segment VI partial liver
resection, resection of retroperitoneal tumor mass; ileal
transverse colostomy anastomosis (side to side).
Social History:
Married. Quit drinking alcohol. [**Doctor First Name **] tobacco and illicit drug
use. Not currently emplyed, but worked as an electrician. 2
Healthy children.
Family History:
Mother died of a brain tumor. Father diagnosed with prostate
cancer in his 70s and is still living. He has 3 siblings and 2
children without medical concerns. Maternal aunt with lymphoma.
Father and sister have had h/o "blood clots."
Physical Exam:
VS: T 98, BP 120/80, P 91, R 18, saO2 98 @ RA
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, tender in his right flank and RUQ area, +BS. no
rebound/guarding. neg HSM. neg [**Doctor Last Name **] sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL. sensation intact to LT, cerebellar fxn intact (FTN,
HTS). gait WNL.
Upon discharge:
T 97.8 120/70 75 16 96RA
GEN: NAD,
HEENT: sclera anicteric. no oral lesions.
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: CTAB
Abd: soft, NT, +BS. no rebound/guarding.
Extremities: no edema
Neuro: A&Ox3, 5/5 strength in lower extremities
Back: clean dressing in place, staples, non erythematous
Pertinent Results:
CT of abd ([**2111-9-22**])
1. The paraspinal mass which originates at the lytic lesion of
right 12th
rib, invades into the spinal canal, is more prominent as
compared to the prior studies. Spinal cord compression at the
level of D12, D11, and D10, mostly from the right side but
crossing anteriorly to the left at the level of D11. Findings
are consistent with spinal cord compression and can be further
evaluated by MRI.
2. The overall size of the paraspinal lesion is mildly
increased, as compared to the prior study.
3. The mass in the right lateral posterior abdominal wall
adjacent to the
liver now demonstrates small amount of air in it with possible
tract into
adjacent small bowel loop, suggesting a fistula.
4. Increase in size and number of numerous bilateral pulmonary
metastases and one of them in the right middle lobe with a
cavitation.
5. New small right pleural effusion.
CT L spine [**10-16**]:
IMPRESSION:
1. Extensive fluid surrounding the surgical bed, without
definite
organization or rim to suggest abscess formation.
2. Large, peripherally enhancing fluid collection centered in
the right
paraspinal location near the level of the liver. This is
concerning for a
paraspinal abscess. However, given the presence of a lesion near
this
location on a previous MRI, it is unclear if there is also a
component of
necrotic neoplastic disease. Correlation to prior studies, if
available,
would be helpful.
3. Small, rim-enhancing collection in the left paraspinal
musculature on the
left, also concerning for a paraspinal abscess.
4. Numerous pulmonary nodules, the largest of which are
described above.
.
[**2111-10-19**] 06:45AM BLOOD WBC-10.6 RBC-3.03* Hgb-8.5* Hct-26.7*
MCV-88 MCH-28.1 MCHC-32.0 RDW-16.7* Plt Ct-388
[**2111-10-2**] 05:15AM BLOOD WBC-5.8 RBC-4.08* Hgb-10.5* Hct-33.4*
MCV-82 MCH-25.7* MCHC-31.3 RDW-15.2 Plt Ct-281
[**2111-10-19**] 06:45AM BLOOD Neuts-87.5* Lymphs-6.0* Monos-4.7 Eos-1.6
Baso-0.3
[**2111-10-2**] 05:15AM BLOOD Neuts-74.7* Lymphs-12.5* Monos-9.6
Eos-2.8 Baso-0.2
[**2111-10-13**] 03:50AM BLOOD PT-14.1* PTT-25.5 INR(PT)-1.2*
[**2111-10-2**] 05:15AM BLOOD PT-13.0 PTT-25.2 INR(PT)-1.1
[**2111-10-18**] 06:10AM BLOOD Glucose-100 UreaN-10 Creat-0.9 Na-143
K-5.7* Cl-103 HCO3-32 AnGap-14
[**2111-10-2**] 05:15AM BLOOD Glucose-89 UreaN-10 Creat-1.0 Na-136
K-4.8 Cl-101 HCO3-31 AnGap-9
[**2111-10-11**] 01:03AM BLOOD ALT-10 AST-14 AlkPhos-94 Amylase-27
TotBili-0.3
[**2111-10-2**] 05:15AM BLOOD ALT-16 AST-19 AlkPhos-109 TotBili-0.3
[**2111-10-18**] 06:10AM BLOOD Calcium-9.6 Phos-4.3 Mg-2.2
[**2111-10-2**] 05:15AM BLOOD Albumin-3.5 Calcium-9.7 Phos-3.5 Mg-2.2
Brief Hospital Course:
47 yo male with renal cell cancer with intrahepatic and
paraspinal metastasis treated with stereotactic body
radiotherapy, completed on [**2111-8-5**], admitted for pain control
s/p T10-L2 fusion and removal of 12th vertebrae.
.
#Back/leg pain secondary to known spinal mets and cord
compression seen on imaging without neurological deficits:
Radiation oncology and Neurosurgery were consulted and decided
that a
surgical approach was best for his management. Pain was
controlled prior to surgery with fentanyl patch 400 mcg/hr,
hydromorphone 1-3 mg every 2-3 hrs IV prn, and gabapentin 300 mg
q8. Patient underwent surgical decompression on [**10-8**]-> he
underwent T12 transpedicular decompression and posterior fusion
T10 to L2 under general anesthesia. Had 1500cc EBL. During
procedure he was transfused with 2 units of PRBC and his POD#1
hematocrit was 32. Went to SICU post op and remained intubated
overnight as he required nasal intubation. He was extubated
POD#1 without difficulty. Given his long history of chronic
pain, the pain managment team was consulted and recommended a
ketamine drip for pain control and dilaudid IV as needed. They
continued to follow him post operatively and his ketamine drip
was dc'd on POD#4. His JP drain drain was DC'd on POD#4 without
difficulties. His HCT continued to trend down and on [**2111-10-12**] he
received 2 units of PRBC's for a HCT of 21.7. His hematocrits
remained stable for the rest of his hospital course. He was
transferred to the floor in stable condition although he
suffered [**2111-4-9**] back pain and intense headache. The pain team
continued to follow him on the floor and his pain regimen was
optimized. The IV dilaudid was changed to PO dilaudid and
slowly decreased as tolerated. He was started on methadone 5 mg
[**Hospital1 **] which was decreased to 2.5 mg [**Hospital1 **]. He was given IV caffeine
and benadryl for his headache with minimal improvement.
Indomethacin 25 mg tid in combination with the methadone seemed
to help his headache tremendously and he denied headache on day
of discharge. He will be discharged on fentanyl patch 400
mcg/hr q72 hrs, gabapentin 300 mg q8, indomethacin 25 mg tid,
tylenol 1000mg tid, methadone 2.5 mg [**Hospital1 **], and prn dilaudid [**3-23**]
mg po as needed for breakthrough pain. He should f/u with his
PCP, [**Name10 (NameIs) 12207**], and neurosurgery, and his pain regimen should
be adjusted and decreased as tolerated. Of note, a CT L-spine
[**10-16**] was read as concerning for possible paraspinal abscess.
This was not clinically correlated as the patient was afebrile
without leukocytosis. The neurosurgery team reviewed the CT
films and reported that the changes seen were most consistent
with post-op surgical changes rather than infection. He will be
seen as an outpatient by neurosurgery to follow-up.
.
#asymptomatic elevated TSH: elevated at 5.5. No symptoms. [**Month (only) 412**]
be elevated due to
general illness/hospital stay. Will not pursue further workup
at this time. Consider outpatient work-up after discharge.
Medications on Admission:
Transfer meds:
Duragesic patch 400mcg Q3 days
Lidoderm patch for 12 hours
ativan 1mg daily
Miralax 17g daily
Dilaudid 2-3 mg Q 2hours PRN
Flexeril 5mg tid
Ativan 1mg QHS
Zofran 2mg IV Q 6hours PRN
Home meds:
ativan prn
fentanyl for pain
Discharge Medications:
1. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
2. acetaminophen 650 mg/20.3 mL Solution Sig: 1000 (1000) mg PO
TID (3 times a day) as needed for fever or pain: Please do not
exceed 4 g in 24 hours.
Disp:*60 solution* Refills:*2*
3. gabapentin 250 mg/5 mL Solution Sig: Three Hundred (300) mg
PO Q8H (every 8 hours).
Disp:*100 ml* Refills:*2*
4. indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
5. fentanyl 100 mcg/hr Patch 72 hr Sig: Four (4) Patch 72 hr
Transdermal Q72H (every 72 hours): Please do not combine with
alcohol or drive while taking this medication.
Disp:*40 Patch 72 hr(s)* Refills:*2*
6. hydromorphone 4 mg Tablet Sig: 1-4 Tablets PO Q3H (every 3
hours) as needed for pain: Please do not combine with alcohol or
drive while taking this medication.
Disp:*30 Tablet(s)* Refills:*2*
7. methadone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day):
Please do not combine with alcohol or drive while taking this
medication.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**University/College 12215**]
Discharge Diagnosis:
T 12 Spinal metastasis
epidural spinal cord compression seen on imaging with no
neurological deficits
metastatic renal cell carcinoma, mets to spine, liver, and with
pulmonary nodules
back/leg pain
elevated TSH, asymptomatic
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure participating in your health care. You were
admitted to [**Hospital1 536**] for pain
control. Your pain was managed with a fentanyl patch,
intravenous dilaudid, and gabapentin prior to your operation.
After surgery, your pain was controlled with a fentanyl patch,
oral dilaudid, gabapentin, indomethacin, tylenol, and methadone.
Please make the following changes to your medications:
STOP flexeril 5mg three times daily
START Fentanyl patch 400 mcg/hr every 72 hours
START Gabapentin 300 mg every 8 hours
START Indomethacin 25 mg three times a day
START Methadone 2.5 m twice a day
START HYDROmorphone (Dilaudid) 4-8 mg every 3 hours as needed
for uncontrolled pain.
START Acetaminophen (Tylenol) 1000 mg three times a day
Please work with your physician to reduce the amount of pain
medications that you are taking as your pain improves.
Please continue your other home medications.
In addition, please follow the instructions below:
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in
follow up/ begin daily showers [**2111-10-12**]
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for
signs of infection
?????? Take pain medication as instructed above;
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
?????? Clearance to drive and return to work will be addressed
at your post-operative office visit
Followup Instructions:
The following appointments have been made for you:
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2111-10-14**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5637**], MD [**Telephone/Fax (1) 1578**]
Building: SC [**Hospital Ward Name **] Clinical Ctr [**Location (un) 1579**]
Campus: EAST Best Parking: [**Hospital Ward Name **] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2111-10-14**] at 4:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12210**], MD [**Telephone/Fax (1) 1578**]
Building: SC [**Hospital Ward Name **] Clinical Ctr [**Location (un) 1579**]
Campus: EAST Best Parking: [**Hospital Ward Name **] Garage
* PLEASE RETURN TO Dr[**Name (NI) 12211**] OFFICE IN [**4-13**] DAYS FOR REMOVAL OF
YOUR STAPLES/SUTURE(CLINIC DAYS TUES OR FRI). PLEASE CALL
[**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT.
* PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.YOU WILL NEED XRAYS PRIOR TO THIS
APPOINTMENT
* Please arrange an appointment with your primary care physician
[**Name9 (PRE) **] [**Last Name (NamePattern4) 12212**],MD for 2-3 weeks after discharge. Please call
[**Telephone/Fax (1) 12213**] to arrange an appointment.
[**Doctor First Name **] [**Last Name (NamePattern5) 12216**] MD [**MD Number(2) 12217**]
Completed by:[**2111-10-21**]
|
[
"338.3",
"V15.3",
"V10.51",
"V10.52",
"197.0",
"338.18",
"V10.05",
"285.1",
"198.89",
"997.09",
"V45.4",
"564.09",
"197.7",
"336.3",
"288.60",
"198.5",
"V12.51",
"V87.41",
"276.8",
"E878.1",
"V45.72",
"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.51",
"81.05",
"81.07",
"81.63"
] |
icd9pcs
|
[
[
[]
]
] |
46654, 46737
|
42190, 45276
|
33901, 33980
|
47005, 47005
|
39549, 42167
|
48820, 50272
|
38394, 38629
|
45565, 46631
|
46758, 46984
|
45302, 45542
|
47156, 47564
|
38644, 39204
|
47593, 48797
|
35181, 35737
|
33851, 33863
|
39220, 39530
|
34008, 35162
|
47020, 47132
|
37863, 38200
|
38216, 38378
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,813
| 149,311
|
43690
|
Discharge summary
|
report
|
Admission Date: [**2116-12-6**] Discharge Date: [**2116-12-13**]
Date of Birth: [**2044-6-19**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Amiodarone / Betapace / Heparin Agents
Attending:[**First Name3 (LF) 11261**]
Chief Complaint:
admit for pre-op for total knee replacement
Major Surgical or Invasive Procedure:
left total knee arthroplasty
History of Present Illness:
HPI: This is a 72y/o male with extensive cardiac history who
presents today for pre-op for L total knee replacement. The
patient states that he injured his knee approx 3yrs ago while
walking his dog. He tripped and fell on the street and tore his
meniscus. At the onset of injury, the patient was receiving
Cortisone injections. He had a total of 3 with no relief.
.
The patient reports that he experiences pain when he walks a
block and a half and when he's sleeping at night. The pain is a
dull-ache. The patient takes Tyelenol Arthritis intermittently
without any alleviation of his symptoms.
.
Of note the patient has a history of flash PE, CHF, afib, VT
(s/p ICD replacement). He's been in rehab. Unfortunately his
cardiac rehab has been limited by the pain in his L knee. He
presents for elective L knee replacement.
Past Medical History:
1. Chronic atrial fibrillation status post cardioversion.
2. Congestive heart failure with cardiomyopathy.
3. Hypercholesterolemia.
4. Noninsulin-dependent diabetes mellitus.
5. History of thyroid surgery in [**2109**].
6. Colon cancer status post resection [**2109**].
7. History of Bell's palsy.
8. Status post appendectomy.
9. Status post tonsillectomy.
10. s/p ICD replacement in [**2116-3-10**] (b/c orginal [**Company **] PM
faulty) and subsequent started on dofetilte tx (originally
placed in [**2114**])
11. CABG [**2114**]
Social History:
120 pack year smoker, quit smoking 20 years ago.
Family History:
non-contributory
Physical Exam:
VS T96.4, BP 130/70, HR64, R20, O2sat 97% RA
Gen: NAD, sitting in bed talking with family
HEENT: MMM, OP clear, 7cm JVP, -bruits
Heart: nl rate, skipped beats, II/VI systolic murmur along LUSB
Chest: midline surgical scar
Pulm: midline surgical scar
Abdomen: benign
Ext: no c/c/e, 2+pt, 2+dp b/l
Groin: 2+femoral pulses b/l, no bruit
Neuro: II-XII grossly intact;good flexion and extension of knees
bilaterally, non-erythematous, no floctulence
Pertinent Results:
P-Mibi [**11-14**]:
IMPRESSION: Moderate fixed defect in the posterior portion of
the septum with global hypokinesis and a depressed ejection
fraction of 47%.
[**2116-12-6**] 07:00PM WBC-8.5 RBC-4.37*# HGB-12.7*# HCT-35.4*#
MCV-81*# MCH-29.0 MCHC-35.9*# RDW-14.5
[**2116-12-6**] 07:00PM PLT COUNT-140*
[**2116-12-6**] 07:00PM PT-13.3 PTT-22.9 INR(PT)-1.2
[**2116-12-6**] 07:00PM GLUCOSE-158* UREA N-30* CREAT-1.0 SODIUM-135
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-23 ANION GAP-16
[**2116-12-6**] 07:00PM CALCIUM-9.7 PHOSPHATE-3.2 MAGNESIUM-1.9
[**2116-12-6**] 07:00PM ALT(SGPT)-21 AST(SGOT)-14 ALK PHOS-87 TOT
BILI-0.6
Brief Hospital Course:
Pt. was admitted to the medical service on the evening before
his scheduled surgery for preoperative workup. He then was taken
to the operating room with Dr. [**Last Name (STitle) 7111**] for left total knee
arthroplasty on [**2116-12-7**]. See operative report for details. He
became slightly hypotensive after the induction of anesthesia,
requiring dopamine throughout the case. He tolerated the
procedure well, was extubated in the OR, and was transferred to
the ICU for postoperative monitoring. He was weaned off the
dopamine that evening. He was started on Coumadin for DVT
prophylaxis as well as for his history of atrial fibrillation.
He was started on CPM for range of motion and was seen by
physical therapy. He remained stable and on [**12-9**] he was
transferred to the surgical floor under the orthopaedic service.
He had an episode of atrial fibrillation which resolved with an
increased dose of carvedilol. He was followed by his
cardiologist Dr. [**Last Name (STitle) **] throughout his admission. On [**12-13**] he
was stable for discharge to rehabilitation. He will follow up
with Dr. [**Last Name (STitle) 7111**] as well as Dr. [**Last Name (STitle) **] as an outpatient.
Medications on Admission:
zantac 150 [**Hospital1 **]
glipizide 10 [**Hospital1 **]
lipitor 20 daily
coreg 12.5 [**Hospital1 **]
MVI
aldactone 25 daily
dofetilide 250 [**Hospital1 **]
proscar 5 daily
glucophage 500 [**Hospital1 **]
coumadin (hold) 2.5 3x/wk, 5mg 4x/wk
vasotec 20 [**Hospital1 **]
lasix 60 [**Hospital1 **]
flomax 0.4 hs
Lumigan eye drops 1 drop in each eye QHS
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for spasms.
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
8. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Dofetilide 250 mcg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
12. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
13. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
16. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. Glipizide 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
20. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
goal INR 2.0-2.5.
21. Insulin Asp Prt-Insulin Aspart 70-30 unit/mL Cartridge Sig:
Sixteen (16) units Subcutaneous once a day: at breakfast.
22. Insulin Asp Prt-Insulin Aspart 70-30 unit/mL Cartridge Sig:
Twenty One (21) units Subcutaneous qPM: at dinner.
23. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection QACHS: per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 19504**] of [**Location (un) 1514**] - [**Location (un) 1514**], NH
Discharge Diagnosis:
left knee severe osteoarthritis s/p total knee replacement
atrial fibrillation
systolic congestive heart failure
coronary artery disease
non-insulin dependent diabetes mellitus
hypercholesterolemia
history of colon cancer s/p resection in [**2109**]
history of thyroid surgery
s/p ICD placement in [**3-/2116**]
Glaucoma
Discharge Condition:
stable
Discharge Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in [**2-13**] weeks.
Please follow-up with Dr. [**Last Name (STitle) 7111**] as scheduled.
Keep incision clean and dry.
Physical Therapy:
WBAT, ROM as tolerated
no CPM needed
Treatments Frequency:
Daily dry sterile dressing changes to L knee incision. Staples
will be removed at your first postoperative office visit.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Date/Time:[**2117-1-6**] 12:30
|
[
"414.00",
"715.36",
"V45.81",
"427.31",
"V45.02",
"V10.05",
"272.0",
"428.0",
"428.20",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.54"
] |
icd9pcs
|
[
[
[]
]
] |
6625, 6732
|
3035, 4229
|
349, 380
|
7097, 7106
|
2382, 3012
|
7526, 7721
|
1884, 1902
|
4631, 6602
|
6753, 7076
|
4255, 4608
|
7130, 7304
|
1917, 2363
|
7322, 7359
|
7381, 7503
|
266, 311
|
408, 1238
|
1260, 1802
|
1818, 1868
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,524
| 106,072
|
8000
|
Discharge summary
|
report
|
Admission Date: [**2172-3-18**] Discharge Date: [**2172-3-24**]
Date of Birth: [**2102-1-7**] Sex: F
Service:
CHIEF COMPLAINT: Back pain.
HISTORY OF PRESENT ILLNESS: The patient is a 70 year-old
female with a history of multiple medical problems and severe
emphysema/COPD as well as peripheral vascular disease who had
morning. It was severe, sharp stabbing pain that is in the
center of the back below in the infrascapular area. The
patient denies any nausea, vomiting, abdominal pain or chest
pain. The pain is unchanged in character since it started.
PAST MEDICAL HISTORY: Hypertension, peripheral vascular
disease, status post multiple foot ulcers and multiple
post appendectomy, status post C section times three, former
alcoholic, anxiety, ? Diagnosis of diabetes.
MEDICATIONS ON ADMISSION: Paxil. The patient does report
taking a blood pressure medication, but she cannot recall
what medication that was.
ALLERGIES: Prednisone causes pneumonia.
FAMILY HISTORY: Noncontributory. States that her mother is
in her 90s and alive in [**State 1727**]. Her health care proxy is
daughter [**Name (NI) 2808**] who lives in [**Location 479**] [**Location (un) 1514**].
SOCIAL HISTORY: The patient currently smokes one pack per
day. She has been smoking for a very long time and was a
much heavier smoker in the past. She does have a history of
alcoholism, but she states she quit after her hip surgery and
is unable to recall the date of the surgery. She lives by
herself.
REVIEW OF SYSTEMS: Reports fifteen pound weight loss from 90
to 75 pounds during the last month. She drinks large amounts
and urinates large amounts including wetting bed at night.
She walks with a walker and sometimes in a wheel chair. She
reports no chest pain or shortness of breath, but her
mobility is very limited by COPD.
PHYSICAL EXAMINATION ON ADMISSION: Blood pressure 168/87.
Pulse 72. Respiratory rate 14. O2 sat 91% on 4 liters nasal
cannula. In general, the patient was an elderly ill
appearing female. HEENT was very dry. Chest clear to
auscultation anteriorly, but breath sounds were distant.
Heart had distant heart sounds. Regular rate and rhythm. No
murmur. Abdomen was soft, nontender, nondistended with good
bowel sounds. Extremities showed thin, brown discoloration
of lower half of calf. No palpable dorsalis pedis pulses.
Feet without ulcers. Pulses were dopplerable.
LABORATORY STUDIES ON ADMISSION: White blood cell count 11.5
with a differential of 92% neutrophils, 4% lymphocytes, 2
monocytes. Hematocrit was 34.1, platelet count 476, PT 12.7,
PTT 27, INR 1.1. Chem 7 sodium 134, potassium 3.9, chloride
102, bicarb 26, BUN 10, creatinine 0.4, glucose 284.
IMAGING: 1. Chest CT showed ascending aorta aneurysmally
dilated and measuring 5 cm. The descending aorta had a
normal caliber and intrathoracic diameter measuring 2.5 to 3
cm. However, there was a low attenuation rim around the
descending aorta starting from the aortic arch to about 2 cm
above the origin of the renal arteries. It was
circumferential and was low attenuation most likely
corresponding to old hemorrhage. There was a focal area of
extravasation from the posterior aorta at about 5 cm distal
from the left subclavian artery origin. No frank intimal
flap was identified.
ASSESSMENT/PLAN: In summary, the patient is a 70 year-old
female with a history of severe emphysema/COPD, peripheral
vascular disease, tobacco use who presents with sharp back pain
and was found on CT to have evidence of aortic dissection with
possible oblique aneurysm extending into soft tissue. Myocardial
infarction was r/o.
During this hospitalization the patient's clinical problems
included:
1. Aortic dissection: After extensive discussion with the
family, in consideration of the patients over all health
especially the limitations of her lung disease, the decision was
made to proceed with medical management of the aortic dissection
since the patient was a very poor surgical candidate due to her
age and compromised pulmonary status, malnutrition. The patient
was initially started on Esmolol and nitroprusside drips with
resolved systolic blood pressure around 100. She tolerated the
blood pressure control well and was converted from the drips to
Metoprolol 100 mg po t.i.d., Hydralazine 10 mg po q.i.d., and
Hydrochlorothiazide 12.5 mg po q.d. Following her transfer
to the regular medicine floor the patient's hydralazine was
titrated to 25 mg q.i.d. and Hydrochlorothiazide 25 mg q.a.m.
for better blood pressure control. Her goal blood pressure
is below 120s. After initial drop of her hematocrit from 34
to 27 with hydration the patient's hematocrit remained stable
in the low 30s.
2. Chronic obstructive pulmonary disease: The patient was
maintained on Albuterol inhaler and Atrovent inhaler was
added. She required supplemental oxygen. On repeat chest
x-ray she was found to have pneumonia. In the setting of low
grade fevers as well as sputum production, the patient was
started on Levaquin. The sputum grew penicillin-sensitive
strep pneumo and the patient's antibiotics were switched to
Amoxicillin.
3. During this hospitalization her sugars remained in normal
range.
4. Code: DNR/DNI confirmed with the health care proxy.
DISCHARGE DIAGNOSES:
1. Pneumonia.
2. Hypertension.
3. Aortic dissection managed medically.
4. Emphysema
5. Peripheral vascular disease status post multiple foot
ulcers and multiple hospitalization.
6. Status post left hip replacement, status post
appendectomy, status post C section times three.
7. Former alcoholic.
8. Anxiety.
DISCHARGE MEDICATIONS: Hydrochlorothiazide 25 mg po q.a.m.,
Hydralazine 25 mg po q.i.d., Metoprolol 100 mg po t.i.d.,
Tylenol 650 mg po q 4 to 6 hours prn, Albuterol one to two
puffs q 4 to 6 prn, Atrovent two puffs q.i.d., amoxicillin
500 mg po q 6 hours for an additional six days, Protonix 40
mg po q.d., Trazodone 50 mg po q.h.s., Colace 100 mg po
b.i.d., Dulcolax 10 mg po prn, Paxil.
DR.[**Last Name (STitle) 1413**],[**First Name3 (LF) 1412**] 12-663
Dictated By:[**Last Name (NamePattern1) 1762**]
MEDQUIST36
D: [**2172-3-24**] 10:43
T: [**2172-3-24**] 14:01
JOB#: [**Job Number **]
|
[
"443.9",
"305.1",
"441.00",
"486",
"300.00",
"401.9",
"303.93",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
998, 1199
|
5300, 5619
|
5643, 6249
|
822, 981
|
1528, 1862
|
143, 155
|
184, 576
|
2451, 5279
|
599, 795
|
1216, 1508
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,841
| 126,517
|
22485
|
Discharge summary
|
report
|
Admission Date: [**2143-8-10**] Discharge Date: [**2143-8-17**]
Date of Birth: [**2083-8-4**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 60 year old male with
sudden onset of chest pain who was seen at the [**Hospital **]
Hospital where he was noted to have T wave changes in the
anteroseptal area and poor R wave progression. The patient
underwent a catheterization which showed the patient had a
calcified stenosis of the left anterior descending and also
severe obtuse marginal disease and nondominant right coronary
artery disease. The patient had an intra-aortic balloon pump
placed and the patient was receiving Integrilin and Plavix,
and was transferred to the [**Hospital6 2018**].
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: Bilateral inguinal hernia repair.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME: None.
SOCIAL HISTORY: The patient is a heavy smoker and drinks
approximately two to three beers per day.
PHYSICAL EXAMINATION: Heart rate 86 in sinus rhythm, blood
pressure 142/74 with intra-aortic balloon pump, respiratory
rate of 16, sating 99 percent. The patient appears
malnourished but alert and oriented with poor hygiene. The
patient has temporal fat wasting and poor dentition and dry
membranes. The patient's heart is regular rate and rhythm.
Lungs are clear to auscultation bilaterally. No rales. The
patient's abdomen is soft, nontender, nondistended.
Extremities are cool and the patient has intra-aortic balloon
pump in the right femoral artery.
LABORATORY DATA: Laboratory data at [**Hospital1 **], white count
13, hematocrit 39, platelets 384. The patient's sodium was
139, potassium 4.2, chloride 103, bicarbonate 24, BUN 18,
creatinine 0.8. The patient had bedside echocardiogram which
showed the patient had anterior akinesis.
HOSPITAL COURSE: The patient was admitted to the Cardiac
Surgery Service and underwent a coronary artery bypass graft
times three, left internal mammary artery to left anterior
descending, saphenous vein graft to ramus and saphenous vein
graft to obtuse marginal 3. Please see the dictated
operative note for details of the operation. After the
operation the patient was transferred to the Cardiac Surgery
Recovery Unit. On postoperative day No. 1, the patient was
off of Propofol and was continued on Milrinone at 0.5. The
patient's heart rate was 110 sinus, blood pressure 109/55
with cardiac index of 3.56 with intra-aortic balloon pump at
1 to 2. The patient was positive for approximately 2 liters.
The patient was extubated and had a respiratory rate of 24,
and was sating 96 percent. The patient's temperature maximum
was 101.5 and the current was 100.4. White count was 10.2
and hematocrit was 27.8. BUN was 12 and creatinine was 0.7.
On day #1, neurologically, the patient was weaned off of
intra-aortic balloon pump and also weaned from Milrinone,
continued on intravenous fluids and chest physical therapy.
The patient's diet was advanced to a cardiac diet and the
patient's hematocrit was followed and electrolytes were
repeleted.
On postoperative day #2, the patient would still required
some Milrinone at 0.25, heart rate 115 sinus, blood pressure
105/58. Cardiac index 3.48. The patient was positive,
approximately 300 cc and had a temperature of 101.1, white
count of 12.3, hematocrit 28.8, otherwise the patient was on
a preoperative dose of Vancomycin and was started on
Metoprolol and Lasix. The patient's chest tubes were removed
and Milrinone was stopped and the Swan was removed. The
patient was put on a cardiac diet and stayed in the Intensive
Care Unit.
On postoperative day No. 3, the patient had some low blood
pressure issues and needed some Neo-synephrine drip for over
night but then it was weaned off by the morning. The
patient's heart rate was 96 in sinus with a low blood
pressure of 92/54. The patient was then negative,
approximately 1 liter and was sating 97 percent on 4 liters
and with good p.o. and had a temperature of 100.9, white
count of 14.5 and hematocrit of 28.4. The patient's
creatinine was 0.6. The patient was on Metoprolol, Lasix and
Captopril. The patient's Captopril was stopped for low blood
pressure and was the patient was continued on Metoprolol and
was put on a cardiac diet and a Lasix was stopped. On
postoperative day No. 4, the patient was on the floor and was
doing well. The patient requested a nicotine patch and was
started on a Nicotine patch for a history of smoking. He
remained afebrile with good blood pressure, but tachycardiac
to 100. He had a hematocrit of 26.6 and creatinine of 0.6.
Otherwise doing well, was continued on Metoprolol. The
patient worked with physical therapy and was cleared from
their standpoint. On postoperative day #5, the patient had
no complaints, remained afebrile with blood pressures in the
80s/40s. The patient had a hematocrit of 26.3, creatinine
0.6. The patient 's Lopressor was held and blood pressures
were monitored. On postoperative day No. 6, over night, the
patient had a temperature of 101.3 without any obvious source
with negative chest x-ray and negative cultures. Otherwise
the patient's blood pressure was better at 116/68. The
patient's hematocrit was 24.1 which the patient received one
unit of packed red blood cells with Lasix and creatinine was
0.7. On postoperative day No. 7, the patient had no events
over night, remained afebrile with stable vital signs. The
patient's hematocrit in the morning was 28.3 and creatinine
was 0.3. The patient was doing well and was discharged home.
DISCHARGE DIAGNOSIS: Status post coronary artery bypass
graft times three, coronary artery disease.
Status post bilateral inguinal hernia repair.
DISCHARGE MEDICATIONS:
1. Metoprolol 12.5 mg p.o. b.i.d.
2. Colace 100 mg p.o. b.i.d.
3. Percocet 1 to 2 tablets q. 4-6 hours prn pain.
4. Zantac 150 mg p.o. b.i.d.
5. Aspirin 325 mg p.o. q. day.
6. Multivitamin one p.o. q. day.
7. Thiamine 100 mg p.o. q. day.
8. Folic acid 1 mg p.o. q. day.
9. Nicotine patch 14 mg q. day, please have this dose
adjusted by the primary care physician.
FOLLOW UP: Please follow up with primary care physician in
one to two weeks. Please follow up with Dr. [**First Name (STitle) **] in two weeks
and please follow up with Dr. [**Last Name (STitle) **] in four weeks.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with [**Hospital6 407**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Doctor Last Name 6052**]
MEDQUIST36
D: [**2143-8-17**] 12:58:46
T: [**2143-8-17**] 14:20:38
Job#: [**Job Number 58406**]
|
[
"305.1",
"V45.82",
"263.9",
"458.29",
"998.89",
"414.01",
"410.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"36.15",
"39.61",
"97.44",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6395, 6659
|
5753, 6122
|
5603, 5730
|
1857, 5581
|
879, 886
|
784, 857
|
6134, 6339
|
1010, 1839
|
164, 730
|
753, 760
|
903, 987
|
6364, 6371
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,623
| 178,444
|
12361
|
Discharge summary
|
report
|
Admission Date: [**2164-2-14**] Discharge Date: [**2164-2-22**]
Date of Birth: [**2101-7-4**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Erythromycin Base / Iodine; Iodine Containing /
Cottonseed Oil / Ceftazidime / Clindamycin / Naloxone
Attending:[**First Name3 (LF) 17865**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is 62 year old male with history of transverse myelitis
complicated by paraplegia who presents with two days of
shortness of breath. The patient has had a complicated recent
history involving a leg fracture sustained while moving in his
wheel chair. This was not treated surgically. He also has a
sacral decub which was treated with 2 weeks of cipro then 2
weeks of levofloxacin. Over the past two days he has been having
increasing shortness of breath. He has oxygen at home which he
normally does not use. He has been using up to 4L 1 day PTA. He
reports no fevers of chills. He has been taking his temp and no
documented fevers. He does not endorse ant chest pain. His wife
notes that although his right leg is constantly swollen from the
fracture, his left leg has been having increasing swelling over
the past few days. His wife also notes that he has been
increasingly lethargic over the past few days as well.
In the ED, he recieved Vanc and Zosyn. CTA neg for PE but
showed no central PE but Bibasal GGO and more consolidative opc
w/enlarged subcarinal [**Last Name (un) **] ? pna.
Upon arrival to the floor his sats were in the 80s on NC and he
required a NRB to attain sats in the 90s. An ABG was performed
7.49/44/141. He was given 20mg IV lasix. He was eventually able
to be placed on a 40% venturi mask. His oral temp was 99.7. He
was short of breath when not on the NRB.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
TRANSVERSE MYELITIS: [**1-2**] virus in 90s.
CHRONIC PAIN
CHRONIC UTI
NEUROGENIC BLADDER
DEPRESSION
ASTHMA
CONSTIPATION
NASAL POLYPS
BURSITIS - R HIP
DECUBITUS ULCER
[**Doctor Last Name **] SYNDROME
Social History:
Lives with wife and has two children. Completely dependent upon
wife for ADLs, recently has been largely bed bound. PhD in
physics, worked at Bell laboratories. Denies tobacco, EtOH, and
drugs.
Family History:
Non-contributory
Physical Exam:
Vitals - T: 100.3 po BP: 110/75 HR: 113 RR: 20 02 sat: 100%
NRB
GENERAL: Thin, NAD
HEENT: PERRL, MM dry
CARDIAC: s1s2 RRR
LUNG: fine crackles bilaterally
ABDOMEN: soft, NT/ND
EXT: [**1-3**]+ pitting edema to knees bilaterally
NEURO: A&O x 3
DERM: scattered erythema over the LLE, + warmth; sacral decub
with packing
Pertinent Results:
ADMISSION LABS
[**2164-2-14**] 12:30PM WBC-16.4*# RBC-3.61* HGB-9.6* HCT-29.3*
MCV-81* MCH-26.4*# MCHC-32.6 RDW-13.8 NEUTS-87.3* LYMPHS-6.7*
MONOS-4.3 EOS-1.5 BASOS-0.2
[**2164-2-14**] 12:30PM GLUCOSE-149* UREA N-5* CREAT-0.5 SODIUM-129*
POTASSIUM-3.9 CHLORIDE-90* TOTAL CO2-31 ANION GAP-12
[**2164-2-14**] 12:30PM CK(CPK)-33*
[**2164-2-14**] 12:30PM cTropnT-<0.01
[**2164-2-14**] 06:45PM LACTATE-1.1
DISCHARGE LABS
[**2164-2-22**] 05:43AM BLOOD WBC-16.5* RBC-3.91* Hgb-10.2* Hct-33.3*
MCV-85 MCH-26.2* MCHC-30.8* RDW-14.0 Plt Ct-588* Neuts-91.3*
Lymphs-5.8* Monos-2.8 Eos-0.1 Baso-0.1
[**2164-2-22**] 05:43AM BLOOD PT-17.7* PTT-74.6* INR(PT)-1.6*
[**2164-2-22**] 05:43AM BLOOD Glucose-181* UreaN-21* Creat-1.1 Na-140
K-3.5 Cl-98 HCO3-31 AnGap-15 Calcium-8.8 Phos-4.6* Mg-2.4
[**2164-2-22**] 05:43AM BLOOD Triglyc-252*
[**2164-2-16**] 05:30AM BLOOD PREALBUMIN- 2
IMAGING
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2164-2-14**]
2:22 PM
1. No pulmonary embolus.
2. Progressed interstitial lung disease including honeycombing,
cylindrical bronchiectasis, and diffuse ground-glass
opacification predominantly in the lower lobes. Nonspecific
interstitial pneumonia is a primary diagnostic consideration,
with the possibility of superimposed aspiration suggested
particularly in light of the patulous esophagus. Although
unlikely given age, connective tissue disease may also present
in this manner. It would be atypical however to present at this
advanced age.
3. Meidastinal adenopathy. Given relative dramatic sizes, felt
out of
proportion to be reactive nodes. Follow up CT in [**2-3**] months
recommended to
further evaluate.
4. Large hiatal hernia with patulous esophagus. Contributes to
possibility
of superimposed aspiration.
Portable TTE (Complete) Done [**2164-2-15**] at 11:13:00 AM FINAL
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Transmitral and tissue Doppler imaging
suggests normal diastolic function, and a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Normal regional and global biventricular systolic
function. Mild mitral regurgitation. There appears to be a mass
that is external to the lateral and posterior sides of the right
atrium. This mass is indenting/compressing the right atrium
without causing hemodynamic compromise. This is probably the
same mass/lymhpadenopathy seen on the recent chest CT.
BILAT LOWER EXT VEINS PORT Study Date of [**2164-2-15**] 8:04 AM
Limited study. Deep venous thrombosis in the left proximal and
mid femoral vein.
TIB/FIB (AP & LAT) RIGHT Study Date of [**2164-2-15**] 5:49 PM
Angulated and minimally displaced fractures involving the
proximal metaphyses of the tibia and fibula.
CHEST (PORTABLE AP) Study Date of [**2164-2-21**] 11:00 AM
In comparison with the study of [**2-19**], there is little interval
change. Again there is striking dilatation of the
tracheobronchial tree.
Bibasilar areas of opacification persist, consistent with
consolidation
superimposed upon underlying interstitial lung disease.
Brief Hospital Course:
62M quadraparetic s/p transverse myelitis, sent to ICU from
floor for hypoxia and closer monitoring/nursing care.
# Hypoxia: CTA r/o PE but showed mostly dependent ground glass
opacity and concern for aspiration pneumonia pneumonitis vs CAP
vs ILD (less likely as spares apices) vs pulmonary edema.
Leukocytosis of 16.4, lactate 1.1. He was initially started on
broad spectrum antibiotics including Vanco/Zosyn/Levaquin.
These were narrowed to Levoquin / Vanco on [**2-21**] given no
cultures had grown out. The exact etiology of his hypoxia
remained somewhat unclear throughout his hospitalization but is
likely multifactorial including interstitial disease, likely
silent aspiration and anxiety. He was started on steroids while
inpatient, with plan to have this tapered by his primary care.
# LE Edema: Pt with notable LE edema upon exam which by report
was new. Bilateral, with some erythema which could represent
venous stasis vs cellulitis. Ultrasound revealed DVT in his
left leg. He was started on a heparin drip for this while
inpatient. Upon discharge, continued anticoagulation was
discussed with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Lovenox
was not a reasonable option due to his minimal subcutaneous fat.
He was also taking minimal oral intake. Given this, his PCP
recommended discharged without anticoagulation but plan to
consider it should his underlying poor health status change.
# Sacral decubiti: Multiple sacral decubiti, with some concern
of osteomyelitis per wife. Was [**Name2 (NI) 38511**] with levaquin as
outpatient, scheduled for Plastics evaluation as oupatient prior
to admission. Was seen by Wound Care and Plastics who left
recommendations but did not think surgical intervention was
warranted given his overall decompensated state. With these
interventions, his wounds showed interval improvement and he was
dishcarged with VNA services.
# Tibula /fibular fracture: Fracture sustained falling from WC.
This was not treated surgically. Continued in boot per Ortho
recommendations.
# Chronic pain: Pt is on several medications, including
methadone, dilaudid and Fentanyl. His medications were changed
while inpatient and included IV Fentanyl. Given minimal
subcutaneous fat, it is also unlikely that his Fentanyl patches
were working. This was discussed extensively with the patient
and his wife, and they plan to continue to address his pain
issues as an outpatient with his PCP.
# Anxiety: Patient with significant anxiety. As outpatient is
reportedly on Alprazolam, Diazepam and Clonazepam. During
hospitalization would become very agitated. Ultimately started
on IV Ativan and Haldol PRN. Discharged on Haldol PRN.
Medications on Admission:
Albuterol Sulfate 0.083 % Nebulization tid prn
Albuterol Sulfate 90 mcg 1-2 puffs q 4 hrs prn
AllanEnzyme 830,000 unit/gram-10 % Spray, Non-Aerosol
Alprazolam 0.25 mg Tablet [**12-2**] tid prn
Baclofen 30mg [**Hospital1 **] and 2 qhs prn
BARD TOUCHLESS PLUS UNISEX CATHETER 14 FR FIVE TIMES PER DAY AS
DIRECTED
Becaplermin 0.01 % Gel daily
Bupropion 100 mg SR [**Hospital1 **]
Zyrtec 10 mg Tablet daily
Ciprofloxacin 500 mg [**Hospital1 **] starting [**2164-1-30**]
Clonazepam 0.5 mg TID
Diazepam 5 mg Tablet [**Hospital1 **] prn
Fentanyl 25 mcg/hour Patch 72 hr QOD
Fentanyl 50 mcg/hour Patch 72 hr prn 2-3 days
Fentanyl 100 mcg/hour Patch 72 hr 2 patches q2 dats
Fentanyl Citrate 400 mcg Lozenge on a Handle [**12-2**] qid prn
Fentanyl Citrate 800 mcg Lozenge on a Handle use as directed
when 400 mc is not adequate for pain control qid prn
breakthrough pain
FLOVENT 220MCG Aerosol 4 PUFFS TWICE A DAY - TAPER AS DIRECTED
Fluconazole 200 mg one-3 Tablet(s) by mouth qd prn
Hydrocortisone 2.5 % Cream apply to affected area [**Hospital1 **] prn
Hydromorphone 4 mg Tablet 0.5 to 2 tid prn pain
Ipratropium-Albuterol 0.5 mg-2.5 mg/3 mL
lactulose 10 gram/15 mL Solution 2 OZ by mouth twice a day
Levofloxacin [Levaquin] 500 mg daily [**2164-2-10**]
Levothyroxine 100 mcg daily
LIPITOR 20MG daily
Methadone 10 mg Tablet [**2-1**] [**Hospital1 **] for pain
Methenamine [**Last Name (un) **]-Sod Biphos [Utac] 500 mg-500 mg 2 [**Hospital1 **]
Mexiletine 150 mg TID
Montelukast 10 mg daily
Mupirocin Calcium [Bactroban] 2 % Cream qd or prn
Nystatin 100,000 unit/mL 1 teaspoon tid prn
Omeprazole 20 mg Capsule daily
Polyethylene Glycol 17 grams TID prn
Theophylline 600 mg Tablet Sustained Release daily
Beano
Ascorbic Acid
Discharge Medications:
1. Alprazolam 0.25 mg Tablet Sig: 0.5 - 1 Tablet PO every six
(6) hours as needed for anxiety.
2. Duragesic 75 mcg/hr Patch 72 hr Sig: Three (3) patches
Transdermal EVERY OTHER DAY (Every Other Day): This medication
may not be absorbing given your decreased body fat; discuss
discontinuing with Dr. [**Last Name (STitle) **].
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) NEB Inhalation three times a day as needed for shortness
of breath or wheezing: Resuming home regimen.
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day: Resuming home
regimen.
6. Haloperidol 0.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day) as needed for agitation.
Disp:*20 Tablet(s)* Refills:*0*
7. Prednisone 20 mg Tablet Sig: Four (4) Tablet PO once a day:
This medication will be tapered by your primary care.
Disp:*40 Tablet(s)* Refills:*1*
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing: Resuming prior regimen per Dr. [**Last Name (STitle) **].
9. Oxygen therapy
Patient needs Nonrebreather and humidified facemask. Provide up
to 10L/min O2 for oxygen saturation > 92%. Patient may be
weaned to nasal cannula and room air as directed by primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: Dyspnea, Hypoxia, Anxiety, Deep vein thrombosis
Secondary: Paraplegia, Transverse myelitis, tracheomegaly
Discharge Condition:
Hemodynamically stable and afebrile.
Discharge Instructions:
You were admitted with difficulty breathing and increasing
oxygen needs at home. You were found to have a blood clot in
your leg and changes on your lung imaging which could have be
due to infection or an inflammatory process.
Your blood clot in your leg was discussed with your primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], who recommended no anticoagulation (blood
thinning) at this time given your other illnesses.
Your medications have been changed while you were in the
hospital because you weren't taking many oral medications.
These have been discussed with your primary care, Dr. [**Last Name (STitle) **]. As
your oral intake improves, you may resume some of these
medications. You should continue to discuss this with Dr. [**Last Name (STitle) **].
Please keep all outpatient appointments.
Call your primary care physician if you develop fever, chills,
abdominal pain, worsening difficulty breathing or any other
symptom which is concerning you.
Followup Instructions:
Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to schedule a follow-up appointment
after your discharge. His phone number is [**Telephone/Fax (1) 38512**].
|
[
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"518.81",
"493.90",
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"471.0",
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"338.29",
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"596.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
12441, 12499
|
6430, 9158
|
392, 399
|
12659, 12698
|
2877, 6407
|
13747, 13942
|
2502, 2520
|
10925, 12418
|
12520, 12638
|
9184, 10902
|
12722, 13724
|
2535, 2858
|
333, 354
|
427, 2052
|
2074, 2274
|
2290, 2486
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,835
| 167,803
|
12473
|
Discharge summary
|
report
|
Admission Date: [**2137-7-7**] Discharge Date: [**2137-7-14**]
Date of Birth: [**2072-6-12**] Sex: F
Service: SURGERY
Allergies:
Percocet / Latex / Ciprofloxacin
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname **] presented to the emergency department with severe,
constant periumbilical abdominal pain for the past 2 days. She
was previously evaluated ([**4-26**]) for concern of SBO and SMV
thrombus. At that time she was anticoagulated and bridged to
Coumadin without complication. Two months ago ([**4-27**]) her
Coumadin was discontinued. On admission, her exam showed difuse
periumbilical pain with nausea and non-bilious vomitin x2.
Past Medical History:
Obesity
Atrial Fibrilation
Hypertension
Trieminal neuralgia
Multiple ortho injuries s/p trauma
h/o MRSA+
Social History:
Married, No tob, No EtoH
Family History:
non contributory to this admission
Physical Exam:
T-98.9 HR-81 BP-144/78 RR-20 98%RA
Pt is alert and orientedx3
RRR
Lungs CTA bilaterally
Abdomen soft, nontender (no rebound), obese
Extremities WWP
Pertinent Results:
[**2137-7-14**] 08:25AM BLOOD PT-25.9* INR(PT)-2.5*
INR:
2.5 [**2137-7-14**]
2.3 [**2137-7-13**]
1.5 [**2137-7-12**]
[**2137-7-12**] Glucose-98 UreaN-4 Creat-0.7 Na-143 K-2.9 Cl-108
HCO3-25 AnGap-13
Brief Hospital Course:
Pt was admitted to the SICU on [**2137-7-7**] with severe abdominal
pain concerning for worsening SMV thrombosis and possible
ischemic bowel. At that time her lactate was 2.3 and CT
abd/pelvis showed an interval increase in the size of her SMV
thrombosis ([**4-/2136**]) and possible hypoenhancement concerning for
bowel ischemia. Pt was started on heparin gtt with a target PTT
of 60-100. Her abdomen continued to be diffusely tender durin a
3 day ICU course but she remained clinically stable. Lactate
improved to 1.7 and she was transfered to the surgical floor.
She was continued on a heparin gtt with daily PTT and bridge to
coumadin with a target INR 2.5 to 3.0. Coumadin was started at
10mg QD on [**7-11**]. INR 1.7 ([**7-12**]) and 2.5 on [**7-14**].
Pt was anxious throuhout hosptial course requiring occasional
ativan and 1x haldol.
Medications on Admission:
Cymbalta 60mg PO QD
Carbatrol 300mg PO BID
Lisinopril 40mg PO QD
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Carbamazepine 200 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day) as needed for trigeminal neuralgia.
3. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO once a day for 30
days.
Disp:*60 Tablet(s)* Refills:*0*
4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Worsening SMV thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Pt stable
Discharge Instructions:
You were admitted with severe abdominal pain concerning for
increase in SMV thrombosis and potential ischemic bowel. You
were monitored in the SICU for worsening symptoms while you were
placed on anticoagulation therapy. At the time of discharge you
are clear to eat a soft diet of low residues.
Please continue to take all medications as indicated. You [**Location (un) **]
currently on 10mg coumadin per day and your INR at the time of
discharge is 2.5 (Goal 2.5-3.0). You will need to have your INR
monitored on a regular basis and your coumadin levels adjusted
accordingly. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], who has monitored this for you
in the past, will monitor your coumadin dosing. We will contact
his office to set up an appointment later this week (~[**7-18**]) to
have your INR checked.
Please go to the Emergency Department if you develop new
symptoms or your current symptoms worsen.
Followup Instructions:
You should follow up with your PCP (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) later
this week (approximately [**2137-7-18**]) to have your INR rechecked
and your coumadin dosing scheduled adjusted. At this time the
goal for your INR is 2.5-3.0. Dr.[**Name (NI) 38722**] office will contact
you with your appointment date and time.
You will also need to follow-up with Dr. [**First Name8 (NamePattern2) 38723**] [**Last Name (NamePattern1) 3060**] of
Hematoloy in the next 2-3 weeks for further evaluation regardin
possible etiologies for your SMV thrombosis. Dr.[**Name (NI) 16545**] office
will contact you with your appointment date and time.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"300.00",
"557.0",
"276.52",
"715.90",
"345.90",
"278.00",
"276.2",
"401.9",
"427.31",
"350.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2798, 2804
|
1422, 2268
|
306, 313
|
2873, 2873
|
1198, 1399
|
3994, 4799
|
979, 1015
|
2384, 2775
|
2825, 2852
|
2294, 2361
|
3033, 3971
|
1030, 1179
|
252, 268
|
341, 793
|
2888, 3009
|
815, 921
|
937, 963
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,212
| 124,308
|
53697
|
Discharge summary
|
report
|
Admission Date: [**2125-6-23**] Discharge Date: [**2125-6-29**]
Date of Birth: [**2044-11-26**] Sex: F
Service: SURGERY
Allergies:
Percocet / Percodan / Codeine
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Small bowel perforation and new onset rapid a-fib
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80 yo F w/ ex lap and LOA [**5-28**] at OSH, sent home roughly 2
weeks after surgery. Postop complicated by infected abdomen felt
to be secondary to bowel perf. Pt returned to OSH [**6-18**] w/ fever
101.8, drainage from incision site, abdominal discomfort. CT abd
at [**Last Name (un) 1724**] revealed perforated distal ileum w/ extraluminal free air
lower right pelvis, interval resolution of bilat pleural
effusions and near complete resolution of pericardial effusion.
Pt then developed SOB found to be in new onset AFIB, started on
Amio gtt. Pt transferred to SICU for further management, HD
stable on Amio gtt upon arrival.
Past Medical History:
hypothyroid, osteoporosis
PSH: SB resection [**2125-5-28**], ex-lap w/ LOA '[**21**], c/s x2, hernia
repair, cystectomy from breast x2, thyroidectomy, TAH
Physical Exam:
HR=75 , BP=96/47 , RR=30 , O2sat=97 RA
Gen- NAD, AA0 x 3
Head and neck- NCAT, anicteric, PERRLA
Heart-RRR, S1S2
Lungs-CTAB
Abd- soft, nontender, mild distention, mild-line lap. scar
noted,
ecchymosis noted in LLQ, +BS.
Ext- LES: no c/c/e, LUE - mild antecubital thromboplebitis
noted,
heat pack in place.
Pertinent Results:
[**2125-6-23**] 11:38PM BLOOD WBC-12.4* RBC-3.54* Hgb-10.5* Hct-31.6*
MCV-89 MCH-29.7 MCHC-33.3 RDW-14.2 Plt Ct-411
[**2125-6-26**] 08:14AM BLOOD WBC-7.3 RBC-3.65* Hgb-10.6* Hct-32.3*
MCV-89 MCH-29.1 MCHC-32.9 RDW-14.1 Plt Ct-330
[**2125-6-26**] 08:14AM BLOOD Glucose-115* UreaN-5* Creat-0.7 Na-141
K-3.3 Cl-106 HCO3-29 AnGap-9
[**2125-6-23**] 11:38PM BLOOD Lipase-27
[**2125-6-26**] 08:14AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.0
[**2125-6-25**] 10:45AM BLOOD TSH-3.7
.
Radiology Report CT ABDOMEN W/O CONTRAST Study Date of [**2125-6-24**]
2:08 PM
IMPRESSION:
1. Extensive phlegmonous inflammatory process in the right lower
quadrant
with given surgical history of recent distal ileal perforation.
2. Some of the phlegmonous abnormality has a mass-like quality.
While likely inflammatory in nature, followup is advised to
ensure resolution of these findings.
3. Small foci of extraluminal gas are identified within the
phlegmon.
4. Possible dilation/ aneurysm of left internal iliac artery,
(incompletely characterised on this non-contrast study.
.
ECHO
Conclusions
The left atrium is elongated. No left atrial mass/thrombus seen
(best excluded by transesophageal echocardiography). There is
mild (non-obstructive) focal hypertrophy of the basal septum.
The left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic arch is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Mild focal basal septal hypertrophy with preserved
regional and global biventricular systolic function. Mild
biatrial enlargement. No left atrial mass/thrombus seen (best
excluded by TEE). Mild pulmonary hypertension. Mild aortic
dilation.
[**2125-6-27**] 06:15AM BLOOD WBC-8.5 RBC-3.53* Hgb-10.4* Hct-31.2*
MCV-88 MCH-29.5 MCHC-33.4 RDW-14.2 Plt Ct-313
[**2125-6-27**] 06:15AM BLOOD Glucose-98 UreaN-8 Creat-0.6 Na-141 K-3.8
Cl-106 HCO3-27 AnGap-12
[**2125-6-27**] 06:15AM BLOOD Calcium-8.2* Phos-3.2 Mg-2.3
Brief Hospital Course:
This is a 80 year old female transferred here with small bowel
perforation and new onset rapid a-fib. CT from [**Last Name (un) 1724**] ([**6-20**])showed
distal ileal perf w extravasation of
contrast, free air in R pelvis, mesentery phlegmon/abscess,
bowel wall thickening c/w ileus, interval resolution of b/l
pleural effusions.
A-fib: she was admitted to the ICU and continued on an Amio gtt.
She was in NSR. Once transferred out to the floor. The Amio was
stopped and she was switched to Lopressor. A Cardiology consult
was obtained and recommended Aspirin, titrating Lopressor and
obtaining an ECHO. ECHO revealed no thrombus and EF>55%.
On [**6-26**], she had 2 short bouts of A-fib. The lopressor dose was
increased, electrolytes repleated and she remained in NSR. At
time of discharge she was NSR and had stable VS.
She will follow-up with cardiology as an outpatient.
SB perf: She was NPO and started on Vanco/zosyn for broad
spectrum coverage. Her abdominal exam was benign and she was
started back on a diet. She was tolerating a regular diet and
switched to PO Cipro/Flagyl. She reported +flatus and +BM prior
to discharge.
Medications on Admission:
levoxyl 150, fosamax, forticol
Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
Disp:*90 Tablet(s)* Refills:*0*
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q8H (every 8 hours) as needed.
Disp:*qs ML(s)* Refills:*2*
5. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel perforation
new onset rapid a-fib
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Take all new meds as ordered. Continue with Lopressor as
directed.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* No heavy lifting (>[**9-19**] lbs) for 6 weeks.
* You may shower and wash. No tub baths or swimming.
Followup Instructions:
Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] (Cardiology) on [**2125-7-4**] at
2:40pm. Call ([**Telephone/Fax (1) 1987**] with questions or concerns.
No follow-up with Dr. [**Last Name (STitle) **] necessary, but certainly do not
hesitate to call his office if any concerns arise
([**Telephone/Fax (1) 1231**]).
Completed by:[**2125-6-29**]
|
[
"733.00",
"244.0",
"569.83",
"427.31",
"V45.89"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5972, 5978
|
3970, 5109
|
339, 346
|
6068, 6075
|
1527, 3947
|
7573, 7959
|
5190, 5949
|
5999, 6047
|
5135, 5167
|
6099, 7550
|
1201, 1508
|
250, 301
|
374, 1006
|
1028, 1186
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,389
| 154,444
|
49752
|
Discharge summary
|
report
|
Admission Date: [**2136-3-6**] Discharge Date: [**2136-3-9**]
Date of Birth: [**2083-4-6**] Sex: M
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Mercaptopurine / Imuran
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
52 yo M with Crohn's disease, s/p multiple small bowel
resections, CKD, HTN, hypothyroidism presents with hypotension
in the setting of 3 days of nausea and non-bloody vomiting. The
emesis has occurred multiple times per day, although the patient
has not had an emesis since he arrived in the ED today. He has
not tolerated any PO intake for several days. He has liquid
stool at baseline, with last liquid stool (small volume) on
Sunday, non-bloody and not black. He does not recall passing gas
from below since Friday. He had fever to 101.5 on Saturday and
has had temperatures to about 100 over the past couple of days.
Other more subacute to chronic symptoms include dyspnea on
exertion, worsening over the past several months, sore throat
for the past few weeks, and chronic right wrist swelling after
an injury. No sick contacts. [**Name (NI) **] pain with urination.
The patient was recently admission from [**Date range (1) 104010**] for nausea,
vomiting, urinary retention and acute on chronic kidney injury.
He required a Foley catheter. His urinary retention was treated
with tamsolosin and finasteride, and he discharged with
intermittent self-catheterization. He self-catheterized once
since discharge, but otherwise has been voiding on his own.
However, urine output decreased on Saturday, and the patient has
been unable to urinate since he presented to the ED.
.
The patient was seen at [**Company 191**] today and was noted to be
hypotensive to the 80s when lying down, with further SBP drop to
70 when sitting up. He was referred to the ED for further
management.
.
In the ED inital vitals were 98.3 74 119/63 16 100% RA. Exam was
notable for right CVA tenderness. Bedside ultrasound showed
little urine in bladder, no hydronephrosis. Labs notable for Hct
33.5 (baseline), creatinine 1.8 (baseline). The patient was
given 2L NS, solumedrol 125 mg IV, Zofran 4 mg IV. ICU admission
was requested given persistent hypotension to SBP 90 despite
fluid resuscitation. On transfer, vitals BP 104/71, HR 50, RR
14, Sat 100%/RA. Access is 20-gauge IV x 1.
.
On arrival to the ICU, the patient complain of abdominal and
back pain. No nausea, vomiting. No dizziness or lightheadedness.
.
Review of systems:
(+) Per HPI
(-) +fever per HPI. Weight fluctuates. +sore throat. Denies
cough. Has chronic dyspnea on exertion. Denies chest pain, chest
pressure. GI and GU symptoms per HPI. Has chronic back pain.
Denies rashes or skin changes.
Past Medical History:
# Crohn's disease on chronic steroids, s/p multiple surgeries
with ileocolonic resection
# Chronic kidney disease- baseline creatinine 1.2-1.7
# HTN- not currently on medication as BP low
# Hypothyroidism
# Hyperparathyroidism
# Peripheral neuropathy
# Chronic back and abdominal pain
# Osteopenia
# Pernicious anemia
# Hypogonadotrophic hypogonadism [**2-23**] opiate therapy
# s/p hydrocele repair
# s/p L cataract repair
Social History:
Lives in [**Hospital1 392**] with brother. Currently on disability but used
to work for oldest brother in the entertainment business.
Tobacco- denies past or present use
Alcohol- none
Illicits- denies
Family History:
Mother- h/o stroke, died of breast cancer
Father- died of MI at age 62
History of DM in paternal grandparents
Maternal grandmother, aunt with cancers
Two brothers- healthy
Physical Exam:
Admission Physical Exam:
Vitals: T:98.1 BP:132/74 P:65 R:16 O2:98%/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, bowel sounds present, diffusely tender,
especially on right side, with no rebound tenderness or guarding
Back: No CVA tenderness or tenderness of spinous processes.
GU: Foley placed on arrival to ICU
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A+Ox3. Moving all extremities.
Pertinent Results:
LABS:
[**2136-3-6**] 10:00AM BLOOD WBC-9.5 RBC-4.09* Hgb-11.2* Hct-33.5*
MCV-82 MCH-27.5 MCHC-33.6 RDW-15.1 Plt Ct-228
[**2136-3-6**] 10:00AM BLOOD Neuts-66.7 Lymphs-25.8 Monos-4.8 Eos-2.2
Baso-0.6
[**2136-3-6**] 10:00AM BLOOD Glucose-91 UreaN-26* Creat-1.8* Na-137
K-4.3 Cl-102 HCO3-24 AnGap-15
[**2136-3-6**] 10:00AM BLOOD ALT-11 AST-13 AlkPhos-84 TotBili-0.8
[**2136-3-6**] 10:00AM BLOOD Lipase-29
[**2136-3-6**] 10:00AM BLOOD Albumin-4.4
[**2136-3-6**] 02:00PM BLOOD Lactate-3.3*
[**2136-3-6**] 05:10PM BLOOD Lactate-1.6
[**2136-3-6**] 11:35AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2136-3-6**] 11:35AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2136-3-6**] 11:35AM URINE RBC-3* WBC-<1 Bacteri-FEW Yeast-NONE
Epi-<1
[**2136-3-7**] 05:34AM BLOOD WBC-8.1 RBC-3.57* Hgb-9.8* Hct-29.7*
MCV-83 MCH-27.4 MCHC-32.9 RDW-15.1 Plt Ct-189
[**2136-3-7**] 05:34AM BLOOD Glucose-109* UreaN-20 Creat-1.5* Na-137
K-4.9 Cl-108 HCO3-20* AnGap-14
[**2136-3-7**] 06:51AM BLOOD Lactate-2.0
IMAGING:
CXR ([**3-6**])
IMPRESSION: No acute cardiopulmonary process.
KUB ([**3-6**])
FINDINGS:
There are no dilated loops of small or large bowel to indicate
obstruction. There is no evidence of pneumatosis, portal venous
air, or pneumoperitoneum. There are stable phleboliths and a
calcific density projecting in the region of the lower left
pelvis as previously seen on CT from [**2135-7-12**]. The visualized
osseous structures are intact.
In addition, multiple calcific densities projecting over the
left iliac [**Doctor First Name 362**] can be correlated to subcutaneous granulomas as
demonstrated on prior CT.
IMPRESSION: Non-obstructive bowel gas pattern.
Brief Hospital Course:
Assessment and Plan: 52 yo M with Crohn's disease, s/p multiple
small bowel resections, CKD, HTN, hypothyroidism presents with
hypotension and lactic acidosis in the setting of 3 days of
nausea/vomiting.
.
# Nausea/vomiting/abdominal pain: Ddx includes Crohn's flair,
partial SBO, gastroenteritis. Less likely cholecystitis or
pancreatitis in the setting of normal LFTs and lactate. The
patient states that the abdominal pain is similar in quality to
his chronic abdominal pain, yet is more severe (nl [**5-31**], now
[**7-31**]). The patient received 2L NS bolus in ED and received 1L
IVF over the course of a few hours in the ICU. The patient was
NPO for most of HD #1, and tolerated clear liquids overnight.
The patient had a KUB overnight which showed no free air or
air/fluid levels. Serial abdominal exams demonstrated stable,
pain w/out peritoneal signs. Nausea managed with zofran IV
alternating with compazine PO. Abdominal pain managed w/
methadone (chronic med) and dilaudid PRN for breakthrough pain.
- Symptoms improved with supportive care
- GI consulted: Felt that symptoms were likely related to
gastroenteritis. Recommended follow up with Dr. [**Last Name (STitle) 3708**].
.
# Lactic acidosis: Likely related to hypovolemia. Resolving with
IVF. 3.3 --> 1.6 --> 2.0.
.
# Hypotension/Acute on chronic kidney injury: Likely related to
hypovolemia. Hypotension resolved with IVF. He had one more
episode of hypotension while on the medical floor, resolved with
IVF. Cr Improved from 1.8 --> 1.5.
.
# Urinary retention: Likely related to BPH and pain medications.
Bladder scan demonstrated > 500cc. Foley placed. continued
finasteride, tamsulosin.
- Foley DCd and passed voiding trial. Continued home regimen
.
# Crohn's disease: Unlikely flair. Continuing home steroids.
contact[**Name (NI) **] Dr. [**Last Name (STitle) 3708**] (outpt GI) via e-mail. Have consulted with
GI colleagues re: management of Crohn's. GI felt Crohn's not
contributing.
.
# Chronic back pain: continued tizanidine, methadone, pregabalin
per home regimen
.
# Hypothyroidism: stable. continued levothyroxine per home dose
Medications on Admission:
methadone 25 mg TID
methylprednisolone 16 mg daily
zolpidem 10 mg QHS PRN insomnia (10 mg per patient, was 5 mg in
recent discharge summary)
tizanidine 8 mg TID
levothyroxine 175 mcg daily
omeprazole 20 mg daily
diazepam 5 mg PO Q8H
tamsulosin 0.4 mg QHS
finasteride 5 mg daily
pregabalin 100 mg [**Hospital1 **]
Discharge Medications:
1. methadone 10 mg Tablet Sig: 2.5 Tablets PO TID (3 times a
day).
2. methylprednisolone 8 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
4. tizanidine 2 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day).
5. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
9. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. pregabalin 25 mg Capsule Sig: Four (4) Capsule PO BID (2
times a day).
11. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Viral gastroenteritis
SECONDARY:
Crohn's disease
Chronic pain
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 for evaluation of nausea,
vomiting, and low blood pressure. With IV fluids and supportive
care your symptoms improved. GI saw you in the hospital, and
felt the likely cause of your symptoms was due to a viral
gastroenteritis. You should improve over the next few days.
Please stay well hydrated for the next few days. Please take
all medications as prescribed and keep all follow up
appointments
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2136-3-22**] at 3:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], RNC [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] None
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: TUESDAY [**2136-4-10**] at 7:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7323**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: FRIDAY [**2136-4-13**] at 8:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7290**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: PAIN MANAGEMENT CENTER
When: FRIDAY [**2136-4-20**] at 8:40 AM
With: [**Name6 (MD) 1089**] [**Name8 (MD) 1090**], MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 18**]-DIVISION OF GASTROENTEROLOGY/GI EAST
Address: [**Last Name (LF) **], [**First Name3 (LF) **] ROSE 101, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 65629**]
**We are working on a follow up appointment with Dr. [**Last Name (STitle) 3708**] within
1-2 weeks. You will be called at home with the appointment. If
you have not heard from the office within 2 days or have any
questions, please call the number above.**
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2136-3-13**]
|
[
"555.2",
"788.20",
"V45.72",
"V58.65",
"780.60",
"252.00",
"584.9",
"281.0",
"462",
"276.2",
"600.01",
"403.90",
"276.51",
"356.8",
"244.9",
"786.50",
"787.01",
"458.0",
"724.2",
"008.8",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9538, 9544
|
6117, 8242
|
324, 330
|
9650, 9650
|
4358, 6094
|
10260, 12288
|
3487, 3661
|
8605, 9515
|
9565, 9629
|
8268, 8582
|
9801, 10237
|
3701, 4339
|
2573, 2804
|
268, 286
|
358, 2554
|
9665, 9777
|
2826, 3251
|
3267, 3471
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,602
| 140,543
|
51357
|
Discharge summary
|
report
|
Admission Date: [**2189-10-25**] Discharge Date: [**2189-11-4**]
Date of Birth: [**2108-2-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2189-10-26**] Left videoassisted thoracoscopy and evacuation of
hemothorax
History of Present Illness:
This 81 year old female underwent Redo sternotomy, Aortic valve
replacement, Tricuspid valve replacement and removal of
pacemaker leads with placement of epicardial left ventricular
leads and new pacemaker generator on [**10-15**].She was transferred to
[**Hospital3 **] at discharge from here. She developed
acute onset of dyspnea on the day of re-admission, without any
history of sa fall. On presentation to the [**Hospital1 18**] ED she was
noted to be hypotensive (80-90s) systolic with a CXR
demonstrating white out of the left lung. A chest tube was
inserted emergently with 900 cc of dark bloody fluid removed.
She was taken to the operating room and a videoassisted
procedure was performed. See operative note for details.
Past Medical History:
coronary artery disease
s/p coronary artery bypass
s/p mechanical mitral valve replacement
Atrial fibrillation
Tachybrady syndrome
s/p pacemaker [**2169**]
Mitral stenosis
Aortic stenosis
Prior strokes
Urinary frequency
s/p cataract surgery
s/p Right hip replacement
s/p Appendectomy
Anemia
Osteoporosis
Social History:
Retired mill worker
Lives with spouse
[**Name (NI) 1139**] 50 pack year history quit in [**2151**]
ETOH denies
Family History:
non-contributory
Physical Exam:
Awake and alert. oriented.
Lungs- essentially clear
Cor- Ventricular demand pacemaker functioning with rate 80
extremeties- warma nd dry. No edema.
Abdomen- benign.
wounds- ecchymotic Left chest from surgery with moderate
hematoma at posterior incision. Scant old bloody drainage. Other
surgical incisions healing well.
Pertinent Results:
[**10-25**] CXR: Interval development of left-sided opacity consistent
with large
pleural effusion and associated mediastinal shift. Stable
right-sided pleural effusion.
[**10-25**] CT: 1. No pulmonary embolism. 2. Large left hemothorax.
Atelectasis of the left lung, with areas of internal diminished
enhancement that could reflect developing infection. Left chest
tube is coiled at the left apex. 3. Moderate right pleural
effusion. 4. No intraperitoneal fluid collection is visualized.
5. Abandoned pacer wires, including a wire fragment in the right
ventricle. 6. Right groin hematoma. 7. Unusual pattern of
opacification within the IVC most likely reflects mixing but
raises the possibility of a thrombus. Attention to this area on
follow-up or further evaluation with ultrasound is advised.
[**10-25**] Echo: 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. The right atrium is dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. No thoracic aortic
dissection is seen. A bileaflet aortic valve prosthesis is
present. The aortic valve prosthesis appears well seated, with
normal leaflet/disc motion and transvalvular gradients. A
bileaflet mitral valve prosthesis is present. The mitral
prosthesis appears well seated, with normal leaflet/disc motion
and transvalvular gradients. A bioprosthetic tricuspid valve is
present. The tricuspid prosthesis appears well seated, with
normal leaflet motion and transvalvular gradients. The tricuspid
prosthesis cannot be adequately assessed. There is large
colelction adjacent to the left side of the LV (extending from
the left chest ? )with no compression of the LV or the La. The
effusion appears loculated. There are no echocardiographic signs
of tamponade.
[**2189-11-2**] 09:00AM BLOOD WBC-9.3 RBC-3.50* Hgb-10.3* Hct-30.8*
MCV-88 MCH-29.4 MCHC-33.4 RDW-16.0* Plt Ct-490*
[**2189-11-2**] 10:55AM BLOOD Glucose-78 UreaN-25* Creat-0.9 Na-137
K-4.8 Cl-102 HCO3-30 AnGap-10
Brief Hospital Course:
The patient was brought to the OR, however, bleeding had stopped
and blood pressure stabilized,so she was transferred to the
CVICU for further management. She remained hemodynamically
stable and returned to the OR on [**10-26**] for VATS evacuation of
hemothorax,which yielded approximately 500cc of old, dark blood.
Overall the patient tolerated the procedure well and
post-operatively she was transferred back to the CVICU in stable
condition for observation and recovery. The patient was weaned
from the ventilator and extubated on POD 1. Diet was advanced
after a speech and swallowing evaluation was done. The patient
did experience some sun-downing and this was managed with
xyprexa.
She patient was transferred to the step down unit on POD 3 for
further physical therapy and recovery.A heparin infusion was
begun due to the presence of a mechanical heart valve until
Coumadin was therapeutic.
On [**11-4**] her PT was 2.4 and heparin was discontinued. She was
ordered for 6mg of Coumadin, her INR target is 2.5-3. She was
taking 6mg of Coumadin M-F, 4mg Sat/Sun pre-admission. She
requires daily PT/INR testing until levels stabilize.
She developed a modearte hematome at VATS site postoperatively.
This was initially tender and hard. It is now stable in size,
nontender and softer daily. There is scant drainage from the
posterior aspect of the wound as the hematoma lyses.
She is ready for rebabilitation prior to returning home.
Medications and restrictions are as noted.
Medications on Admission:
asa
coumadin
lasix
metoprolol
KCl
atorvastatin
Discharge Medications:
1. Influen Tr-Split [**2189**] Vac (PF) 45 mcg/0.5 mL Syringe Sig: One
(1) ML Intramuscular ASDIR (AS DIRECTED).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed. Tablet(s)
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
11. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
13. Benzocaine 20 % Paste Sig: One (1) Appl Mucous membrane TID
(3 times a day) as needed.
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
16. Warfarin 2 mg Tablet Sig: per order Tablet PO once a day:
INR target 2.5-3.
Discharge Disposition:
Extended Care
Facility:
[**Male First Name (un) **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Left Hemothorax
s/p evacuation via videoassisted thoracoscopy
Aortic stenosisT
Tricicuspid Regurgitation
s/p Redo-Sternotomy, Aortic valve replacement, Tricuspid valve
replacement and removal of pacemaker leads, placement of
epicardial left ventricular leads and new pacemaker generator on
[**10-15**]
Coronary Artery Disease
s/p Coronary Artery Bypass Graft and mechanical mitral valve
replacement [**2171**]
chronic Atrial fibrillation
s/p pacemaker [**2169**]
Prior strokes
Urinary frequency
s/p cataract surgery
s/p Right hip replacement
s/p Appendectomy
Anemia
Osteoporosis
Discharge Condition:
Good
Discharge Instructions:
Report redness or drainage from incisions
Report any fever greater then 100.5.
Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1
week.
No lotions, creams or powders to incision.
Shower daily. No bathing or swimming for 1 month.
No lifting greater then 10 pounds for 10 weeks from date of
surgery.
No driving for 1 month or while taking narcotics for pain.
Call with any questions or concerns.
Take all medications as directed
Followup Instructions:
DR. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2189-12-3**]
10:20
Dr. [**Last Name (STitle) **] in [**1-21**] weeks
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) **] 2 weeks
Please call for appointments
Completed by:[**2189-11-4**]
|
[
"733.00",
"V45.81",
"276.52",
"998.11",
"427.81",
"E878.2",
"511.89",
"518.81",
"427.31",
"V43.64",
"V42.2",
"998.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"99.07",
"34.06",
"96.04",
"99.04",
"34.04",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
7400, 7506
|
4259, 5756
|
340, 419
|
8129, 8136
|
2029, 4236
|
8626, 9018
|
1656, 1674
|
5853, 7377
|
7527, 8108
|
5782, 5830
|
8160, 8603
|
1689, 2010
|
281, 302
|
447, 1184
|
1206, 1512
|
1528, 1640
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,667
| 119,458
|
32427
|
Discharge summary
|
report
|
Admission Date: [**2140-10-12**] Discharge Date: [**2140-10-24**]
Date of Birth: [**2081-11-29**] Sex: F
Service: PLASTIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 5883**]
Chief Complaint:
L breast cancer
Major Surgical or Invasive Procedure:
delayed breast reconstruction with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5884**]
History of Present Illness:
58F with L breast cancer s/p mastectomy/chemo presents to [**Hospital1 18**]
for elective delayed breast reconstruction with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5884**]
Past Medical History:
s/p L mastectomy [**10-27**]
COPD
lung CA s/p RML wedge resection [**2139**]
nephrolithiasis s/p stent, infection
s/p L nephrectomy [**2134**]
anemia
s/p appy [**2102**]
Social History:
smokes [**2-25**] cigarettes daily
Family History:
breast CA in grandmother and mother, CAD
Physical Exam:
ON ADMISSION [**2140-10-12**]
AVSS
GEN: NAD, AAO x3
PULM: CTA, slightly diminshed on R side
CV: RRR, s1 s2
ABD: NT/ND, +BS
Breast: [**Last Name (un) 5884**] side, +dopplerable signal, flap warm, abdominal
incisions C/D/I, no SOI
Neuro: CN2-12 intact
Pertinent Results:
CHEST (PORTABLE AP) [**2140-10-12**] 5:39 PM
Reason: s/p intubation.
[**Hospital 93**] MEDICAL CONDITION:
58 year old woman s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5884**] flap surgery. Resp arrest postop
REASON FOR THIS EXAMINATION:
s/p intubation.
PORTABLE CHEST
Status post intubation.
FINDINGS: A single portable image of the chest was obtained. The
patient is status post intubation. The tip of the endotracheal
tube is low lying, approximately 7 mm from the carina. There is
a MediPort in place that terminates within the mid SVC. There is
slight motion artifact that degrades the image quality of the
lower right hemithorax. No focal opacities are seen to suggest
an underlying pneumonia. Surgical clips project over the left
hemithorax. The cardiomediastinal silhouette is within normal
limits. The bony thorax is grossly intact. A gas-filled gastric
bubble is noted.
Findings were discussed with Dr. [**Last Name (STitle) **] at the time of
interpretation at [**2140-10-13**] who stated the EYY had subsequently
been removed.
CHEST (PORTABLE AP) [**2140-10-14**] 6:31 AM
CHEST (PORTABLE AP)
Reason: r/o PE
[**Hospital 93**] MEDICAL CONDITION:
58 year old woman with acute onset desat to 44%RA this am, now
mentating well, clear, =BS, sat 100% NRB. has h/o apnea, denies
CP, SOB.
REASON FOR THIS EXAMINATION:
r/o PE
HISTORY: Acute onset desaturation this morning; to exclude
pulmonary embolism.
FINDINGS: In comparison with the study of [**10-12**], there is
increase in the diffuse reticular changes throughout both lungs,
suggesting volume overload. The possibility of developing
pneumonia either in the right upper or left lower lung zones
must be considered.
The endotracheal tube has been removed. Central catheter tip
remains in position in the lower superior vena cava.
Cardiology Report ECG Study Date of [**2140-10-14**] 6:19:20 AM
Sinus tachycardia. Poor R wave progression. Non-specific diffuse
T wave
flattening. Compared to tracing of [**2140-10-7**] tachycardia and ST-T
wave changes
are new. The QRS changes in leads V2-V3 could be positional and
there is lower
QRS voltage.
TRACING #1
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
122 144 80 296/404 40 18 47
Cardiology Report ECG Study Date of [**2140-10-14**] 11:53:24 AM
Sinus tachycardia. Non-specific diffuse T wave flattening. RSR'
pattern in
leads V1-V2. Low QRS voltage in the precordial leads. Compared
to tracing #1
on [**2140-10-14**] no significant change.
TRACING #2
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
122 142 84 294/402 38 11 89
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2140-10-15**] 8:30 AM
Reason: ?PE
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
58 year old woman with PMH of lung and breast cancer s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
flap, presenting with hypoxemia, tachycardia and hypotension
without clinical respiratory distress
REASON FOR THIS EXAMINATION:
?PE
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Respiratory distress. Rule out PE.
COMPARISON: None.
TECHNIQUE: MDCT axial images through the chest were obtained
with IV contrast. Multiplanar reformatted views were displayed.
CT OF THE CHEST WITH IV CONTRAST: The patient is status post
left mastectomy with post-surgical changes including surgical
clips and a surgical drainage. Diffuse bilateral ground-glass
opacities with sparing of the left apex. Bilateral small pleural
effusions, left greater than right, with compressive
atelectasis. The heart is at the upper limits of normal. The
great vessels are normal in size. The pulmonary artery is patent
without filling defects to suggest pulmonary embolism. Enlarged
mediastinal lymph nodes are seen in the subcarinal station.
Small prevascular and bilateral hilar lymph nodes are noted.
There is no axillary lymphadenopathy.
This study is not designed for subdiaphragmatic evaluation,
however, the visualized portions of the upper abdomen
demonstrates a 2.0 cm cystic lesion within the left lobe of the
liver. The liver appears diffusely hypodense consistent with
fatty infiltration. There is a 2.6 x 1.9 cm hypodense lesion
within the left adrenal gland, which is not fully characterized
in this study.
BONE WINDOWS: No suspicious lytic or sclerotic lesions are
identified.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Diffuse bilateral ground-glass opacities. Differential
diagnosis includes hydrostatic pulmonary edema, aspiration
pneumonia and drug reaction.
3. A 2.6 x 1.9 cm right adrenal hypodense lesion, not fully
characterized.
4. Mediastinal lymphadenopathy.
5. Diffuse low attenuation within the liver parenchyma likely
represents fatty infiltration. A 2.0 cm hypodense lesion within
the left lobe of the liver most likely a cyst.
CHEST (PORTABLE AP) [**2140-10-15**] 1:55 AM
Reason: ?pulmonary edema vs PE
[**Hospital 93**] MEDICAL CONDITION:
58 year old woman with PMH of lung and breast cancer, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
flap, presenting with hypoxemia, hypotension and tachycardia
without clinical respiratory distress
REASON FOR THIS EXAMINATION:
?pulmonary edema vs PE
CHEST X-RAY
INDICATION: Pulmonary and breast cancer. Postop. Hypoxia,
hypotension, tachycardia.
COMPARISON: [**2140-10-14**].
FINDINGS:
There is diffuse alveolar opacification more marked in the mid
and lower zones bilaterally. There are bilateral pleural
effusions, mild on the left moderate on the right. These
findings are consistent with pulmonary edema. There is
deterioration in these findings compared to chest x-ray
performed one day earlier.
There is a Port-A-Cath in situ with its tip in the distal SVC.
IMPRESSION: Diffuse bilateral pulmonary edema with bilateral
pleural effusions.
*********
[**2140-10-16**] ECHO
CHEST (PORTABLE AP) [**2140-10-17**] 5:24 AM
Reason: improvement
[**Hospital 93**] MEDICAL CONDITION:
58 year old woman with hypoxemia, pulm edema?
REASON FOR THIS EXAMINATION:
improvement
HISTORY: Hypoxia and pulmonary edema; has this improved?
FINDINGS: In comparison with the study of [**10-15**], there is little
overall change. However, from the initial study of [**10-12**], there
has been a substantial increase in the bilateral opacifications.
This is consistent with the clinical diagnosis of pulmonary
edema, though widespread pneumonia or even ARDS could present a
similar pattern.
CHEST (PORTABLE AP) [**2140-10-21**] 10:05 AM
CHEST (PORTABLE AP)
Reason: F/u pulm infiltrates.
[**Hospital 93**] MEDICAL CONDITION:
58 year old woman with hypoxemia s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] flap. Diffuse pulm
infiltrates. O2 dependence.
REASON FOR THIS EXAMINATION:
F/u pulm infiltrates.
HISTORY: Hypoxemia with diffuse pulmonary opacifications for
comparison.
FINDINGS: In comparison with the study of [**10-17**], there is
substantial decrease is the still prominent interstitial
pattern. This is consistent with the clinical impression of
progressive clearing of pulmonary edema. Central catheter again
extends to the lower portion of the superior vena cava.
----
Swallow eval [**10-24**]:
1. There is penetration with thin liquids only, without evidence
of aspiration. If patient experiences changes in mental status,
would recommend repeat examination for further evaluation.
Brief Hospital Course:
Briefly, Ms. [**Known lastname **] was admitted to [**Hospital1 18**] on [**2140-10-12**] for elective
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5884**]. Post-operatively, she required re-intubation in the
PACU for respiratory distress which was attributed to
oversedation. Per propofol was weaned, and she was extubated
uneventfully. She remained tachycardic post-operatively, and
her flap continued to have dopplerable arterial and venous
signals. Her abdominal incisions were clean, dry, and intact
without appreciable drainage. Her 3 JPs remained to bulb
suction with appropriate serosanguinous drainage. She received
a 500NS bolus in PACU and her UOP responded accordingly.
POD#1 pt was afebrile, but remained tachycardic to 110s. all
home meds restarted.
POD#2 Pt triggered for O2 desaturation to 43%/3L NC. Pt placed
on NRB and her O2 sats rose to 97%. EKG, CXR, and ABG
performed. Pt placed on tele. Given 1u pRBC and lasix with
goal -2L. Over the day, pt became increasingly tachypneic, CXR
looked wet, so she was diuresed with lasix for presumed
pulmonary edema. Later that day, pt was transferred to TSICU
for 1:1 monitoring and continued diuresis.
POD#3 CTA negative for PE, but positive for interstitial lung
disease. Cardiology and pulmonology were consulted while pt was
treated in ICU.
-Pulm rec adding Levoflox
-trying to lower FiO2 and weaning trials
POD#5 cards s/o, did not think her pulm edema came from cardiac
source.
-pulm: s+s, video eval to r/o aspiration, chk viral resp cx,
bcx, sputum cx
vanco+cefepime x8d to tx presumed nosocomial pna
POD#6 +1u RBC hct 22.4->26.5 rose appropriately.
PT to get pt oob daily
hct 22.4 received 1uRBC/lasix -> hct rose appropriately to 26.5
-pulm: get s+s w video eval r/o asp, asp precautions, cbc/d,
send sputum for pcp as well
POD#8 no BM x7d, given dulcolax pr
continues OOB to chair, needs to increase ambulation w PT to
monitor desats
no cards/pulm input today
POD#9 PT stabilized on decreased O2 requirements, continued
ambulating OOB without significant desaturations, transferred to
floor.
S+S eval: no acute issues, no change in plan for now, appears to
be chr dysphagia
CXR:
POD#10 uneventful. continued to wean O2. ambulated with PT and
desaturated to 86% after walking 100 feet.
POD#11 had small bowel movements after lactulose added to bowel
regimen. O2 requirement down to 2L while in bed.
POD#12 abdominal JPs removed after draining little over the past
24h. She passed her speech and swallow video evaluation today.
Pt is to f/u with pulmonolgy in 1 month, she will be discharged
with home oxygen.
She will follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within 1 week, pulmonary
in 1 month
Medications on Admission:
Seroquel, Clonazepam, Zoloft, Lipitor, Arimidex, Hydrocodone,
Oxybutynin
Discharge Medications:
resume all home medications
1. oxygen
pt likely will require 2L oxygen by nasal canula continous for
2-4 weeks duration portable pulsed dosing system
2. Aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO
DAILY (Daily).
Disp:*qs Tablet, Chewable(s)* Refills:*2*
3. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO qd ().
4. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Sertraline 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation: take with pain
medications.
Disp:*30 Capsule(s)* Refills:*0*
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
L breast cancer
Discharge Condition:
stable
Discharge Instructions:
Please call your physician or go to the emergency room if you
develop chest pain, shortness of breath, fever greater than
101.5F, foul smelling or colorful drainage from your incisions,
redness or swelling, severe abdominal pain or distention,
persistent nausea or vomiting, inability to eat or drink, or any
other symptoms which are concerning to you.
Please do not get your incisions wet until your follow-up
appointment. If there is clear drainage from your incisions,
cover with a dry dressing. Leave white strips above your
incisions in place, allow them to fall off on their own.
Activity: You may resume activity limited to walking at home.
No overly strenuous activity. Speak with your surgeon during
your follow-up appointment regarding advancing your activity
level.
Medications: Resume your home medications. You should take a
stool softener with your pain medication. Your pain medication
may make you drowsy, so please do not drive while taking pain
medicine. Please DO NOT take aspirin or ibuprofen for 2 weeks.
Followup Instructions:
Call the office of [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD at [**Telephone/Fax (1) 6331**] to arrange
for a follow-up appointment within 1 week.
Call the office of [**First Name8 (NamePattern2) 4944**] [**Last Name (NamePattern1) **], MD (pulmonology) at ([**Telephone/Fax (1) 514**] to arrange for a follow-up appointment within 1 month.
Arrange for a follow-up appointment with your PCP.
Completed by:[**2140-10-24**]
|
[
"V10.3",
"V45.71",
"V10.11",
"486",
"518.4",
"496",
"285.9",
"515",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"99.04",
"85.84",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
12594, 12652
|
8691, 11443
|
299, 402
|
12712, 12721
|
1212, 1284
|
13800, 14254
|
884, 926
|
11566, 12571
|
7875, 8020
|
12673, 12691
|
11469, 11543
|
12745, 13777
|
941, 1193
|
244, 261
|
8049, 8668
|
430, 623
|
645, 816
|
832, 868
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,799
| 114,453
|
36454
|
Discharge summary
|
report
|
Admission Date: [**2119-10-20**] Discharge Date: [**2119-10-25**]
Date of Birth: [**2044-8-14**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 12131**]
Chief Complaint:
Right leg weakness
Major Surgical or Invasive Procedure:
- OPERATIONS:
1. Fusion T2-T8.
2. Extra cavitary decompression T5.
3. Laminectomies T4, t6
4. Instrumentation T2-8.
5. Cage placement at T5.
6. Autograft.
History of Present Illness:
This is a 75 year old male with a history of metastatic renal
cell carcinoma with metastasis to multiple ribs and lungs with
associated pleural effusions s/p Genentech study drug who
presents with right leg weakness, urinary retention, and
constipation over the past several days. Ordinarily, Mr
[**Known lastname 82579**] is able to ambulate with a walker without difficulty at
home - he prepares meals for himself at his home he shares with
his wife. Over the past few days, due to increasing weakness in
his right leg, he has had difficulty with walking. He has also
been constipated over this same time period, his last bowel
movement 5 days ago. His PO intake has been diminished over the
last several months, although he takes considerable fluids. He
has also described urinary retention over the past three months.
Otherwise, he denies any other extremity weakness, with no
numbness or tingling. Back pain is minimal at rest, although
coughing does make it worse. He recently had a pleurex catheter
in place for pleural effusion during last admission.
An MRI was performed on day of admission which reveals multiple
spinal mets with significant collapse of the T5 vertebral body
with epidural extension and marked canal narrowing with cord
impingement at this level. The other areas of metastases are
not associated with cord compression. For the MRI, the patient
was intubated for claustrophobia and anxiety treatment - he was
immediately extubated thereafter without need for supplemental
O2.
Neurosurgery saw the patient and plan on taking the patient to
the OR assuming that this plan is acceptable per the Oncology
team, based on their overall treatment plan.
At time of transfer to floor, the patient was comfortable with
no pain, but continued symptoms as described above.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-- On [**2117-7-22**], MRI revealed a 3.2 cm solid exophytic lesion
arising from the lower pole of left kidney suspicious for clear
cell renal cell carcinoma and a 1.6 cm solid lesion in the
anterior left pole of the left kidney and a 2.4 cm lesion in the
mid pole of the right kidney, both of which concerning for tumor
cell carcinoma, papillary type. He was referred to Dr. [**Last Name (STitle) 3748**]
on
[**2117-4-13**]. Given its small size, he was recommended to have
followup imaging ([**2117-7-22**] MRI at [**Hospital1 18**] compared to CT without
contrast from [**2117-4-2**]).
-- On [**2118-1-13**], he underwent repeat MRI, which showed no
significant change and bilaterally no masses.
-- On [**2118-9-28**], he underwent repeat MRI, which revealed
significant interval increase in the lower pole of the left
kidney obstructing mass, now measuring 4.9 x 3 cm from 3.1 x 2.7
cm and development of nodules in the perinephric fat, consistent
with extrarenal spread suspicious for clear cell renal cell
carcinoma, and there were also two other lesions that were
minimally increased in size. On [**2118-11-15**], he underwent
laparoscopic left radical nephrectomy, which revealed a 4.6 cm
clear cell carcinoma and a 2.8 cm papillary renal cell
carcinoma,
grade 3 tumors with tumor extension into the perinephric tissue
(T3a N0), 0/11. Of note, the clear cell renal cell carcinoma
shows no areas of signaling, no definitive sarcomatoid
differentiation.
Renal cell carcinoma is diffusely positive CA9, negative for CK7
and patchy positivity for P504s. The papillary renal cell
carcinoma is again diffusely positive for CK7 and P504s and
focally positive for CA9. Packs two shows focal weak staining
for both tumors with no after lymphovascular invasion as
identified on CT31 staining.
-- on [**2118-11-16**] Splenectomy showed vascular congestion with
subcapsular hematoma.
-- On [**2118-1-29**], the lesion in the pole of the right kidney most
consistent with papillary renal cell carcinoma is unchanged, and
fluid collection consistent with pseudocyst of one of the
pancreas is noted.
-- On [**2118-4-13**], he underwent partial right nephrectomy of the
2.6 cm papillary renal cell carcinoma, grade 2 (T1a Nx) with the
size of the tumor measured as a solid part 2.6 cm, adjacent cyst
continued minimal tumor. Specimen one in the belt of the cyst
adjacent to the tumor, right margin with papillary carcinoma
cauterized.
--On [**2119-4-15**], post-nephrectomy period complicated by fever and
treated for pneumonia. He was noted to have a low O2 and
underwent a chest x-ray, which noted a 5 cm elliptical opacity
in
the left upper hemi collapse with apparent adjacent local
destruction, new since [**18**]/[**2118**].
--On [**2119-4-17**], CT abdomen and pelvis revealed a 5.1 x 2.2 soft
tissue density lesion with destruction of the third posterior
lateral rib, fluid collection in the right partial nephrectomy
bed with a seroma. Coronary and aortic valve calcifications,
enlarged pulmonary artery, right lower lobe consolidation
concerning for pneumonia. A 7-mm right lung nodule, nonspecific
left upper lobe ground-glass opacity.
--On [**2119-10-1**] admitted for pleural effusion which was tapped by
IP. Interval need of supplemental O2. He was stopped on his
experimental therapy.
Past Medical History:
PMH: HTN, bilateral renal masses, HLD
PSH: splenectomy [**2118**], lap left radical nephrectomy [**2118**], R CEA
([**Doctor Last Name **]) [**2116**], hernia repair x 2
Social History:
He is a senior project coordinator for the Department of Mental
Health, specializes in [**Doctor First Name **] networks. He has a 50-pack-year
smoking history, continues to smoke one pack per day, occasional
alcohol, no drug use. He drinks rare alcohol. He is retired but
still works two days a week.
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM ON DISCHARGE:
Vitals - T: 97.6 BP: 118/52 HR: 65 RR: 18 02 sat: 96% 2L NC
GENERAL: NAD, tired appearing
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmers, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
BACK: Dressing c/d/i with drain in place
ABDOMEN: nondistended, [**Month (only) **] BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength 5/5 biceps and triceps
bilaterally, left hip flexors, plantar and dorsiflexion; 4- R
dorsiflexion, 4+ R hip flexors
Pertinent Results:
MR [**Name13 (STitle) 1093**] [**10-20**]: There are multiple vertebral body metastases
demonstrated. These are identified at T1, T2, T4, T5, and
sacrum. The largest of these lesions is at T5 where there is
collapse of the vertebral body, to a considerably greater extent
than present on the [**9-26**] CT scan. There is extensive
soft tissue extending from the posterior vertebral body into the
spinal canal producing severe spinal cord compression at T5.
Tumor extends into the canal from the T2 body and just touches
the left anterior surface of the spinal cord. Tumor also
extends into the canal from the T4 body, again touching the
anterior surface of the cord. There is no evidence of cord or
cauda equina compromise at the other metastatic levels.
At the level of most severe spinal compression, there is
hyperintensity in the spinal cord on the long TR images,
presumably edema related to severe compression.
The metastases enhance after contrast administration. No
intradural tumor is identified.
Again noted are multiple other metastases in the chest wall,
incompletely
evaluated on this examination. Also again seen are bilateral
pleural
effusions, greater on the left than right.
CONCLUSION: Multiple spinal vertebral metastases with collapse
of the T5 vertebral body and a soft tissue extending into the
canal at this level producing severe spinal cord compression.
Soft tissue extends into the canal at T2 and T4 contacting the
spinal cord but not producing cord compression.
Brief Hospital Course:
Mr. [**Name13 (STitle) 54864**] is a 75M with metastatic renal cell carcinoma with
known malignant right sided pleural effusion s/p recent drainage
who presented with several days of right sided leg weakness,
urinary retention for several weeks/months and constipation,
with radiographic evidence of cord compression at the level of
T5 as above.
1) Cord compression - Upon admission, Mr. [**First Name (Titles) 82581**] [**Last Name (Titles) 23156**]
clinical signs of cord compression, including right leg
paralysis and radiographic evidence of T8 cord invasion. He
underwent operative intervention on [**2119-10-22**] with decompression
at the level of the T5 lesion, fusion T2-T8, laminectomies at T4
and T6, instrumentation T2-8, cage placement at T5, and
autografting. Please see the operative report for complete
details. Following this procedure, his strength improved. He was
placed on a post-operative steroid taper, starting at
dexamethasone 6mg IV q6hrs to be tapered down by 1mg q6hrs every
other day. This regimen was converted to PO on the day of
discharge. He was discharged taking 4mg PO q6hrs. His next
adjustment was to be a decrease to 3mg PO q6hrs, to be initiated
48 hours after discharge.
2) Pleural Effusion - Patient was recently discharged after
drainage of a recurrent malignant right pleural effusion and
placement of Pleurx catheter. Admission CXR demonstrated a
stable/slightly decreased effusion. He was saturating well on
room air at time of discharge. This collection was drained every
other day per his regular scheduled.
3) Hyponatremia - Stable sodium at 132 upon admission.
Previously attributed to SIADH. Stable throughout this
hospitalization; sodium equal to 133 on day of discharge.
4) Hypercalcemia - Calcium at admission 10.4. Previous
admissions with suspicion of etiology secondary to combination
of bony metastases and paraneoplastic hypercalcemia, though no
definitive work-up for PTHrP performed. Managed well via
intravenous fluids. Corrected calcium equal to 9.1 on day of
discharge.
4) Leukocytosis - Patient with persistent leukocytosis of
several years - attributed on previous admissions to be
secondary to his renal cell carcinoma. Relatively stable
througout admission, though did exhibit increase in WBC count
status-post initiation of dexamethasone therapy. WBC count equal
to 21.4 on day of discharge, comparable to previous values.
Expected to trend downwards with tapering of steroids as above.
5) Thrombocytosis - Patient's thrombocytosis attributed to
previous splenectomy/hyposplenism.
6) Metastatic renal cell carcinoma - Had been receiving Genetech
study drug, but discontinued on recent admission secondary to
dyspnea and progressive disease. Mr. [**Name13 (STitle) 54864**] is to follow-up as
an outpatient for re-evaluation and initiation of chemotherapy.
CHRONIC ISSUES:
7) Hyperlipidemia - continued simvastatin.
8) Hypertension - continued metoprolol.
==========================================
TRANSITIONAL ISSUES:
- Mr. [**Known lastname 82579**] remained full code throughout his
hospitalization.
- His HCP is [**Name (NI) 2411**] [**Name (NI) 44263**] (girlfriend of many years):
[**Telephone/Fax (1) 82582**], Cell phone: [**Telephone/Fax (1) 82583**]
- He will require outpatient follow-up with [**First Name8 (NamePattern2) 20062**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
NP [**Telephone/Fax (1) 63699**] after discharge.
- He has an appointment with Dr. [**Last Name (STitle) **] (neurosurgery) on
TUESDAY [**2119-10-31**] at 9:30 AM
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Metoprolol Tartrate 25 mg PO BID
4. Senna 1 TAB PO BID:PRN constipation
5. Simvastatin 10 mg PO DAILY
6. Tamsulosin 0.4 mg PO BID
7. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
Breakthrough pain. Hold for RR < 12.
8. Bisacodyl 10 mg PO DAILY
9. Morphine SR (MS Contin) 30 mg PO Q8H
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
2. Polyethylene Glycol 17 g PO DAILY constipation
3. Tamsulosin 0.4 mg PO BID
4. Simvastatin 10 mg PO DAILY
5. Dexamethasone 4 mg PO Q6H Duration: 48 Hours
6. Ondansetron 4 mg IV Q8H:PRN nausea
7. Pantoprazole 40 mg PO Q24H
8. Metoprolol Tartrate 25 mg PO BID
9. Morphine SR (MS Contin) 30 mg PO Q8H
RX *morphine 30 mg 1 tablet(s) by mouth q8hrs Disp #*52 Tablet
Refills:*0
10. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
Breakthrough pain. Hold for RR < 12.
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth q4hrs
Disp #*80 Tablet Refills:*0
11. Senna 1 TAB PO BID:PRN constipation
12. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
PRIMARY:
- metastatic renal cell carcinoma
SECONDARY:
- T5 cord compression
- hypercalcemia
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. [**Last Name (Titles) 54864**],
Thank you for choosing [**Hospital1 18**] for your medical care. You were
admitted to the hospital for compression of your spinal cord
caused by a metastatic lesion from your renal cancer. You
underwent surgery to relieve this compression. You did well.
Upon discharge, please keep all of your scheduled appointments
with your doctors. Please take all medications as prescribed.
Refrain from driving while taking pain medication.
Please return to the hospital or call Dr.[**Name (NI) 9034**] office at
[**Telephone/Fax (1) 3231**] if you experience any of the following: fever,
chills, night sweats, loss of conciousness, chest pain, trouble
breathing, opening of your incision, foul smelling or pus-like
discharge from your wound, worsening back pain, increasing
weakness, or any other symptoms that concern you.
Spine Surgery recommendations per Dr. [**Last Name (STitle) 14354**] [**Name (STitle) **]:
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
?????? Dressing may be removed on Day 2 after surgery.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any medications such as Aspirin unless directed by
your doctor.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
You will have a follow-up appointment in approximately 2 weeks
with Dr. [**Last Name (STitle) **] and [**First Name8 (NamePattern2) 622**] [**Last Name (NamePattern1) 17265**] to discuss chemotherapy
options. They will call you with an appointment. Please call
[**First Name8 (NamePattern2) 20062**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 63699**] if you have not heard from
them within approximately one week.
Neurosurgery Follow-up:
Wound check w/ Nurse [**Month (only) **]
Date: Tuesday, [**2119-10-31**]
Time: 9:30am
Location: [**Hospital Ward Name 517**], [**Hospital Unit Name **] ([**Hospital Unit Name 12193**])
[**Last Name (NamePattern1) 439**], [**Location (un) 86**], [**Numeric Identifier 718**]
T-Spine CT scan **NPO 3 hrs prior to scan**
Date: Tuesday, [**2120-1-30**]
Time: 1:30pm
Location: [**Hospital Ward Name 517**], Clinical Center ([**Location (un) 470**])
[**Hospital1 7768**], [**Location (un) 86**], [**Numeric Identifier 718**]
[**First Name8 (NamePattern2) **] [**Doctor Last Name **], M.D, PhD
Date: Tuesday, [**2120-1-30**]
Time: 2:30pm
Location: [**Hospital Ward Name 517**], [**Hospital Unit Name **] ([**Hospital Unit Name 12193**])
[**Last Name (NamePattern1) 439**], [**Location (un) 86**], [**Numeric Identifier 718**]
If you know that you will not be able to keep your appointment,
please give us a call and we will be happy to re-schedule your
appointment for you. Please call [**Telephone/Fax (1) 3231**].
Department: NEUROLOGY
When: MONDAY [**2119-10-30**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12567**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1844**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROSURGERY
When: TUESDAY [**2119-10-31**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 82584**], NP [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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32,551
| 190,198
|
31624
|
Discharge summary
|
report
|
Admission Date: [**2123-8-14**] Discharge Date: [**2123-8-24**]
Date of Birth: [**2044-7-29**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Intracranial Hemorrhage
Major Surgical or Invasive Procedure:
Craniectomy and evacuation of intracerebral hemorrhage
History of Present Illness:
79 yo male with no known pmh who presents with intracranial
hemorrhage after fall of unclear etiology. Per EMS reports,
patient was at a store and fell backwards and hit his head with
proable LOC. The fall was not reportedly witnessed. EMS was
called and en route to OSH, the patient reportedly had a 2
minute generalized tonic clonic seizure treated with 2 mg IV
ativan. At OSH, he reported had CT findings of subdural
hematoma and parietal bone fracture. He was then transferred to
[**Hospital1 18**] for neurosurgical evaluation.
ROS: Patient reports no HA, neck pain, SOB, CP, abdominal pain,
visual changes, dysarthia, dysphagia, or diplopia.
Past Medical History:
Unknown
Social History:
Lives alone, denies smoking history. Unclear ETOH/drug history.
Family History:
deferred
Physical Exam:
T: 96.2 BP: 128-144/60-70 HR: 64-67 R [**1-30**] 96%O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRLA. EOMI.
Neck: c-collar on.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.MAE without complaints of pain
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, "[**Hospital1 756**] and Woman's Hospital",
reports date as "[**2094-2-11**]" despite prompting
Recall: [**2-17**] objects at 5 minutes.
Attention: DOW forwards but not backwards.
Language: Speech fluent with good comprehension to follow
midline
and appendicular.
Naming intact to hi frequency objects. No dysarthria or
paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields to threat intact.
III, IV, VI: Extraocular movements intact bilaterally with
primary and end gaze nystagmus
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements.
Has intention tremor bilaterally. Strength full power [**6-19**]
throughout. Both arms drift slightly with pronator drift.
Sensation: Intact to light touch, propioception, pinprick.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Withdraws bilaterally
Coordination: normal on finger-finger movement. Gets confused
when asked to do heel to shin. Has slow fingers taps.
Pertinent Results:
CT c-spine: No acute fracture or malalignment of the cervical
spine. Mild retrolisthesis at the C4-5 level.
Trop-T: <0.01
Comments: cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
.
TRAUMA
142 106 25 110 AGap=17
4.5 24 1.4
estGFR: 49/59 (click for details)
CK: 145 MB: 6
Ca: 9.1
ALT: 26 AP: 77 Tbili: 0.3 Alb: 4.3
AST: 37 LDH: Dbili: TProt:
[**Doctor First Name **]: 162 Lip:
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative
WBC 14.0 Hgb 13.5 Plts 258 Hct 38.5
N:82.6 L:11.0 M:4.9 E:1.1 Bas:0.4
PT: 11.7 PTT: 24.0 INR: 1.0
UA: neg nits and leu, mod blood
Brief Hospital Course:
Mr. [**Known lastname **] is 79 year old male with an unknown past medical
history who presented with intracerebral hemorrhage following a
reported fall. CT scan revealed extensive L frontal
intraparenchymal hemorrhage with large subdural component. He
was admitted to the trauma ICU service and on HD #2 developed
worsened mental status with CT evidence of midline cerebral
shift. He was taken emergently to the OR for craniectomy and
evacuation of the hemorrhage. Follow up CT scanning revealed
improvement in midline shift. The patient continued to have
severely depressed mental status, unable to follow verbal
commands, right upper and lower extremity hemiparesis, with
occasional spontaneous flexion of left upper and lower
extremities. The patient required appointment of a temporary
guardian ([**Name (NI) 3608**] [**Name (NI) 4334**] [**Telephone/Fax (1) 74331**]). Given his depressed mental
status and inability to protect or maintain adequate upper
airway patency the patient went for tracheostomy and PEG
placement [**2123-8-22**].
At time of discharge to extended care facility the patient was
tolerating trach mask and tube feedings. From his extended care
facility at [**Hospital1 **] Care in [**Location (un) 1456**], he should follow up in
neurosurgery clinic with Dr. [**Last Name (STitle) 739**] in 5 weeks with a
repeat head CT scan.
Medications on Admission:
Unknown
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. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
3. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
5. Tube Feedings
per nutrition recommendations
6. Phenytoin 100 mg/4 mL Suspension Sig: One (1) PO Q8H (every
8 hours).
7. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Intracerebral hemorrhage
Discharge Condition:
fair. neurologic exam stable.
Discharge Instructions:
Admission for intracerebral hemorrhage.
Alert physician or return to emergency department for depressed
mental status, fever or any other concerning symptoms.
Followup Instructions:
You have an appointment to see Dr. [**Last Name (STitle) 66048**] with
neurosurgery in 5 weeks with a follow up head CT scan.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
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|
1126, 1192
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,212
| 148,135
|
4663+55594
|
Discharge summary
|
report+addendum
|
Admission Date: [**2145-6-2**] Discharge Date: [**2145-6-17**]
Date of Birth: [**2073-4-9**] Sex: M
Service: CARDIAC SURGERY
CHIEF COMPLAINT: Chest pain
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old
male with multiple medical problems, including three types of
cancer, bladder, skin and kidney, coronary artery disease,
recurrent deep venous thrombosis and pulmonary emboli, status
post stent implantation, who presents with chest pain for
three to four days, described to be gradual in onset, and not
being relieved with nitroglycerin.
PAST MEDICAL HISTORY: Anterior myocardial infarction in
[**2138**], stent implantation in [**2138**], Persantine MIBI showed
fixed anterior apical defect consistent with a total
occlusion of the obtuse marginal I in 12/00.
Gastroesophageal reflux disease, total hip replacement due to
osteoarthritis, upper gastrointestinal bleed in [**2137**], renal
cell carcinoma in [**2129**] status post left nephrectomy, bladder
cancer four years ago status post chemotherapy, squamous cell
skin carcinoma on abdomen six years ago,
hypercholesterolemia, right carotid endarterectomy, multiple
deep venous thromboses, multiple transient ischemic attacks
and embolic cerebrovascular accidents, recurrent deep venous
thromboses, history of motor vehicle accident.
MEDICATIONS ON ADMISSION: Nexium 40 mg once daily, Digoxin
.25 mg once daily, Zocor 40 mg once daily, Captopril 25 mg
three times a day, Isordil 20 mg twice a day, Lopressor 50 mg
twice a day, vitamin E 1600 units, multivitamin, fish oil,
aspirin 325 mg once daily, Ambien and Coumadin.
HOSPITAL COURSE: The patient was admitted under the Medical
service. He was investigated. His chest CTA revealed
multiple filling defects, consistent with acute on chronic
pulmonary emboli. He was started on an intravenous heparin
drip as he was subtherapeutic on his Coumadin, with an INR of
1.6. His troponin was elevated as well. He [**Year (4 digits) 1834**] lower
extremity noninvasive vascular studies, which were negative
for clot.
A Pulmonary consult was obtained at this time, and he was
started on Levaquin. Because of a strong history of deep
venous thrombosis and pulmonary emboli and pending cardiac
surgery, Pulmonary consult recommended placement of an
inferior vena cava filter. Mr. [**Known lastname 1356**] [**Last Name (Titles) 1834**] placement of
an inferior vena cava filter on [**2145-6-7**]. Subsequently
Cardiothoracic Surgery was consulted, and he was taken to the
operating room. He was symptomatically comfortable at this
time.
On [**2145-6-8**], he [**Date Range 1834**] coronary artery bypass graft x 3
which was off-pump, with left internal mammary artery to
diagonal, left radial to left anterior descending, left
saphenous vein graft to posterior descending artery. He
tolerated the procedure well, and was transferred to the
Intensive Care Unit in an intubated condition. He remained
intubated over the next couple of days and on a heparin drip.
He was extubated on postoperative day two. He had
gram-negative rods in his sputum and gram-positive cocci at
this point, and therefore was started on Levaquin.
He continued to make slow progress. His heart rate was
irregular, and he was started on amiodarone. During the
subsequent days, he had a few periods of confusion, which
later resolved. His condition continued to improve with
chest physical therapy. He was ready for transfer to the
floor on postoperative day seven, in a stable condition.
He is now ready for discharge, awaiting a rehabilitation bed.
DISCHARGE MEDICATIONS: Plavix 75 mg once daily, isosorbide
mononitrate 60 mg once daily, enteric-coated aspirin 325 mg
once daily, lasix 20 mg once daily for one week, potassium
chloride 20 mEq once daily for one week, Coumadin 2 mg at
bedtime, amiodarone 400 mg once daily, Zocor 40 mg once
daily, Ambien 5 mg at bedtime, percocet one to two tablets
every four to six hours as needed, Levaquin 500 mg once daily
for seven days.
FOLLOW UP: With primary care physician in two weeks, and
with Dr. [**Last Name (STitle) 1537**] in four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2145-6-17**] 21:39
T: [**2145-6-18**] 00:36
JOB#: [**Job Number 19716**]
Name: [**Known lastname **], [**Known firstname **] J. Unit No: [**Numeric Identifier 3255**]
Admission Date: [**2145-6-2**] Discharge Date: [**2145-6-24**]
Date of Birth: [**2073-4-9**] Sex: M
Service: Cardiac [**Doctor First Name **]
DISCHARGE SUMMARY ADDENDUM: Amended discharge date [**2145-6-24**].
The patient's discharge was delayed for several days. Around
the time he was scheduled to be transferred to
rehabilitation, he had an increased in his white blood cell
count to as high as 18,000. He was afebrile with this and
remained asymptomatic without complaint. He had multiple
urine specimens that were sent to the lab that were negative
both by dip stick and by culture. He had no infiltrate on his
chest x-ray and his wounds remained without erythema.
During this time he had been covered with antibiotics for a
positive respiratory culture that had originally be obtained
in the ICU. His Vancomycin was continued for approximately
six days as his white count started to trended down, this was
discontinued. His Levaquin was continued for approximately
two days after that and was also discontinued.
The patient remained afebrile off of antibiotics and his
white count decreased to 13,000. The following day his white
count had trended back upwards to approximately 15,000.
However given the absence of a fever and the absence of any
clinical symptoms, we stopped checking his white blood cell
count and simply followed him clinically. After this time it
was felt the patient was safe to be discharged. Proper
arrangements were made.
During this period in discharge delay he continued to work
with inpatient Physical Therapy. By the time he was ready for
discharge he did not need acute inpatient rehabilitation any
more and was safe to be discharged home.
On [**2145-6-24**] the patient was discharged home in stable
condition with visiting nurse assistance.
DISCHARGE MEDICATIONS:
1. Plavix 75 mg po q day.
2. Isosorbide Mononitrate 60 mg po q day.
3. Enteric coated aspirin 325 mg po q day.
4. Coumadin 2 mg po q HS.
5. Amiodarone 400 mg po q day.
6. Zocor 40 mg po q day.
7. Ambien 5 mg po q HS.
8. Percocet one to two po q four to six hours prn.
His Levaquin course within the hospital had been completed.
In addition clinically he did not need any more Lasix or
potassium.
The patient's Coumadin will be followed by his primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) 1431**]. His office is [**Telephone/Fax (1) 3256**]. As
part of discharge planning, his office was contact[**Name (NI) **] and they
agreed to follow his INR. He will be checked as an outpatient
and results will be phone to them.
[**First Name11 (Name Pattern1) 63**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1509**]
Dictated By:[**Last Name (NamePattern1) 1295**]
MEDQUIST36
D: [**2145-6-24**] 11:48
T: [**2145-6-25**] 10:17
JOB#: [**Job Number 3257**]
|
[
"412",
"414.00",
"425.4",
"415.19",
"263.9",
"E878.2",
"997.3",
"411.1",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"88.56",
"36.15",
"38.7",
"37.23",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
6350, 7447
|
1353, 1615
|
1634, 3580
|
4024, 6327
|
163, 175
|
205, 573
|
596, 1325
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
256
| 153,771
|
43790+58658
|
Discharge summary
|
report+addendum
|
Admission Date: [**2166-7-21**] Discharge Date: [**2166-7-23**]
Service: MED
The patient was in the Fenard ICU.
HISTORY OF PRESENT ILLNESS: This is a 79-year-old male with
a history of coronary artery disease status post right
coronary stent, deep venous thrombosis, paroxysmal atrial
fibrillation, chronic obstructive pulmonary disease,
abdominal aortic aneurysm, peptic ulcer disease, hypertension
presenting from [**Hospital3 2558**] with confusion, hematemesis,
and high white count. The patient was recently admitted from
[**2166-2-6**] to [**2166-2-14**] for a right hip open reduction
internal fixation status post a fall. He was also treated
with Levofloxacin from [**2166-7-15**] to [**2166-7-22**] for presumed
urinary tract infection. On admit he complained of several
bouts of diarrhea over the past few days prior to admission
as well as fevers and chills. He has a history of recurrent
aspiration pneumonia but did not complain of a cough.
The day prior to admit he complained of abdominal pain
diffusely with bloody emesis times one concurrent with a
nosebleed. The morning of admission he was found to be
diaphoretic, pale, and his white count was elevated to 34.
In the Emergency Department he received vancomycin,
ceftriaxone, and Flagyl empiric. His hematocrit was found to
be 29 and decreased to 17. After one unit of packed red
cells it was improved to 26. He was guaiac negative and
trace guaiac positive brown stool. Nasogastric lavage was
clear with flecks of blood. Chest x-ray was negative.
Abdominal CT showed no acute process. His systolic blood
pressure in the Emergency Department dropped to the 80s which
was responsive to intravenous fluid boluses. His heart rate
also transiently decreased to the 40s with an atrial
arrhythmia. He was given two liters of normal saline as well
as two units of packed red cells.
PAST MEDICAL HISTORY: Coronary artery disease status post
non-ST elevation myocardial infarction
Status post right coronary artery stent in [**2-/2166**] with two-
vessel disease, diastolic dysfunction, ejection fraction 60
percent
Deep venous thrombosis [**3-/2166**] on Coumadin
Status post right hip open reduction internal fixation in
[**7-/2166**]
Paroxysmal atrial fibrillation
Mild chronic obstructive pulmonary disease
Abdominal aortic aneurysm repair
Diverticulosis
Peptic ulcer disease/gastroesophageal reflux disease
Hypertension
Hyperlipidemia
Depression
Carotid stenosis
Osteoarthritis
Benign prostatic hypertrophy status post transurethral
resection of the prostate
Chronic renal insufficiency with baseline creatinine of 1.6
to 1.8
MEDICATIONS:
1. Lopressor 50 mg p.o. b.i.d.
2. Atorvastatin 10 mg q.d.
3. Venlafaxine 150 mg q. a.m., 225 mg q. p.m.
4. Aspirin 325 mg q.d.
5. Protonix 40 mg q.d.
6. Colace 100 mg b.i.d.
7. Atrovent nebulizer and Albuterol nebulizer p.r.n.
8. Calcium carbonate 500 mg p.o. t.i.d.
9. Vitamin D 400 units q.d.
10. Alprazolam 1 to 2 mg q. h.s. p.r.n.
11. Trazodone 25 mg q. h.s. p.r.n.
12. Senna
13. Percocet one to two tabs p.o. q. 4 to 6 hours p.r.n.
14. Coumadin 3 mg q. h.s.
15. Levofloxacin 250 mg q.d. Finish course [**2166-7-22**].
ALLERGIES: No known drug allergies.
PERTINENT LABORATORY DATA ON ADMIT: His white count was
34.5, hematocrit 29, 17, and then 26, INR 1.3, BUN 67,
creatinine 1.8, anion gap 15, cardiac enzymes negative times
three, haptoglobin normal. Urinalysis showed positive
nitrites, moderate bacteria, trace leukocyte esterase, 11 to
20 white blood cells, 0 red blood cells, lactate 6 and on
repeat 2.2.
CT of the abdomen and pelvis showed bibasilar atelectasis
with relative sparing of subpleural region. Abdominal aortic
aneurysm unchanged to prior study.
Chest x-ray: No acute cardiopulmonary process.
EKG in Emergency Department during a bout of hypotension
showed [**Street Address(2) **] depressions anterolaterally with resolution
of depressions on the floor.
HOSPITAL COURSE BY PROBLEM: Hematemesis: The patient was
transfused a total of four units of packed red blood cells
and continued to have a stable hematocrit checked every six
hours. EGD was done by Gastroenterology which showed no
active bleeding and was consistent with erosive esophagitis.
He was continued on Protonix 40 mg q.d. Likely, his
hematemesis was secondary to his episode of epistaxis the day
prior to admit. H. pylori is pending.
Infectious Disease: Patient's white count was 34 on admit.
He had low-grade temperatures to 99 and 100 degrees
Fahrenheit. He was started empirically on a course of p.o.
Flagyl to cover for Clostridium difficile as the patient was
recently on Levofloxacin and complained of diarrhea prior to
admit. His urinalysis was also a positive. On admit he was
started on ceftriaxone as well as vancomycin. This was
switched to Bactrim before discharge. Cultures are pending.
Deep venous thrombosis: The patient has a history of a deep
venous thrombosis in [**3-/2166**] on Coumadin with a goal INR of 2
to 3. He was given two doses of vitamin K at [**Hospital3 2558**]
before transfer. His INR on admit was 1.3. As the patient
could not be anticoagulated on the first night, inferior vena
cava filter was placed and after the normal EGD, his Coumadin
was resumed.
Pulmonary: The patient is on Albuterol and Atrovent
nebulizers. He was 7 to 8 liters positive during the course
of this stay and mildly fluid overloaded. He required two
liters oxygen by nasal cannula and responded well to Lasix
during his diastolic cardiac dysfunction. He will be
discharged on 20 mg p.o. q.d.
Renal: Patient's creatinine improved to baseline and anion
gap resolved, likely from a non-gap metabolic acidosis from
his prior diarrhea.
Coronary artery disease status post stent: He was continued
on his aspirin and Plavix.
Fluids, electrolytes, and nutrition: The patient's diet was
advanced and he tolerated it well before discharge.
Contact: Wife.
Full Code.
DISPOSITION: The patient will be discharged back to [**Hospital3 7511**] for continued rehabilitation after his open reduction
internal fixation.
DISCHARGE STATUS: Good.
DISCHARGE MEDICATIONS:
1. Coumadin 3 mg p.o. q. h.s.
2. Protonix 40 mg p.o. q.d.
3. Aspirin 81 mg p.o. q.d.
4. Plavix 75 mg p.o. q.d.
5. Percocet one to two tabs p.o. q. 4 to 6 hours p.r.n.
6. Flagyl 500 mg p.o. t.i.d. times 12 days
7. Bactrim one tablet p.o. b.i.d. times seven days
8. Trazodone 12.5 mg p.o. q. h.s. p.r.n.
9. Albuterol and Atrovent nebulizers q. 6 hours p.r.n.
10. Venlafaxine 150 mg p.o. q. a.m., 225 mg q. p.m.
11. Lipitor 10 mg p.o. q.d.
[**First Name11 (Name Pattern1) 122**] [**Last Name (NamePattern4) 24325**], [**MD Number(1) 24326**]
Dictated By:[**Last Name (NamePattern1) 35922**]
MEDQUIST36
D: [**2166-7-23**] 11:26:52
T: [**2166-7-23**] 15:31:50
Job#: [**Job Number 94092**]
Name: [**Known lastname 14877**],[**Known firstname 33**] Unit No: [**Numeric Identifier 14878**]
Admission Date: [**2166-7-21**] Discharge Date: [**2166-7-28**]
Date of Birth: [**2086-7-31**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 211**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
IVC filter placement [**2166-7-22**]
EGD [**2166-7-22**]
Brief Hospital Course:
Addendum to hospital course:
Hematemesis: The patient??????s hematocrit remained stable. H pylori
was negative. The patient did have a tarry melanotic stool on
[**7-27**], however, his hematocrit remained very stable in the 35-37
range, and so this was thought to represent old blood that the
patient was passing. He should have an outpatient colonoscopy
and perhaps evaluation of his small bowel to evaluate for any
source of bleeding.
Infectious Disease: The patient??????s WBC came down significantly on
bactrim and metronidazole. He remained afebrile without diarrhea
or dysuria. He should continue to complete a 7 day course of
bactrim (ending [**7-30**]) and a 14 day course of metronidazole
(ending [**8-4**]).
DVT: The patient has a filter in place. If the decision is made
to remove the filter, this will have to be done within 2 weeks
of placement ([**2166-8-4**]). Interventional radiology should be
called to arrange this. He received 1 mg SC vitamin K on [**7-25**]
for an INR of 7.3 (repeat 4.9). His INR before discharge was
1.8. At this point, the decision was made to hold coumadin
despite the patient??????s Atrial fibrillation. This can be
re-addressed on an outpatient basis with the patient??????s PCP.
Pulmonary: The patient was continued on albuterol and atrovent
nebulizer treatments. He had no further evidence of fluid
overload, no oxygen requirement and required no more lasix. If
he develops shortness of breath or evidence of fluid overload,
small doses of lasix (20mg po) should be considered.
Psych: The patient was seen by psychiatry to evaluate his
capacity and suicidal risk. The patient was noted to have no
evidence of psychosis, delirium, dementia. Although he did
report some symptoms of depression and suicidal thoughts, he was
not at risk of suicide acutely. At one point, the patient
requested to go home for 3 days prior to going to rehab.
Although he was secretive about reason for wanting to go home,
it was determined that he convincingly denies that this involves
any suicidal or otherwise dangerous activity.
Renal: The patient??????s creatinine increased somewhat from 1.1-1.4
but this was below his baseline of 1.5-1.7. He has been stable
at 1.4.
CAD: The patient was continued on ASA, plavix and metoprolol.
His blood pressure was still somewhat high in the 140-150s, and
he may need another [**Doctor Last Name 932**] to control his BP to be started if he
is still hypertensive as an outpatient.
Contact: daughter: [**Name2 (NI) 14880**] home ([**Telephone/Fax (1) 14881**])
work (wknd and even): [**Telephone/Fax (1) 14882**]
work (weekdays): [**Telephone/Fax (1) 14883**] (ext 325)
FULL CODE
Discharge Medications:
1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Venlafaxine HCl 75 mg Tablet Sig: Two (2) Tablet PO QAM (once
a day (in the morning)).
3. Venlafaxine HCl 75 mg Tablet Sig: Three (3) Tablet PO QPM
(once a day (in the evening)).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
6. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 2 days.
11. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**5-13**]
hours.
12. Seroquel 25 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 2196**] [**Last Name (un) 4454**] - [**Location (un) 729**]
Discharge Diagnosis:
Epistaxis
Presumed Urinary Tract Infeciton and Clostridium Difficile
colitis
Deep Venous Thrombosis status post Inferior vena cava filter
Erosive esophagitis
status post Right hip ORIF
Coronary artery disease s/p stent
Diastolic cardiac dysfunction
Discharge Condition:
good
Discharge Instructions:
Please complete 7 day course of Bactrim 1 tab po BID for
presumed UTI and Flagyl 500 mg po TID (14 day course) for
presumed C. diff colitis.
Please call your doctor or return to ED if you have temperatures
> 101.5, severe chest pain, shortness of breath, bleeding or if
your symptoms worsen.
Followup Instructions:
Follow up with your PCP [**Last Name (NamePattern4) **] [**2-7**] weeks.
Provider: [**Name10 (NameIs) **] SCAN Where: [**Hospital6 189**] RADIOLOGY
Phone:[**Telephone/Fax (1) 491**] Date/Time:[**2166-9-1**] 2:30
Provider: [**Name10 (NameIs) 1421**] BREATHING TESTS Where: [**Hospital6 189**]
Phone:[**Telephone/Fax (1) 1422**] Date/Time:[**2166-9-4**] 3:45
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 189**]
Date/Time:[**2166-9-4**] 4:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**] MD [**MD Number(1) 225**]
Completed by:[**2166-7-28**]
|
[
"496",
"784.7",
"427.31",
"V45.82",
"276.2",
"441.4",
"599.0",
"008.45",
"578.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11282, 11385
|
7427, 7439
|
7345, 7404
|
11678, 11684
|
12025, 12708
|
10152, 11259
|
11406, 11657
|
7457, 10129
|
11708, 12002
|
7294, 7307
|
4001, 6154
|
154, 1873
|
1896, 3972
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,230
| 166,249
|
54639
|
Discharge summary
|
report
|
Admission Date: [**2136-9-5**] Discharge Date: [**2136-9-20**]
Date of Birth: [**2057-5-30**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
[**2136-9-5**] Embolization of lower left renal pole artery
[**2136-9-11**] ORIF tibia right; placement of IVC filter right grion;
chest tube placement [**Location (un) **]
[**2136-9-12**] T12-L2 POSTERIOR SPINAL STABILIZATION INSTRUMETATION
History of Present Illness:
79 yo man w/ PMH of Afib on pradaxa, was the restrained front
seat passenger in a motor vehcile crash going ~45 mph. He
presented initially to [**Hospital3 **] hospital and was intubated and a
left chest tube placed. At presentation to [**Hospital1 18**] he was
hypotensive to 70's/palp, with OSH CT demonstrating hemothorax
with rib fractures to [**8-8**] and bilateral pelvic fractures.
Past Medical History:
HTN, afib
Social History:
Married and resides in [**State 531**] with his wife
Family History:
Noncontributory
Physical Exam:
Upon presentation to [**Hospital1 18**]:
Constitutional: The patient does not grimace, wince, or
exhibit other objective sign of distress
HEENT: NC/AT
Moist mucous membranes
Chest: CTA
Cardiovascular: No murmur
Abdominal: No guarding, rigidity, or rebound
Rectal: no rectal tone
GU/Flank: No CVAT
Extr/Back: Trace edema
Skin: No rash
Neuro: the patient shows no spontaneous movement
Psych: obtunded
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Pertinent Results:
[**2136-9-5**] 09:15PM GLUCOSE-138* UREA N-14 CREAT-0.8 SODIUM-145
POTASSIUM-3.7 CHLORIDE-112* TOTAL CO2-22 ANION GAP-15
[**2136-9-5**] 09:15PM CALCIUM-7.0* PHOSPHATE-5.0* MAGNESIUM-1.7
[**2136-9-5**] 09:15PM WBC-5.5 RBC-3.36* HGB-10.6* HCT-30.2* MCV-90
MCH-31.6 MCHC-35.1* RDW-15.9*
[**2136-9-5**] 09:15PM PLT COUNT-66*
[**2136-9-5**] 09:15PM PT-15.4* PTT-45.8* INR(PT)-1.4*
IMAGING:
[**9-6**] MR [**Name13 (STitle) **]: No ligamentous injury or signs of bony injury.
[**9-6**] MR [**Name13 (STitle) **]: Transverse fracture which appears to extend
through pedicles (Chance fracture). CT lumbar spine can help for
better assessment as clinically indicated. Edema in sacrum
indicates a fracture.
[**9-6**] CT R knee/prox tibia: Comminuted intraarticular fracture of
the proximal tibia with fracture lines extending into the medial
and lateral tibial plateaus (400, 45 and 50). The dominant
fracture line is transverse through the metaphysis and likely
involves the insertion of the patellar tendon. There is mild
impaction and postero-lateral displacement of the distal
fragment.Minimally displaced fracture of the proximal fibula
(401b, 19). Hemorrhagic knee effusion. Severe degenerative
changes and diffuse osteopenia.
[**9-6**] am CXR: The assessment of the lung films reveals no
interval development of new abnormalities besides the right
middle lobe atelectasis that is apparently new. Bilateral small
pleural effusions are better appreciated on the CT torso.
[**9-6**] pm CXR: No change from [**2136-9-6**]. Left basilar opacity is
likely
atelectasis, but supervening infection cannot be excluded.
[**9-8**]: pCXR no clear infiltrate
[**9-9**]: No pneumothorax is identified on the left. There are
bilateral
pleural effusions. There is increased pulmonary vascular
redistribution and alveolar infiltrates, predominantly in the
right lower lobe. There is dense retrocardiac opacity. The
overall impression is that of worsened fluid status.
[**9-10**] CXR: No evidence of pneumothorax. There is evidence of
elevated pulmonary venous pressure. Mild haziness of the lower
zones is consistent with small bilateral pleural effusions and
compressive atelectasis at the bases.
[**9-11**] CXR: Minimal left basal atelectasis. There is no evidence
of pneumothorax. The subtle parenchymal changes at the right
lung bases are constant.
[**9-13**] CXR: Unchanged bilateral parenchymal opacities, combined to
mild-to-moderate right pleural effusion and areas of bilateral
basal atelectasis.
Brief Hospital Course:
On presentation, the OSH CT demonstrated a left retroperitoneal
hematoma with evidence of active extravasation. He was actively
resuscitated in the ED with 7u pRBC, 4u FFP and several liters
crystalloid and taken to IR for embolization. Blush was seen at
the inferior pole of the left kidney and was embolized at that
time. He was transferred to the trauma ICU afterwards for close
monitoring.
His ICU course as follows:
N: He was intubated and weaned off sedation. He was following
commands and responding appropriately. His pain was controlled
with narcotics.
CV: He had short runs of ventricular tachycardia and on HD2 he
went into afib w/ RVR. He was started on an Amiodarone gtt and
he converted to sinus on HD 3. During that time, he was on some
neo, which was weaned off.
Pulm: He was intubated and sedated. he had a left chest tube in
place to suction for him hemothorax. It was placed to water
seal. He had multiple rib fractures
GI: He was NPO and on IV fluids. He had an OGT in place
initially which was later removed, a Dobbhoff was placed and
tube feedings started.
GU: His urine output was monitored closely with Foley catheter
in place.
Heme: He required intermittent blood transfusions with packed
cells during his ICU stay. On HD 2, he was transfused 1u pRBC
for a hct of 24, which had decreased from 33. He also received
albumin and FFP.
MSK: He had multiple fractures in his ribs, spine, pelvis, and
RLE. His pelvic fractures were non-operative and he was weight
bearing as tolerated. However, he was on log roll precautions
for his L1 chance fracture. He underwent repair of his distal
right lower extremity fractures on [**9-11**] by Orthopedics and his
spine fracture was repaired by Orthopedic Spine Surgery on [**9-12**].
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
Once stabilized in the ICU he was transferred to the floor. He
was noted with rapid afib with hypotension within the first 24
hours after leaving the ICU. He was given several doses of IV
Lopressor which was effective. His daily scheduled beta blockers
were subsequently adjusted. His Afib was felt secondary to fluid
volume overload for which he received diuresis with IV Lasix
for. Since this initial episode of afib his heart rate has range
in 70-80's. At home he takes Metoprolol XL 100 mg twice a day -
his home dose was restarted at a lower dose to determine if his
blood pressure remains stable. Once at rehab and with continued
stable blood pressures his home regimen should be resumed.
He underwent a Swallow evaluation at bedside and passed allowing
his diet to be upgraded to regular with thin liquids. The
Dobbhoff was removed and tube feedings stopped. Supplements with
Ensure were initiated as well.
His home medications were resumed.
His Foley was removed on HD#13 and he is voiding without any
difficulties.
He was evaluated by Physical and Occupational therapy and being
recommended for rehab after his acute hospital stay.
Medications on Admission:
Multivitamins 1 TAB PO DAILY
Colchicine 0.6 mg PO DAILY
Dabigatran Etexilate 150 mg PO BID
Metoprolol Succinate XL 100 mg PO DAILY
Discharge Medications:
1. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H pain
2. Artificial Tear Ointment 1 Appl BOTH EYES TID:PRN dry eye
3. Heparin 5000 UNIT SC TID
4. Bisacodyl 10 mg PO/PR DAILY
5. Multivitamins 1 TAB PO DAILY
6. Senna 1 TAB PO BID:PRN constipation
7. Quetiapine Fumarate 12.5 mg PO Q12H
8. Colchicine 0.6 mg PO DAILY
9. Dabigatran Etexilate 150 mg PO BID
10. Docusate Sodium 100 mg PO BID
11. Metoprolol Succinate XL 100 mg PO DAILY
hold for SBP <110; HR <60
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehab Hospital
Discharge Diagnosis:
s/p Motor vehicle crash
Injuries:
Right sacral fracture
Bilateral pelvic fractures
Left hemothorax
Left retroperitoneal bleed
Left rib fractures [**8-8**]
L1 vertebral body racture
Sternal fracture
Right rib fracture Right proximal tibia & distal fibula fracture
Left 5th metacarpal fracture
Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital following a motor vehicle
crash where you sustained multiple injuires inclusidng rib
fractures; collapsed lung; broken bones in your pelvis, back and
right leg. Your spine and leg fractures required operation to
repair the injuries.
You were evaluated by the Physical therapists and being
recommended to go to a rehabilitation facility after you are
discharged from the hospital.
Followup Instructions:
You will need to follow up with your primary care doctor after
you are discharged from the rehabilitation facility.
You will need to follow up with an Orthopedic and Orthopedic
Spine surgeon in the next 3-4 weeks. If you choose to follow up
in [**Location (un) 86**] please contact the following:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Orthopedics [**Telephone/Fax (1) 1228**]
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**], Orthopedic Spine [**Telephone/Fax (1) 1228**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2136-9-20**]
|
[
"958.4",
"868.01",
"807.05",
"285.1",
"293.0",
"482.0",
"427.32",
"427.31",
"902.41",
"274.9",
"805.4",
"808.8",
"041.04",
"276.69",
"401.9",
"860.2",
"824.0",
"807.2",
"599.0",
"724.9",
"823.00",
"868.04",
"287.5",
"815.00",
"E812.0",
"427.1",
"805.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.53",
"38.97",
"96.6",
"88.42",
"38.7",
"81.62",
"88.51",
"81.05",
"96.71",
"38.91",
"34.09",
"39.79",
"79.36"
] |
icd9pcs
|
[
[
[]
]
] |
7792, 7849
|
4111, 7118
|
293, 537
|
8210, 8210
|
1591, 4088
|
8825, 9494
|
1075, 1092
|
7304, 7769
|
7870, 8189
|
7145, 7281
|
8386, 8802
|
1107, 1572
|
230, 255
|
565, 956
|
8225, 8362
|
978, 989
|
1005, 1059
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,086
| 141,984
|
39526
|
Discharge summary
|
report
|
Admission Date: [**2124-4-7**] Discharge Date: [**2124-4-13**]
Date of Birth: [**2060-10-13**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
esophageal cancer
Major Surgical or Invasive Procedure:
Distal esophagectomy with esophagojejunostomy
History of Present Illness:
The 63-year-old woman with a history of Barrett's esophagus and
dysplasia and now intramucosal carcinoma. This has been followed
for several years. More recently, she has been seen here and
has had biopsies which show this. She has had several trials
with ablative therapy. Endomucosal resection was done, which
showed positive margins. She in the past has been very
resistant to
having any surgical treatment, but at the present time, is now
looking for other options.
Past Medical History:
PMH: obestity, DM, seasonal allergies
PSH: gastric bypass in?, shoulder sx 07, CCY '[**93**]
Social History:
No smoking or Etoh use.
Family History:
non-contributory
Physical Exam:
On Discharge:
AVSS
GEN: NAD
CV: RRR, no m/g/r
Lungs: CTAB
ABD: Soft, NT/ND. Wound CDI.
EXT: warm, well perfused.
Pertinent Results:
[**2124-4-7**] 05:56PM BLOOD WBC-18.8*# RBC-4.60 Hgb-13.3 Hct-39.5
MCV-86 MCH-28.9 MCHC-33.6 RDW-13.9 Plt Ct-271
[**2124-4-11**] 06:50AM BLOOD WBC-10.1 RBC-4.05* Hgb-11.4* Hct-34.3*
MCV-85 MCH-28.0 MCHC-33.1 RDW-13.7 Plt Ct-230
[**2124-4-11**] 06:50AM BLOOD Glucose-202* UreaN-8 Creat-0.5 Na-141
K-4.1 Cl-105 HCO3-27 AnGap-13
UGI [**2124-4-11**]: IMPRESSION: Free passage of contrast material from
the esophagus into the jejunum without evidence of stenosis or
extraluminal leak.
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment. On [**2124-4-7**] the patient underwent
distal esophagectomy with esophagojejunostomy. (Please see the
Operative Note for details). The patient was transferred to the
unit post-operatively in stable condition. She was NPO, on IV
fluids with a foley catheter, epidural for pain. The patient
was transferred to the floor on POD2 after an uneventful stay in
the unit.
Neuro: The patient received epidural initially, which was split
with a morphine pca. This provided the patient with good pain
relief. On POD4, the epidural was pulled and the patient was
switched to roxicet via her J-tube with good pain control.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. A BAS was performed on [**2124-4-11**] that showed no
obstruction or leak. NGT was then pulled and patient was started
on sips. Diet was advanced to soft solids, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary. Patient's foley
was dc'd after the epidural came out, and she voided without
problem. Tube feeds were continued throughout the [**Hospital 228**]
hospital stay. The JP drain was pulled on [**2124-4-12**].
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. The patient's wound
remained clean dry and intact.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Omeprazole 40', glyburide 2.5am and 5pm, metformin 850',
lorazepam 1 qhs, Zyrtec, Singulair 10', Sertraline 50'
Discharge Disposition:
Home With Service
Facility:
Home Solutions
Discharge Diagnosis:
esophageal cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General 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 [**6-6**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 2359**] Date/Time:[**2124-4-24**]
2:45
|
[
"V45.86",
"151.0",
"568.0",
"250.00",
"530.85",
"V58.67",
"278.00",
"998.2",
"E870.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90",
"46.73",
"96.6",
"54.59",
"42.54",
"46.39"
] |
icd9pcs
|
[
[
[]
]
] |
4366, 4411
|
1687, 4204
|
289, 337
|
4473, 4473
|
1181, 1664
|
6743, 6884
|
1015, 1033
|
4432, 4452
|
4230, 4343
|
4624, 5605
|
6230, 6720
|
1048, 1048
|
1062, 1162
|
5637, 6215
|
232, 251
|
365, 841
|
4488, 4600
|
863, 958
|
974, 999
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,703
| 132,960
|
19666
|
Discharge summary
|
report
|
Admission Date: [**2128-6-23**] Discharge Date: [**2128-6-24**]
Date of Birth: [**2059-6-20**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Elective admission for coiling
Major Surgical or Invasive Procedure:
[**2128-6-23**]: Cerebral angiogram with coiling of the left basilar/
superior cerebellar artery aneurysm
History of Present Illness:
69F who presented with headaches and imaging showed 3 aneurysms.
She came in for an elective admission for coiling of the left
basilar/ superior cerebellar artery aneurysm.
Past Medical History:
low back pain, supraventricular tachycardia, hypertension,
hemorrhoids, hysterectomy, oophorectomy, pulmonary nodules,
coronary artery disease with history of coronary artery
catheterization, celiac disease. Other medical problems
includes hypothyroidism, anemia, bipolar disorder which is
controlled.
Social History:
She is married and lives with her husband. She has 2 children.
She worked previously as a part time activity assistant at a
nursing home. She is a former smoker and quit 11 years ago.
She does not drink alcohol.
Family History:
non-contributory
Physical Exam:
Pre-operatively on [**2128-6-23**]:
Awake, alert, oriented, speech clear, PERRL, EOM intact, face
symm, tongue midline, MAE full motor, no pronator.
On Discharge:
Nonfocal exam
Groin: soft, old hematoma stable
Pertinent Results:
[**2128-6-23**] Cerebral angiogram:
Successful coiling of the left basilar/superior cerebellar
artery aneurysm. A small residual amount of flow was noted at
the base.
Brief Hospital Course:
Patient underwent a successful coiling of the L basilar/superior
cerebellar artery aneurysm. There was a small residual amount of
blood at the base, ASA was held in hope that the residual amount
of blood would thrombos off. A 6 fr angio seal to the R groin.
She had had a previous angio on [**6-18**] and a R groin hematoma was
noted pre-op today. She was kept intubated immediately post-op
and given more time for reversal. She was transferred to the ICU
for overnight monitoring. She was extubated in the afternoon
without difficulty. Post op exam was nonfocal, her R groin with
old hematoma, no change in size and bilateral pulses intact. On
[**6-24**], patient remianed stable on exam, she was eating and
ambulating appropriately and was discharged home.
Medications on Admission:
Epoetin alpha for anemia, bupropion, albuterol, amlodipine,
levothyroxine, simvastatin, fluticasone.
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 headache.
Disp:*40 Tablet(s)* Refills:*0*
3. bupropion HCl 100 mg Tablet Extended Release Sig: Two (2)
Tablet Extended Release PO QAM (once a day (in the morning)).
4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Left basilar/ superior cerebellar artery aneurysm
Left MCA aneurysm
ACOMM 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:
?????? 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
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please follow-up with Dr [**First Name (STitle) **] in 4 weeks without any imaging.
You will be seen in 6 months with a MRI/MRA Brain ([**Doctor Last Name **]
protocol). Please call [**Telephone/Fax (1) 4296**] to make these appointments.
Completed by:[**2128-6-24**]
|
[
"414.01",
"793.19",
"427.89",
"296.80",
"V15.82",
"724.2",
"285.9",
"401.9",
"244.9",
"437.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"39.72",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
3257, 3263
|
1681, 2442
|
337, 445
|
3390, 3390
|
1489, 1658
|
5507, 5777
|
1223, 1241
|
2594, 3234
|
3284, 3369
|
2468, 2571
|
3541, 4565
|
4591, 5484
|
1256, 1407
|
1421, 1470
|
267, 299
|
473, 648
|
3405, 3517
|
670, 975
|
991, 1207
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,862
| 108,049
|
46336+46337+58903+58907
|
Discharge summary
|
report+report+addendum+addendum
|
Admission Date: [**2175-6-27**] Discharge Date: [**2175-7-7**]
Date of Birth: [**2120-1-16**] Sex: F
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 55-year-old
woman with the past medical history of schizoaffective
disease, atypical Parkinsonism, most likely secondary to
antipsychotic medications, hypothyroidism, lung nodule,
chronic obstructive pulmonary disease, torticollis and
urinary retention. She presented to the ED from her [**Hospital3 12272**], where she was reported to be confused and short of
breath. In the ED, she was 80% on room air, nonrebreather.
Saturations were 92%. The ABG was 7.28, 59, 80, 29. She had
a temperature of 101.4. The blood pressure was 96/50, pulse
81, respiratory rate 24. She was intubated for hypercarbic
respiratory failure on the 12th. She went to the emergency
department. She had Gram-negative rods greater than 100,000
in her urine. however, it was greater than two-colony
morphologies, possibly representing contamination.
The patient was extubated on the [**10-27**] with good
result. She had a sputum culture, which showed
Staphylococcus aureus Methicillin sensitive and sensitive to
Levaquin in her sputum. The patient was treated initially
with Ampicillin and Levaquin in the Intensive Care Unit. She
had two episodes of low blood pressure in 60s that responded
to IV fluids. She was also given Hydrocort empirically. The
Cortisol level was checked and it was 33. She presented
initially with the anion gap of 20, normal on the second day
of hospital stay.
The patient has had multiple admission to [**Hospital6 2121**], [**9-/2174**], [**2175-1-13**], for failure to
thrive, multiple urinary tract infections. The patient had a
suprapubic catheter placed and had another urinary tract
infection two weeks ago. The patient has improved physically
in the unit. But, according to the family members, the
patient had decreased level of functioning in that she had
been prior to admission.
PAST MEDICAL HISTORY:
1. Atypical Parkinsonism. I spoke to the patient's outside
neurologist, Dr. [**Last Name (STitle) 98503**] at [**Hospital1 2025**], who said that the
patient had atypical features of Parkinsonism, most likely
secondary to neuroleptic medications, that the patient had
received for treatment of her schizoaffective disease. The
patient has right torticollis and contractures.
Dr. [**Last Name (STitle) 98503**] reported that the patient had been tried
on a number of antiParkinsonism medicines with no resolution
of her Parkinsonism or torticollis. She had been tried on
Botox injections with no success. He suggested Ativan and/or
Benadryl for relief of her discomfort and muscular pain, but
suggesting that due to the longstanding nature of the
torticollis for approximately three years, that the vertebra
most likely have been permanently damaged by the torticollis.
2. Chronic obstructive pulmonary disease.
3. Emphysema.
4. Hypothyroidism.
5. Osteoporosis.
6. Failure to thrive.
7. Urinary retention status post suprapubic catheter.
The patient is to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], primary care
physician at [**Name9 (PRE) 2025**]. Dr. [**Last Name (STitle) **] had said that the patient had
neurogenic-like bladder and that she was unable to straight
catheterize herself due to her movement disorder and the
decision was between a Foley catheter and a suprapubic
catheter and the suprapubic catheter would be more
comfortable for the patient and less of an infection risk.
MEDICATIONS PRIOR TO ADMISSION:
1. Effexor 32.5 mg q.a.m.
2. Klonopin 0.5 mg q.h.s.
3. Depakote 250/500.
4. Levoxyl 50 q.a.m.
5. Prilosec 20 b.i.d.
6. Tylenol #3 q.d. for pain.
7. Zanaflex 2 mg q.3h.
8. Atrovent MDI.
9. Albuterol MDI.
SOCIAL HISTORY: The patient came from [**Hospital3 **]
[**Hospital3 **]. Her sister, [**Name (NI) 4134**] [**Name (NI) 35914**], was spoken to on many
occasions. Phone #: [**Telephone/Fax (1) 98504**]. PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D.
Phone #: [**Telephone/Fax (1) 64118**] at [**Hospital1 2025**].
PHYSICAL EXAMINATION: Examination at the time of transfer to
the floor revealed the following: Blood pressure 100/60,
pulse 78, oxygen saturation 98% on two liters. GENERAL: The
patient was lying in bed, curled with contractions. HEENT:
The patient had right torticollis using neck accessory
muscles to assist breathing. The patient initially had a
left subclavian line that was pulled two days after being on
the floor. The patient had lung examination clear to
auscultation, bilaterally regular rate and rhythm, no
murmurs, rubs, or gallops. The patient did have some
scattered wheezing, positive bowel sounds, soft, suprapubic
catheter site was clean, dry, and intact on transfer to the
floor. EXTREMITIES: Mild 1+ edema to the ankles.
Peripheral pulses intact. NEUROLOGICAL: The patient was
awake, alert, and in depressed mood. The patient had
shuffling gait, when observed with the walker. The patient
had cogwheel rigidity and right torticollis.
LABORATORY DATA: Labs on admission revealed the following:
White blood cell count 17.8, hemoglobin 12.6, hematocrit
37.2, 249,000 platelet count, INR 1.6, lactate 1.3. Sodium
144, potassium 4.1, chloride 101, bicarbonate 23, BUN 9,
creatinine 0.6, calcium 9.3, magnesium 1.6, phosphorus 3.1,
urinalysis cloudy, 11 to 20 red blood cells, 6 to 7 white
blood cells. Serum toxicology was negative. The patient had
a head CAT scan on admission, which showed no acute
intracranial pathology. The patient had a chest x-ray on
[**6-27**], showing no pneumonia, no CHF, increased
interstitial markings, right middle and lower lobes. As
mentioned before, the patient had Gram-negative rod in the
urine, greater than 100,000 colony-forming units, however,
two different specimen types. The patient had coagulase
positive, Staphylococcus aureus in sputum, sensitive to
Levaquin and oxacillin. Blood cultures: No growth from
final. The patient also had rare amount of Aspergillus
fumitagus on sputum culture, had rare growth. The gram stain
from that culture showed greater than 25 PMNs, 4+
Gram-positive cocci in pairs and clusters, which were the
Staphylococcus aureus and 2+ Gram-negative rods. The patient
had elevated CKs to 475 and 585 with negative troponins and
negative MBs both times.
The patient had a CT scan on the [**7-2**] to evaluate
the possibility of Aspergillosis. This examination showed no
evidence of Aspergillosis or AVPA. There was a 1 cm left
apical nodule, nonspecific apical and right middle lobe
scarring. It was suggested that these studies be followed up
with a CAT scan in two to three months as a new process
cannot be excluded at the present time. The patient had
bilateral pleural effusions, atelectasis, and mild emphysema.
The patient is a 55-year-old woman with the past medical
history of atypical Parkinsonism, schizoaffective disease,
extrapyramidal side effects, torticollis, multiple UTIs,
failure to thrive, suprapubic catheter placed. Chronic
obstructive pulmonary disease, who presented to the ED with
acute respiratory distress. The patient was found to have
gram-negative rod UTI and Staphylococcus positive sputum.
The patient was extubated and now is on the floor doing well.
HOSPITAL COURSE: (by system)
#1. The patient had both the Staphylococcus aureus and
urinary bacteria be covered by Levaquin. The patient was on
Levaquin 500 mg PO q.d, beginning on [**6-28**]. The
patient will finish a two-week course on [**7-12**]. The
patient is doing well, afebrile. White blood cell count has
decreased to 10.5 on the [**7-7**]. The Aspergillosis
was most likely a colonizing organism, discovered on routine
sputum examination and has no pathological significance.
#2. PSYCHIATRY: The patient is being followed by the
Department of Psychiatry. The patient was started on Effexor
75 mg q.d. They suggested adding 1.25 Zyprexa q.h.s. for
sleep and history of psychosis in the past. The patient is
also on Depakote 250 mg PO q.a.m. and 500 mg PO q.a.m.;
Klonopin 0.5 mg PO b.i.d.; Zyprexa 1.25 mg q.h.s. will be
stopped on the 23rd, for fear they may be discontinued even
at such a low dose contributing to the patient's torticollis
that she has been experiencing.
#3. NEUROLOGICAL: Parkinson torticollis rigidity. The
patient is on Zanaflex 2 mg t.i.d. The patient also was
started on Benadryl 25 mg t.i.d. and Ativan 0.5 mg to 1 mg
p.r.n.q.4h. for torticollis muscle rigidity. The patient had
reported some improvement on this regimen.
#4. ENDOCRINE: The patient is on Levoxyl 50 mcg PO q.d. for
hypothyroidism. TSH was checked; it was 0.19. Free T4 was
1.2.
#5. GENITOURINARY: The patient has suprapubic catheter
placed at an outside institution. During her stay here a
[**Hospital1 69**] the catheter became
dislodged and the nursing staff reports that the patient
pulled out the catheter. The patient denies this. The
Department of Urology was contact[**Name (NI) **] and the catheter is to be
replaced on the afternoon of the [**7-7**].
#6. PROPHYLAXIS: The patient was on Protonix 40 mg PO q.d.,
Tylenol, heparin subcutaneously 5000 q. 12. The Department
of Physical Therapy is working with the patient. The patient
is on aspiration precautions, solids are to be chopped.
Medications should be given with applesauce. The patient has
a swallowing study on the [**6-30**], which was not
positive for aspiration, however, it did show that the
patient had quick transition from oropharynx to esophagus and
the recommendations were to chop her solids and to give her
medications in applesauce and to have the patient eat all
liquids and solids in an upright position.
CURRENT PLAN PER DISPOSITION: The patient is being evaluated
for [**Hospital 4820**] rehabilitation skilled nursing facility. This
option was discussed with the patient and the patient's
sister. The patient initially had fears of being locked away
and complained that she did not want to go to a nursing home.
After conversations and explaining to the patient the nature
of skilled care she had received there, including physical
therapy and qualified nursing care, the patient agreed to a
long-term skill nursing facility with the hope that she would
be able to increase her function level to return to [**Hospital3 12272**]. The patient is also being screened by her prior
[**Hospital3 **] institution.
This covers the hospital course up to [**2175-7-7**]. The
rest of the charts should be dictated by the following
physician: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D.
[**MD Number(1) 7855**]
Dictated By:[**Last Name (NamePattern1) 1659**]
MEDQUIST36
D: [**2175-7-7**] 14:28
T: [**2175-7-7**] 14:52
JOB#: [**Job Number 98505**]
Admission Date: [**2175-6-27**] Discharge Date: [**2175-7-14**]
Date of Birth: [**2120-1-16**] Sex: F
Service: MEDICINE, [**Company 191**].
HISTORY OF THE PRESENT ILLNESS: The patient is a 55-year-old
female from [**Hospital3 11148**] [**Hospital3 **] who presents with
shortness of breath. She has extended medical history and
she has been in the rehabilitation facility for failure to
thrive. Subsequently, she was discharged to [**Hospital3 **]
facility. While at assisted-living facility she had an
episode of shortness of breath and breathing difficulties.
She was brought to the emergency [**Hospital1 **] for evaluation. While
in the emergency department she had an oxygen saturations of
80% on room air and then 97% on 100% nonrebreather. Of note:
On the ambulance call-in sheet, the patient was also "not
herself," as reported by the assisted-living facility. There
was a question of mental status change. ABG showed pH of
7.28, pCO2 of 59, and pO2 80. She was intubated for
respiratory depression.
PAST MEDICAL HISTORY:
1. Schizoaffective disease.
2. Chronic obstructive pulmonary disease and emphysema.
3. Hypothyroidism.
4. Urinary retention for which she received suprapubic
catheterization.
5. Psychosis.
6. Parkinson's disease secondary to neuroleptics.
7. Stable lung nodules.
8. Osteoporosis.
9. Torticollis.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Depakote 250 mg PO q.a.m.; 500 mg PO q.p.m.
2. Tylenol #3 q.i.d.p.r.n.
3. Klonopin 0.5 mg q.a.m.
4. Effexor sustained release 37.5 mg q.a.m.
5. Levoxyl 50 mg q.a.m.
6. Zanaflex 2 mg t.i.d.
7. Prilosec 20 mg b.i.d.
8. Atrovent MDI, albuterol MDI.
SOCIAL HISTORY: The patient is a smoker of 30 pack years.
FAMILY HISTORY: Not obtainable. Her sister is [**Name (NI) 4134**]
[**Name (NI) 35914**]. Phone #: [**Telephone/Fax (1) 98504**]. The PCP is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
[**Telephone/Fax (1) 64118**].
PHYSICAL EXAMINATION: Examination revealed the following:
Vital signs: 101.4, heart rate 87, blood pressure 110/47,
MAP 68, respiratory rate 14, FIO2 100%. Ventilation at tidal
volume of 500 and respiratory rate of 14. FIO2 of 100%.
GENERAL: She is a thin, elderly-appearing woman, curved in
bed. HEENT: Torticollis to the right. Normocephalic,
atraumatic, pupils equal and reactive to light. Light
lateral deviation of the right eye, does not follow finger,
intubated. NECK: No jugulovenous distention. CHEST: Bowel
sounds left greater than right. Inspiratory rhonchi, right
greater than left. CARDIOVASCULAR: S1 and S2, normal,
regular rate and rhythm. ABDOMEN Soft, positive bowel
sounds, nondistended, nontender. Suprapubic catheter site
clean. EXTREMITIES: No edema, 1+ peripheral pulses.
NEUROLOGICAL: Blinks to command, minimally responsive,
spontaneously. Bilateral fine hand tremor.
LABORATORY DATA: Laboratory data revealed the following:
White blood count 17.3, hematocrit 37.2, platelet count
249,000, 85% polys, 13% lymphs, 2% monocytes. PT 15.4, INR
1.6, PTT 29.9. The Chem 7 revealed sodium 144, potassium
4.1, chloride 105, bicarbonate 23, BUN 9, creatinine 0.6,
glucose 119, calcium 9.3, magnesium 1.6, phosphorus 5.1. The
serum toxicology was negative. Urinalysis showed positive
nitrites, moderate leukocyte esterase, many bacteria, 6 to 10
white blood cells, 11 to 20 red blood cells. The gas, when
intubated was 7.3 pH, pCO2 52, with a pO2 of 448. The blood
cultures times two and urine cultures, taken at that time,
revealed the following: Chest x-ray in the ED: The
endotracheal tube 6.5 cm above the carina, no pneumonia,
increased right hemidiaphragm and emphysema and the head CT
was negative. The EKG showed normal sinus tachycardia 104
with axis of about 90% with the baseline, no ST and T-wave
changes.
HOSPITAL COURSE: In the ED, on [**6-27**], the patient's
blood pressure continued to trend downward despite IV fluid
hydration and boluses. Systolic blood pressure was 65/38.
Discussion with the family revealed that the patient did not
want resuscitation and the sister [**Name (NI) **] did not want any
invasive procedures performed including central lines and the
IJ subclavian and femoral. She also did not chest
compression or electrical shock should there be a cardiac
event. After extensive discussion again with the family, it
was decided to make her do not resuscitate and focus on
comfort.
On [**2175-6-27**], secondary to the hypotension, Hydrocort was
started and no central access or pressors were begun due to
the family wishes. The labs at that time showed a white
blood cell count of 18.1, hematocrit 29.5. The patient was
febrile with an increased white blood count and started on
Ampicillin and Levofloxacin for positive urinalysis until
sensitivities came back. On [**6-28**] the urine showed
Gram-negative rods. Blood culture showed no growth. The
patient was extubated on [**6-28**]. On that same day she
was afebrile. White cell count was still elevated to 17.5.
Urine culture on [**2175-6-26**] showed a Gram-negative rods of two
morphologies with greater than 100,000 organisms, however, it
showed contamination with mixed skin and genital flora and
the clinical significance was uncertain.
Blood culture from [**2175-6-26**] was negative. Blood culture
times two from [**2175-6-26**] was negative. On [**2175-6-27**] the
sputum grew out moderate growth of Staphylococcus aureus
coagulase positive, Methicillin-sensitive and rate growth of
Aspergillus fumigatus.
The patient was originally started on Vancomycin for the
Staphylococcus aureus pneumonia until sensitivities came
back. She was also continued on Levaquin. It was felt that
the urosepsis lead to hypotension and that the Staphylococcus
was secondary to intubation. The patient was transferred to
the floor to the [**Company 191**] team.
The patient was seen by the Psychiatric Department on
[**2175-6-29**], who made some suggestions about her management.
On [**2175-6-29**], the Staphylococcus aureus was sensitive to
Oxacillin so the Vancomycin was discontinued and she was
started on Oxicillin one gram q.8h.
She had a swallowing study on the 14th because of the concern
about a swallowing risk. She was continued on Depakote,
Effexor, and Klonopin. She did not require Haldol as she was
not agitated.
Although the patient had aspergillus in her sputum she did
not immunocompromise, no neutropenia, no known cavity disease
in the lung. However, chest CT was ordered to further
assess. CT of the abdomen done on [**2175-7-2**] showed 1 cm left
apical nodule and nonspecific left apical and right middle
lobe scarring. There was no evidence of ABPA or an
aspergilloma. The absence of neutropenia, these findings are
unlikely to represent invasive aspergillosis. Recommend
follow up in two to three months as a neoplastic process
cannot be excluded. Bilateral pleural effusions and
atelectasis. Mild emphysema.
Infectious Disease was consulted and felt that the positive
aspergillus in the sputum is likely colonizer in the setting
of pre-existing lung disease and emphysema, so there is no
need to start treatment yet for Aspergillosis now.
Infectious Disease also recommended a total of 10 to 14 day
course of Levaquin. On a note by Infectious Disease date
[**7-5**], they state that due to the patient and the
family's wishes, the patient is not to have any further
diagnostic procedures and will not pursue investigation of
left apical nodule any further.
The Department of Neurology was contact[**Name (NI) **] on [**7-5**],
regarding placement of the suprapubic catheter. However,
they eventually declined to see the patient as she is to get
services at [**Hospital3 **] and they stress that she
return there to continue with the Foley for now. The
patient's neurologist at the [**Hospital3 **],
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 98503**], [**Telephone/Fax (1) 98506**] called regarding the
patient's movement disorder and torticollis. Neurology
suggested Benadryl 25 t.i.d. for torticollis. The patient
reported failing Botox injections.
On [**2175-7-10**] the urine cultures were growing yeast. This is
after a 14-day course of Levaquin. The patient was
complaining of burning in her urine and so she was started on
Mycelex cream times three days. The patient was also having
some episode of hypotension noticeably the systolic blood
pressure came down to the 70s overnight. She was treated
with fluid boluses, which did not lead to much improvement.
Repeat blood cultures were sent, including fungal cultures,
which show no growth to date. She had a cardiac
echocardiogram on [**2175-7-12**], which showed an ejection
fraction of greater than 60% and no valvular abnormalities.
On the 28th, she complained of shortness of breath and chest
pain on inspiration. She had a PT angiogram done, which
showed no evidence of PE, moderate-to-severe emphysema, line
opacities consistent with scarring and they commented again
on the right upper lobe nodule. The patient, on the 29th,
was no longer complaining of shortness of breath. The blood
pressure was taken with the pediatric cuff and it was still
low in the 80s. The TSH returned. The cortisol was 9.4,
taken at 8:40 in the morning. Therefore, it was decided that
it was pertinent to do a Cortrosyn stimulation test in the
morning. T3 and T4 were checked.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Last Name (NamePattern1) 2918**]
MEDQUIST36
D: [**2175-7-13**] 13:45
T: [**2175-7-13**] 14:13
JOB#: [**Job Number 98507**]
Name: [**Known lastname **], [**Known firstname 540**] Unit No: [**Numeric Identifier 15725**]
Admission Date: [**2175-6-26**] Discharge Date: [**2175-7-14**]
Date of Birth: [**2120-1-16**] Sex: F
Service:
1. Endocrine. Closentropin simulation test was performed
which showed no evidence of adrenal insufficiency. 60 minute
level was 30. T3 9.1, T4 9.8, if blood pressures continue to
be low consider starting Florinef 0.1 mg p.o. q day.
Levothyroxine was increased to 75 mcg p.o. q day and a repeat
TSH should be checked in six weeks.
2. Neurology. The patient was seen by Neurology again on
[**2175-7-13**] who recommended beginning Mirapex 0.125 mg p.o. three
times a day. Attempt was made to contact the patient's
primary neurologist, Dr. [**Last Name (STitle) **], he was out of town and the
team felt he would defer to Dr. [**Last Name (STitle) **] on that medication
change. His first available appointment is [**2175-7-27**] at 4 PM
at [**Hospital3 11272**] [**Hospital3 **] but his secretary will call when he
is back from vacation to squeeze her in for an earlier
appointment.
3. Psychiatry. The patient was seen by Psychiatry on
[**2175-7-13**] who recommended increasing Effexor dose.
DISCHARGE MEDICATIONS:
1. Magnesium oxide 800 mg p.o. q day.
2. Protonix 40 mg p.o. q day.
3. Combivent MDI with spacer two puffs b.i.d.
4. Heparin 5000 units subcutaneously b.i.d.
5. Depakote 250 mg p.o. q AM and 500 mg p.o. q PM.
6. Klonopin 0.5 mg p.o. b.i.d.
7. Effexor 100 mg p.o. q day.
8. Levoxyl 75 mcg p.o. q day.
9. Zanaflex 1 mg p.o. three times a day.
10. Atrovent and Albuterol nebs q 4 to 6 hours p.r.n.
11. Percocet one to two tabs p.o. q 4 to 6 hours p.r.n.
12. Milk of Magnesia 50 cc's p.o. q 4 hours p.r.n.
13. Tylenol 325 to 650 mg p.o. q 4 to 6 hours p.r.n.
14. Maalox 30 cc's p.o. q 6 hours p.r.n. nausea.
15. Nicotine patch 7 mg topical q day.
DISCHARGE DIAGNOSIS:
1. Pneumonia.
2. Urosepsis.
CONDITION ON DISCHARGE: Stable.
DISCHARGE: To [**Hospital 15726**].
FOLLOW-UP: [**Hospital 3194**] of [**Doctor Last Name **] is going to organize psychiatrist
see patient. Neurology, Dr. [**Last Name (STitle) 15727**] will call with
earlier appointment . Urology was called and on vacation
until next week therefore, I, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] call to
schedule appointment and will contact [**Name (NI) 3194**] of [**Name (NI) **] with the
appointment. The urology number is [**Telephone/Fax (1) 15728**].
[**Name6 (MD) **] [**Last Name (NamePattern4) 424**], M.D. [**MD Number(1) 425**]
Dictated By:[**Last Name (NamePattern4) 15729**]
MEDQUIST36
D: [**2175-7-14**] 16:20
T: [**2175-7-20**] 07:50
JOB#: [**Job Number **]
Name: [**Known lastname **], [**Known firstname 540**] Unit No: [**Numeric Identifier 15725**]
Admission Date: [**2175-6-26**] Discharge Date: [**2175-7-14**]
Date of Birth: [**2120-1-16**] Sex: F
Service:
ADDENDUM:
The patient is to follow-up with urologist on [**9-21**], at
11:30 a.m. at the [**Hospital6 2241**]. The phone
number there is [**Telephone/Fax (1) 15741**]. This is for a suprapubic
catheter placement and the patient needs a referral from her
managed care for this patient with Dr. [**Last Name (STitle) **].
[**Name6 (MD) **] [**Last Name (NamePattern4) 424**], M.D. [**MD Number(1) 425**]
Dictated By:[**Last Name (NamePattern1) 1464**]
MEDQUIST36
D: [**2175-7-26**] 14:10
T: [**2175-7-26**] 14:33
JOB#: [**Job Number 15742**]
|
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icd9cm
|
[
[
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[
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icd9pcs
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,991
| 132,924
|
51555
|
Discharge summary
|
report
|
Admission Date: [**2112-4-24**] Discharge Date: [**2112-5-23**]
Date of Birth: [**2045-5-15**] Sex: F
Service: SURGERY
Allergies:
Lipitor
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
sigmoid colectomy
History of Present Illness:
Pt is a 66yo F w/ recent LUL VATS wedge resection ([**3-26**]), stroke
([**3-26**]), and CAD s/p MI who presents w/ constipation and
abdominal pain for 2 weeks. The patient notes that immediately
following the surgery, she developed lower abdominal pain, for
which she had been taking po dilaudid post-op, and she did not
have BM since. She has been passing flatus. Over the past few
days, she has been unable to keep down POs and has clear
vomitus--non-bloody, non-bilious. She denies any fevers,
chills, night sweats, breathing complaints, urinary complaints.
No LE edema. She notes that the pain is the same in quality,
location, and severity since it began post-OP.
In the ED, her labs showed elevated WBC, and given her clinical
history, initially concerning for small bowel obstruction.
However, abdominal X-ray was not consistent with this diagnosis;
she had further evaluation with abd/pelvic CT. This study
revealed mild inflammatory stranding of the sigmoid colon which
was suggestive of diverticulitis. In addition, she had evidence
of UTI. Given that the pt could not tolerate PO, she was
admitted for IV antibiotics and IVF.
Past Medical History:
CAD s/p MI c stent '[**04**] c/b retroperitoneal bleed, s/p stent '[**06**];
recent CVA (L hemianopsia), HTN, hyperchol, GERD/Barrett's, h/o
Tob
Lung mass; 12mm noncalcified nodule in the left apex with FDG
avidity on PET CT, suspicious for primary malignancy given
smoking history.
Social History:
Currently not working, but formerly an administrative
assistant. She has a significant history of tobacco use (A
40-pack-year smoking history, discontinued 7 years ago). She
admitted to occasional, social use of alcohol. She denied use
of
illicit drugs.
Family History:
Remarkable for a number of family members with
coronary artery disease.
Brief Hospital Course:
Ms. [**Known lastname 10840**] was admitted to the medical service on [**2112-4-24**] with a diagnosis of diverticulitis. She was initially
managed conservatively with bowel rest and IV antibiotics. She
failed this treatment and required a sigmoid colectomy on
[**2112-4-28**]. Please refer to previously dictated operative note.
Her post-operative course was quite difficult. In the early
post-operative period she developed a myocardial infarction and
required treatment in the ICU. She developed respiratory
failure during this time and required intubation and mechanical
ventillation. During this time she began having high fevers.
Given her clinical appearence and her chest x-rays, she was
treated for pneumonia. She repeatedly failed attempts to wean
from the ventillator. After it was made evident that she would
require a prolonged intubation, a tracheostomy was recommended.
After many long discussions with her family and healthcare
proxy, it was determined thta this course of action was contrary
to her wishes. On [**2112-5-23**], she was made CMO and expired
shortly after extubation.
Medications on Admission:
1. Metoprolol 50 [**Hospital1 **]
2. Ezetimibe 10 mg qd
3. Prilosec 40 mg qd
4. Aspirin 325 mg qd
5. Docusate 100 mg [**Hospital1 **]
6. Mag hydroxide q6h prn
7. Hydromorphone 2-4mg Q3-4H prn
Discharge Medications:
none
Discharge Disposition:
Home with Service
Discharge Diagnosis:
diverticulitis
myocardial infarction
pneumonia
death
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
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icd9cm
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icd9pcs
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|
282, 301
|
3673, 3682
|
3735, 3870
|
2073, 2147
|
3529, 3535
|
3598, 3652
|
3313, 3506
|
3706, 3712
|
228, 244
|
329, 1476
|
1498, 1783
|
1799, 2057
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,499
| 185,887
|
23309
|
Discharge summary
|
report
|
Admission Date: [**2186-5-10**] Discharge Date: [**2186-5-17**]
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] yo F alzhiemer's dementia (AOx1-2 baseline), sick sinus
syndrome s/p pacer, recent admission [**Date range (3) 59861**] for
pneumonia, acute renal failure, thrombocytopenia, transaminitis,
acute delirium, pancreatitis and pyelonephritis presents from
rehab with hypoxia to 70% on RA. Of note, she was treated from
[**Date range (1) 59862**] with levofloxacin 750mg IV q48 for
community-aquired PNA. Her oxygen requirements were 2L on
admission and was 94% on RA on discharge. Mental status waxed
and waned but improved on discharge and she was evaluated by
speech and swallow and felt to be safe to eat. She also had [**Last Name (un) **]
with creatinine of 1.5 on [**2186-4-28**] which trended down to 0.9 on
discharge and felt to be due to relative hypotension (BPs in the
100s) which improved with BPs rose to 130s-140s. She was
hypertensive during the admission requiring IV hydralazine for
BP control. During this admission she also had transaminitis
thought to be possibly from statin use and pancreatitis with
lipase of 900s. She had CT abd and U/S which were unrevealing.
She was given 20mg IV Lasix daily from [**Date range (1) 8762**] but not
discharged on standing lasix.
In the ED, initial vs were: T95.4 P65 (paced) BP92/54 R20 O2
sat99% NRB. Patient was given levoquin, vancomycin, and zosyn.
Patient was hypothermic and started on Bair Hugger. Blood
pressures initially 150s systolic, then became hypotensive into
the mid to low 90s. Received 3 L of NS fluid resuscitation.
BPs were in low 100s on transfer to the floor. CXR that showed
worsening PNA, RUL opacity, bibasilar opacities. She was given
Vancomycin, Zosyn, Levofloxacin.
On the floor, she is somnolent and answers few questions. She
denies pain. She is more responsive for her family. Per her
family, mental status has been waxing and [**Doctor Last Name 688**] since her
previous admission. Prior to this admission she was functioning
well at home, living with her daughter.
Review of systems: unable to obtain
Past Medical History:
1. Dementia
2. Hypertension.
3. Spinal stenosis with severe chronic back pain.
4. Treated H. pylori in [**2179**].
5. Hyperlipidemia
6. Distant smoking history.
7. Pacemaker for sick sinus syndrome.
8. Normal ETT in the mid [**2166**].
9. Osteoarthritis
10. Anemia
11. Chronic kidney disease
12. E. coli UTI
Social History:
Lives with daughter, no [**Name2 (NI) **]/etoh/drugs
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: Bilateral crackles anteriorly with coarse breath sounds
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mildly distended, non-tender, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, 2+ edema to knees
bilaterally
Pertinent Results:
Labs on admission:
[**2186-5-9**] 06:52AM PLT COUNT-308
[**2186-5-9**] 06:52AM WBC-9.7 RBC-3.05* HGB-9.3* HCT-29.2* MCV-96
MCH-30.5 MCHC-31.9 RDW-14.9
[**2186-5-9**] 06:52AM GLUCOSE-45* UREA N-13 CREAT-0.8 SODIUM-136
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-31 ANION GAP-10
[**2186-5-10**] 04:47PM PLT COUNT-342
[**2186-5-10**] 04:47PM NEUTS-76.3* LYMPHS-15.3* MONOS-5.6 EOS-2.2
BASOS-0.6
[**2186-5-10**] 04:47PM WBC-7.5 RBC-3.00* HGB-8.9* HCT-29.2* MCV-97
MCH-29.8 MCHC-30.6* RDW-16.1*
[**2186-5-10**] 04:47PM HCV Ab-NEGATIVE
[**2186-5-10**] 04:47PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE HAV Ab-POSITIVE
[**2186-5-10**] 04:47PM CK-MB-8 cTropnT-<0.01 proBNP-1031*
[**2186-5-10**] 04:47PM LIPASE-188*
[**2186-5-10**] 04:47PM ALT(SGPT)-43* AST(SGOT)-59* LD(LDH)-599* ALK
PHOS-239* TOT BILI-0.7
[**2186-5-10**] 04:47PM UREA N-15 CREAT-0.9
[**2186-5-10**] 04:50PM PT-12.7 PTT-35.1* INR(PT)-1.1
[**2186-5-10**] 04:50PM freeCa-1.12
[**2186-5-10**] 04:50PM O2 SAT-88
[**2186-5-10**] 04:50PM GLUCOSE-84 LACTATE-0.7 NA+-135 K+-3.8 CL--97*
TCO2-32*
[**2186-5-10**] 04:50PM TYPE-ART PH-7.40
[**2186-5-10**] 07:36PM URINE HYALINE-0-2
[**2186-5-10**] 07:36PM URINE RBC-0-2 WBC-[**3-31**] BACTERIA-OCC YEAST-NONE
EPI-[**3-31**]
[**2186-5-10**] 07:36PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2186-5-10**] 07:36PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
IMAGES / STUDIES:
[**2186-5-10**] ECG: A-V paced rhythm. Since the previous tracing of
[**2186-4-26**] A-V delay is decreased.
[**2186-5-10**] CXR: PORTABLE AP UPRIGHT CHEST RADIOGRAPH: The lung
volumes are low. There is a left pacer/AICD with leads extending
to the expected location of the right atrium and right
ventricle, unchanged. There is increased right pleural effusion,
with associated right lower lobe volume loss. There is increased
opacity in the right upper lobe abutting the minor fissure.
Increased opacity is also identified at the left base. This may
reflect layering effusion and atelectasis, though superimposed
pneumonia is not excluded. The cardiac contours are difficult to
evaluate given the low lung volumes. There is prominence of the
right hilar structures, though this may be secondary to
rotation, given lack of right hilar abnormality on recent chest
CT. The pulmonary vasculature is prominent, consistent with
fluid overload. The aorta is again noted to be calcified and
tortuous. Upper abdomen is unremarkable. There is no acute
osseous abnormality. IMPRESSION: Bilateral effusions, increased
on the right, mild CHF. Basilar opacity may reflect atelectasis
versus pneumonia.
[**2186-5-10**] LUE ultrasound: FINDINGS: Grayscale and color
son[**Name (NI) 493**] imaging of the left internal jugular, subclavian,
axillary, brachial, basilic, and cephalic veins was performed.
The contralateral subclavian vein was interrogated for
comparison purposes. There are symmetric respiratory phasicity
in subclavian veins. Left upper extremity veins demonstrate
normal compressibility, flow, and augmentation. There is no
echogenic intraluminal thrombus identified. There is minimal
soft tissue edema in the antecubital region. IMPRESSION: No
evidence for DVT in the left upper extremity.
[**2186-5-11**] Echo: The left atrium is normal in size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is small. Left ventricular systolic function is
hyperdynamic (EF 80%). There is no ventricular septal defect.
The right ventricular free wall is hypertrophied. The right
ventricular cavity is dilated with borderline normal free wall
function. The aortic root is mildly dilated at the sinus level.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Severe [4+] tricuspid regurgitation is seen. There is
severe pulmonary artery systolic hypertension. The main
pulmonary artery is dilated. The branch pulmonary arteries are
dilated. There is no pericardial effusion. Impression: severe
diastolic left ventricular failure and secondary right
ventricular failure. Compared with the findings of the prior
study (images reviewed) of [**2185-10-12**], severe tricuspid
regurgitation and pulmonary hypertension are now evident.
[**2186-5-11**] ECG: Sinus rhythm with A-V conduction delay. Delayed R
wave progression with late precordial QRS transition. Diffuse T
wave changes. Findings are non-specific. Since the previous
tracing of [**2186-5-10**] A-V paced rhythm is now absent.
[**2095-5-10**] CXR: FINDINGS: As compared to the previous radiograph,
there is slight improvement. The extent of the bilateral pleural
effusions is slightly decreased. As a consequence, there is
improved ventilation of both lung bases. Unchanged moderate
cardiomegaly with relatively extensive retrocardiac atelectasis.
No evidence of newly occurred focal parenchymal opacities
suggesting interval appearance of pneumonia. No evidence of
pulmonary edema.
[**2186-5-12**] CXR: FINDINGS: In comparison with the study of [**5-11**],
there is little overall change. Bilateral pleural effusions
persist, more prominent on the left. Basilar atelectatic change
is again seen, especially on the left. Lung volumes have mildly
decreased. Continued enlargement of the cardiac silhouette. No
evidence of acute focal pneumonia.
Brief Hospital Course:
Ms. [**Known lastname 59863**] is a [**Age over 90 **] year old woman with hx of sick sinus syndrome
s/p pacer as well as recent admission for PNA, transaminitis,
pancreatitis, MS changes, who presents from rehab with lethargy
and was found to be hypotensive.
# Hypotension: Patient had SBPs of 80s-90s on arrival to the ICU
depite 3L of fluid resuscitation in the ED. Baseline blood
pressures are 130s-140s and patient was hypertensive at rehab.
The patient (with her family) elected to become DNR/DNI, but had
not made a decision about the placement of a central line or the
use of pressures on admission. These interventions were
therefore withheld, and the patient's blood pressure improved on
its own with diuresis and antibiotics. Toprol XL and nifedipine
were held during her ICU stay. On the floor pt was started on
lopressor and amlodipine (rather than toprol xl and nifedipine
[**2-28**] pt not swallowing pills).
# Hypoxia: The patient's presentation was concerning for early
sepsis from presumed respiratory source vs. CHF exacerbation
with volume overload (as suggested by changes on CXR), and she
was admitted to the MICU. WBC count was not elevated. Negative
cardiac enzymes were reassuring for minimal contribution from
acute cardiac ischemia. She was started on vancomycin and Zosyn
for hospital acquired pneumonia, but antibiotics were
discontinued on HD2. Echocardiogram showed right heart failure
and pulm htn and she received IV Lasix to promote diuresis with
good effect.
# Elevated LFTs: Trending down compared to prior admission. The
thought during her past admission was that this was from statin
vs. hypotension. Statin was held during this admission.
Hepatitis serologies were sent and were negative.
# Hx of Pancreatitis: Patient did not appear to have abdominal
tenderness although this was difficult to assess. Lipase was
slightly elevated but trending down.
# Hypoglycemia: Patient was found to be hypoglcemic with FS < 60
on multiple occasions. She was treated with D50 as needed.
Although patient was not eating during the early portion of this
admission, FS this low remained unexplained. Work up for ?
insulinoma was considered, however it was felt that low blood
sugars were much more likely [**2-28**] acute illness. Blood sugars
remained low normal (lowest am blood sugar 58). Endocrine was
consulted and recommended ACTH and free cortisol levels which
remained pending at discharge.
-ACTH and free cortisol pending at discharge. Pt to follow up
with endocrine on [**6-27**].
# ?Hypothyroid: Pt had elevated TSH and normal FT4 on this
admission. Endocrine recommended check TSH and FT4 2-3 weeks
post-discharge.
-Pt should have recheck TSH and FT4 [**3-1**] wks post-discharge
# Mental Status Changes: Felt likely from acute medical issues
and underlying dementia. Improved with diuresis and antibiotics.
Per family, pt was at her baseline by HD3.
# Prophylaxis: Holding subcutaneous heparin as pt had elevated
PTT while on it
# Code: DNR/DNI, confirmed with family, pt may benefit from
referral to palliative care consult as pt has many serious
medical conditions
Medications on Admission:
Medications per prior D/C summary from yesterday:
Acetaminophen 325-650mg PO q4H PRN pain, fever
Calcium Carbonate 500mg PO QID PRN indigestion
Donepezil 10mg PO qHS
Senna 1 tab PO BID PRN constipatin
Colace 100mg PO BID
Albuterol Sulfate Nebulizer q6H
Toprol XL 75mg PO qday
Nifedipine SR 60mg PO qday
Pantoprazole 40mg PO qday
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (3) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
2. Acetaminophen 325 mg Tablet [**Month/Day (3) **]: 1-2 Tablets PO every eight
(8) hours as needed for pain/fever: no more than 2g tylenol in
24 hrs.
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Day (3) **]:
[**1-28**] Adhesive Patch, Medicateds Topical DAILY (Daily): 12 hours
on, 12 hours off.
4. Donepezil 5 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO HS (at bedtime).
5. Senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO twice a day.
6. Miralax 17 gram Powder in Packet [**Month/Day (2) **]: One (1) PO once a day:
hold for loose stool.
7. Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO BID (2
times a day): hold for sbp <110 or HR <60.
8. Furosemide 20 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q48H (every 48
hours): hold for sbp <100.
9. Amlodipine 2.5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily): hold for sbp < 110 .
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
primary: CHF, hypotension
secondary: hypoglycemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted for low blood pressure and shortness of
breath. We removed some fluid from your lungs by giving you
diuretics (water pill) and you felt better.
You are going to rehab to get your strength back.
Followup Instructions:
Department: MEDICAL SPECIALTIES, [**Hospital Ward Name **] 7
When: TUESDAY [**2186-6-27**] at 9:20 AM
With: [**First Name4 (NamePattern1) 8990**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1803**]
Specialty: Endocrinology
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2186-5-17**]
|
[
"427.81",
"511.9",
"428.0",
"293.0",
"416.8",
"294.10",
"458.9",
"V45.01",
"585.9",
"285.21",
"790.4",
"331.0",
"E942.6",
"799.02",
"244.9",
"428.33",
"397.0",
"790.5",
"790.94"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13544, 13616
|
8777, 11893
|
231, 238
|
13710, 13710
|
3229, 3234
|
14125, 14533
|
2712, 2730
|
12273, 13521
|
13637, 13689
|
11919, 12250
|
13888, 14102
|
2745, 3210
|
2274, 2293
|
183, 193
|
266, 2255
|
3248, 8754
|
13725, 13864
|
2315, 2625
|
2641, 2696
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,378
| 172,805
|
1638
|
Discharge summary
|
report
|
Admission Date: [**2142-4-26**] Discharge Date: [**2142-5-1**]
Date of Birth: [**2060-5-11**] Sex: F
Service: MEDICINE
Allergies:
Losartan / Lisinopril / Penicillins / Ultram
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Osteoarthritis
Major Surgical or Invasive Procedure:
[**2142-4-26**]: Primary hybrid left total hip arthroplasty
History of Present Illness:
81 year-old woman with severe COPD, SVT, atrial fibrillation,
chronic diastolic CHF, hypertension, history of PE and DVT,
admitted for elective left hip arthroplasty performed [**2142-4-26**]
(EBL 500cc), transferred to ICU for tachycardia and hypotension.
In the PACU, patient was hypotensive to 80/50 and had
tachycardia with rates into the 110s. EKG demonstrated an
accelerated junctional rhythm with rate in 100s with depressions
in the lateral leads. She was asymptomatic. She was given
lopressor 5mg IV x 2 and phenylephrine 100 mcg x 8. Her heart
rate came down to ~70 and bp increased to 110s/60s, and was
sinus rhythm on EKG. She was started on a morphine PCA, and
given 1u PRBC. She was transferred to the ICU for further
management of hemodynamics.
On the floor, patient was asymptomatic except for post-op L hip
pain.
Past Medical History:
- H/o C. diff colitis-
- H/o MSSA and pseudomonas PNA
- AFib and h/o SVT on coumadin
- Large right PE and bilateral DVT [**7-25**]-on coumadin
- COPD
- Chronic diastolic CHF, EF 55% on lasix (not on ACE at primary
MD's discretion)
- Osteoarthritis
- H/o myocarditis in [**2137**] with EF 20-25% at that time, cath
negative -does not tolerate BB
- Hyperlipidemia
- Peripheral artery disease
- HTN diet controlled
- Migraine HA
- Chronic eosinophilic lung disease (chronic eosinophilic
pneumonia or Churg-[**Doctor Last Name 3532**] syndrome)
- Hypoalbuminemic
- H/o angioneurotic edema on [**Last Name (un) **] therapy
- S/p left eye surgery [**2141-11-15**]
Social History:
Patient lives at home in [**Hospital1 392**] with her husband and daughter.
She is a housewife. She used to smoke 1.5-2ppd cigarettes for
~20 yrs (stopped 25yrs ago). Denies alcohol or illicit drugs.
Family History:
Mother CAD died of endocarditis, father "cancer of the spleen."
Physical Exam:
Vitals: T 98, BP 134/68, HR 75, RR 18, O2sat 96% on 2L (at rest)
General: Thin 81 yo female, alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: 1+ edema LLE, Left hip surgical site, with dressing in
place.
Skin: Tears on left elbow and right knee
Neuro: Attentive, alert
Psych: Calm, appropriate
Pertinent Results:
[**2142-4-26**]
WBC-6.1 RBC-2.94*# Hgb-8.7*# Hct-26.5*# MCV-90 Plt Ct-193
PT-12.2 PTT-22.6 INR(PT)-1.0
Glucose-87 UreaN-13 Creat-0.7 Na-139 K-3.5 Cl-108 HCO3-25
AnGap-10
CK(CPK)-415* CK-MB-5 cTropnT-0.02*
Calcium-7.9* Phos-3.4 Mg-1.7
ABG Temp-36.7 O2 Flow-3 pO2-106* pCO2-42 pH-7.38 calTCO2-26 Base
XS-0 Lactate-1.5
freeCa-1.10*
[**2142-4-27**]
PELVIS IMPRESSION: Status post left total hip arthroplasty with
expected post-surgical changes and no evidence of hardware
complications.
[**2142-4-28**]
HIP XR: Left total hip arthroplasty with satisfactory alignment.
[**2142-4-29**]:
Portable CXR: Cardiomediastinal contours as well as pulmonary
vascularity are unchanged in appearance, except for development
of retrocardiac opacities, probably due to atelectasis in the
recent postoperative setting. Small left pleural effusion has
also developed. Right cardiophrenic angle has been excluded and
cannot be evaluated.
Brief Hospital Course:
81 yo F with h/o COPD, CHF now s/p L THA ([**2142-4-26**]), presents
with an episode of tachycardia (junctional rhythm),
asymptomatic, now resolved. COPD is stable, but has significant
oxygen desaturation with minimal exertion.
# S/p Left total hip arthroplasty [**2142-4-26**]:
- Pain controlled: On Tylenol 650mg Q6hrs and Oxycodone 5mg
Q6hrs prn-
- DVT prophylaxis with Lovenox 40mg Daily until INR [**3-21**] on
Warfarin.
- Weight bear as tolerated with posterior precautions (pillow
between knees when rolled)
# COPD/eosinophilic lung disease: Most recent spirometry: FEV1
0.69; vital capacity 1.44 (44 and 62% of predicted,
respectively). FEV1 to vital capacity ratio is 72% of
predicted.
- Albuterol nebs prn
- Tiotropium 1 cap daily
- Advair 250/50 [**Hospital1 **]
- Prednisone 5mg Q2days.
# Anemia. HCT post-op 26. Transfused 1 unit PRBCs on [**4-28**] and
another unit on [**4-29**]. HCT now stable since [**4-29**] at about 29-30.
# Chronic diastolic CHF (last echo [**7-/2141**], LVEF 50-55%):
Euvolemic.
- Continue Metoprolol 12.5mg [**Hospital1 **], Lasix 20mg PO daily
- Follow electrolytes and replete K and Mg as needed
# CAD: Continue Atorvastatin 40mg daily, ASA 81mg daily,
Metoprolol 12.5mg [**Hospital1 **]
# History of AFib: Rate control with metoprolol. Warfarin for
anticoagulation. Patient has been receiving Warfarin 1mg since
[**2142-4-27**]. Last INR 1.4 on [**2142-4-30**].
# History of PE/DVT: Anticoagulate with Warfarin (see above)
Medications on Admission:
ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution neb q6hrs prn
ALENDRONATE [FOSAMAX] - 70 mg Tablet - 1 Tablet(s) by mouth qwk
ATORVASTATIN [LIPITOR] - 40 mg 1 Tablet(s) by mouth once a day
BENZONATATE - 100 mg Capsule - 2 Capsule(s) by mouth tid prn
cough
FLUTICASONE - 50 mcg Spray, Suspension - 2 squirts(s) in each
nostril once daily
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk
with Device - one inhalation once or twice daily
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth every other day
GABAPENTIN - 100 mg Capsule - 1 Capsule(s) by mouth HS (at
bedtime)
METOPROLOL- 25 mg Tab Sustained Release 24 hr - 0.5 (One half)
Tab po once a day
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - prn
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - daily
POTASSIUM CHLORIDE [KLOR-CON 10] - 10 mEq Tablet Sustained [**Hospital1 **]
PREDNISONE - 5 mg Tablet - 1 (One) Tablet(s) by mouth every
other day
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, 1
puff once daily
WARFARIN - 2 mg Tablet - Take up to 2 Tablet(s) by mouth daily
or as directed
ASPIRIN - (OTC) - 81 mg Tablet, EC qd
CALCIUM CARBONATE-VITAMIN D3 [CALCARB 600 WITH VITAMIN D]
LORATADINE - 10 mg Tablet - 1 (One) Tablet(s) by mouth at
bedtime
MULTIVITAMINS-IRON (HEMATINIC) [CENTAVITE A-Z COMPLETE-MINERAL]-
27 mg-0.4 NEBULIZER - Kit - use albuterol solution in nebulizer
up to every 4 hours prn
SACCHAROMYCES BOULARDII [FLORASTOR] - dosage uncertain
Discharge Medications:
1. Oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain.
2. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every
6 hours): Give around the clock as long as narcotics still
required for pain.
3. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension [**Hospital1 **]:
15-30 MLs PO Q6H (every 6 hours) as needed for Dyspepsia.
4. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
6. Magnesium Hydroxide 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30)
ML PO BID (2 times a day) as needed for Constipation.
7. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
8. Trazodone 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed for Insomnia.
9. Multivitamin Tablet [**Hospital1 **]: One (1) Cap PO DAILY (Daily).
10. Ferrous Sulfate 300 mg (60 mg Iron) Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: [**2-17**] Inhalation Q6H (every 6 hours) as needed
for wheeze, shortness of breath.
12. Atorvastatin 20 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY
(Daily).
13. Benzonatate 100 mg Capsule [**Month/Day (2) **]: Two (2) Capsule PO TID (3
times a day) as needed for cough.
14. Fluticasone 50 mcg/Actuation Spray, Suspension [**Month/Day (2) **]: Two (2)
Spray Nasal DAILY (Daily).
15. Gabapentin 100 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO HS (at
bedtime).
16. Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO BID (2
times a day): Hold for SBP<110 or HR<50.
17. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Month/Day (2) **]:
One (1) Cap Inhalation DAILY (Daily).
18. Enoxaparin 40 mg/0.4 mL Syringe [**Month/Day (2) **]: One (1) Subcutaneous
DAILY (Daily).
19. Prednisone 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
20. Furosemide 20 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
21. Warfarin 1 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Once Daily at 4
PM.
22. Aspirin 81 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
23. Alendronate 70 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a week.
24. Advair Diskus 500-50 mcg/Dose Disk with Device [**Month/Day (2) **]: One (1)
inhalation Inhalation twice a day.
25. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
26. Calcium Carbonate-Vitamin D3 600 mg(1,500mg) -400 unit
Capsule [**Month/Day (2) **]: One (1) Capsule PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Left hip osteoarthritis with left total hip arthroplasty
SECONDARY DIAGNOSES:
- Chronic obstructive pulmonary disease, stable
- Chronic eosinophilic lung disease (chronic eosinophilic
pneumonia or Churg-[**Doctor Last Name 3532**] syndrome)
- Chronic diastolic heart failure, EF 55% on lasix (not on ACE
at primary MD's discretion)
- Atrial fibrillation on coumadin
- Large right pulmonary embolism and bilateral deep venous
thrombosis [**7-/2141**] on coumadin
- Myocarditis in [**2137**] with EF 20-25% at that time, cath negative
- Hypertension diet controlled
- History of C. diff colitis
- History of MSSA and pseudomonal PNA
- Hyperlipidemia
- Peripheral artery disease
- Migraine headache
- Hypoalbuminemic
- History of angioneurotic edema on [**Last Name (un) **] therapy
- S/p left eye surgery [**2141-11-15**]
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair
stable. Weight bearing as tolerated
Discharge Instructions:
Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
WOUND CARE: Please keep your incision clean and dry. It is okay
to shower five days after surgery but no tub baths, swimming, or
submerging your incision until after your four week checkup.
Please place a dry sterile dressing on the wound each day if
there is drainage, otherwise leave it open to air. Check wound
regularly for
signs of infection such as redness or thick yellow drainage.
Staples will be removed by the visiting nurse or rehab facility
in two weeks.
PT/OT, dressing changes as instructed, wound checks, and staple
removal at two weeks after surgery.
ACTIVITY: Weight bearing as tolerated on the operative
extremity. Posterior hip precautions. No strenuous exercise or
heavy lifting until follow up appointment.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Appointment #1
Department: ORTHOPEDICS
When: FRIDAY [**2142-5-25**] at 1:20 PM
With: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], PA [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Appointment #2
Department: DERMATOLOGY
When: TUESDAY [**2142-5-29**] at 10:00 AM
With: [**Name6 (MD) 2975**] [**Name8 (MD) 2976**], MD [**Telephone/Fax (1) 2977**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Appointment #3
Department: [**Hospital3 249**]
When: WEDNESDAY [**2142-5-30**] at 10:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) 9501**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
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"V58.61",
"285.1",
"V58.65",
"V12.51",
"428.32",
"518.3",
"427.31",
"E878.1",
"733.00",
"715.35",
"458.29",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.51"
] |
icd9pcs
|
[
[
[]
]
] |
9726, 9798
|
3829, 5308
|
319, 380
|
10683, 10683
|
2884, 3806
|
11868, 12857
|
2157, 2222
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6816, 9703
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10891, 11024
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9919, 10662
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265, 281
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11036, 11845
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408, 1241
|
9838, 9898
|
10698, 10867
|
1263, 1922
|
1938, 2141
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,995
| 198,725
|
54271
|
Discharge summary
|
report
|
Admission Date: [**2156-3-15**] Discharge Date: [**2156-3-24**]
Service: MEDICINE
Allergies:
Reglan
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] y/o male with h/o end-stage pulmonary fibrosis and
interstitial lung disease, on home O2 of [**12-8**].5L, as well as
esophageal diverticular disease presents with dyspnea developing
over 2 days. Recent cough with sputum production. No observed
apsiration events. Reports no symptomes of lower extremity
swelling. Denies leg pain. Occassional chest tightness. In ED,
temp to 101.8, BP 107/65 ranging 107-124 SBP, HR 87, RR 28 with
Sat 93% on RA. Treated with Combivent nebs, 500 mg IV
Levofoaxacin, and 80 mg IV solumedrol.
Past Medical History:
HTN
CHF with EF 45% by Echo [**2150**]
Interstitial Lung Disease with Pulmonary Fibrosis
Type II Diabetes
CRI, Baseline Cr 1.1-1.4
GERD, hiatal hernia
Esophageal dysmotility causing chronic regurgitation of food
Esophageal diverticulae
Gastroparesis
Chronic constipation
Lumbar spinal stenosis with LE weakness
BPH s/p TURP
Cataracts, s/p R eye surgery (cannot see out of right eye)
Oral thrush
hx. aspiration with eating
arthritis
Social History:
He lives with his daughter. Daughter assists with ADLs,
including feeding, ambulating, bathing, and dressing. He does
not drink alcohol, and he is a former smoker. Worked in a sugar
refining factory with inhalation exposures.
Family History:
Non-contributory.
Physical Exam:
T 97.7 HR 90 BP 122/60 RR 22 SAT 100% on NRB mask
Elederly male, mildly tachypneic, able to speak in short
sentances
HEENT: Pupils equal, no conjunctival pallor, oral thrush.
NECK: No LAD. No JVP elevation.
CHEST: No axillary LAD. Lungs with diffusely coarse crackles.
HEART: Regular. No audible murmurs.
ABD: NABS, soft, NT, ND, no masses.
EXT: Thin, good femoral and popliteal pulses. Weak DP pulses.
NEURO: Oriented to person and hospital. Unable to correctly give
month or year. Moves all extremities equally.
Pertinent Results:
Laboratory studies on admission:
[**2156-3-15**]
WBC-12.0 HGB-12.1 HCT-36.9 MCV-83 RDW-16.8 PLT COUNT-213
NEUTS-83.4* LYMPHS-7.9* MONOS-7.7 EOS-0.8 BASOS-0.2
CALCIUM-8.6 PHOSPHATE-1.9* MAGNESIUM-2.3
CK-MB-NotDone cTropnT-<0.01
CK(CPK)-32*
GLUCOSE-283* UREA N-24* CREAT-1.1 SODIUM-137 POTASSIUM-4.7
CHLORIDE-104 TOTAL CO2-24
LACTATE-2.5*
D-DIMER-2575*
EKG [**2156-3-15**]: Sinus rhythm First degree A-V delay, Left atrial
abnormality.
[**Month (only) 116**] be otherwise normal ECG, but unstable baseline makes
assessment difficult. Since previous tracing of [**2155-9-23**],
probably no significant change.
Radiology:
[**2156-3-15**] CT CHEST:
1. No central or segmental pulmonary embolus.
2. Extensive pulmonary disease, including fibrosis and
honeycombing. There is superimposed failure. Additionally, the
more confluent confluent opacities in the dependent right lung
may represent aspiration pneumonia, particluarly in light of a
hiatal hernia and patulous esophagus.
3. Ground-glass opacities, interlobular septal lines, most
likely representing failure.
4. Extensive mediastinal lymphadenopathy, differential diagnosis
includes reactive lymphadenopathy versus lymphoma.
5. Left hepatic 11-mm liver lesion, incompletely characterized.
MR may be performed if further evaluation is desired.
6. Cardiomegaly, coronary artery disease.
[**2156-3-16**] CXR: Mild interstitial edema has worsened congestion and
mild volume loss in the right upper lobe is chronic, possibility
a function of mild upper lobe bronchial narrowing due to
adenopathy seen on the chest CT [**3-15**]. Borderline cardiomegaly
and moderate-sized hiatus hernia, unchanged. Small bilateral
pleural effusion may be present. Thoracic aorta is generally
large and tortuous, but unchanged in caliber compared to recent
prior studies. No pneumothorax.
[**2156-3-16**] ECHO: The left atrium is elongated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Left ventricular systolic function is
hyperdynamic (EF 80%). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior report (images
unavailable for review) of [**2151-2-24**], the pulmonary artery
systolic pressure is increased; otherwise the findings are
similar.
[**2156-3-17**] CXR: Multiple chronic changes. New
consolidation/aspiration on the left.
Brief Hospital Course:
[**Age over 90 **] year old male with end-stage pulmonary fibrosis and
dysphagia presents with respiratory distress, likely due to a
flare of his known IPF and chronic aspiration. The patient was
initially admitted to the ICU, subsequently transferred out to
the general medical floor.
1) Interstitial fibrosis: The patient was started empirically on
steroids, of which he will continue a slow outpatient taper. The
case was discussed with his outpatient pulmonolgist, who noted
that, unfortunately, this is end-stage interstitial fibrosis for
which there are no additional treatment options. Despite maximal
treatment (steroids, antibiotics, bronchodilators), the
patient's clinical status did not improve significantly. After
extensive discussion with the [**Hospital 228**] health care proxy and
family, it was decided that the patient would be discharged to a
[**Hospital1 1501**] with hospice services, given his very poor prognosis and the
family's desire to keep him as comfortable as possible.
2) Aspiration pneumonia: The patient has a known history of
dysphagia, and was noted on chest CT to have more confluent
confluent opacities in the dependent right lung likely
representing aspiration pneumonia. He was begun on a 14 day
course of levofloxacin and metronidazole. He was evaluated by
the speech and swallow service, who recommended pureed solids
and thick liquids, with close observation during feeding.
3) Esophageal diverticlum/dysmotility: The patient was treated
by continuing home dose of zelnorm. Given aspiration event,
speech swallow was consulted with recs noted below. Given
hiatal hernia/GERD; his PPI was changed to Carafate liquid.
4) Urinary retention: The patient was noted to have recurrent
urinary retention, despite continuing his home dose of
terazosin. A foley was placed for patient comfort, although a
voiding trial can also be considered as an outpatient.
5) Hypertension: The patient was continued on his home doses of
amlodipine and atenolol.
6) Type II diabetes: The patient's glyburide was held throughout
his hospital stay. His fingersticks were initially monitored,
however, given minimal insulin requirement and a desire to
maintain the patient's comfort, this was discontinued.
7) DNR/DNI: The patient was discharged to a [**Hospital1 1501**] with hospice
services.
Medications on Admission:
Atenolol 25mg po daily
Amlodipine 5mg po daily
ASA 325mg po daily
Pulmicort Turbuhaler 200 mcg 4 ampules inhaled daily
Duoneb [**Hospital1 **]
Albuterol neb prn
Home O2 1.5L at all times
Prilosec EC 20mg po bid
Zelnorm 6mg po bid
Lactulose daily
Mycelex 3-5 times/day
Boost tid
Glucerna tid
Oral hypoglycemic [**Doctor Last Name 360**] prn blood sugar>300 per pt's daughter
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
5. Budesonide 0.5 mg/2 mL Solution for Nebulization Sig: Two (2)
ML Inhalation qday ().
6. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
7. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
8. Zelnorm 6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
10. Prednisone 20 mg Tablet Sig: Forty (40) mg PO DAILY (Daily)
for 2 days: then 3 mg daily for 3 days, then 20 mg daily for 3
days, then 10 mg daily for 3 days.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
13. Docusate Sodium 50 mg/5 mL Liquid Sig: Two Hundred (200) mg
PO BID (2 times a day).
14. Morphine Concentrate 10 mg/0.5 mL Solution Sig: 5-10 mg PO
Q4H PRN ().
15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
16. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name **] manor
Discharge Diagnosis:
Primary: interstitial fibrosis
Secondary: aspiration pneumonia, hypernatremia, constipation,
urinary retention, hypertension, Type II diabetes well
controlled without complications
Discharge Condition:
The patient is being discharged to a hospice facility
Discharge Instructions:
You were admitted with worsening interstitial pulmonary fibrosis
and recurrent aspiration pneumonia. You are being discharged to
a hospice facility
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Date/Time:[**2156-5-17**] 11:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2156-3-24**]
|
[
"403.90",
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"750.4",
"530.81",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8979, 9036
|
4830, 7152
|
234, 240
|
9261, 9317
|
2098, 2117
|
9513, 9807
|
1530, 1549
|
7576, 8956
|
9057, 9240
|
7178, 7553
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9341, 9490
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1564, 2079
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175, 196
|
268, 812
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2131, 4807
|
834, 1267
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1283, 1514
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,520
| 103,985
|
22263
|
Discharge summary
|
report
|
Admission Date: [**2153-2-6**] Discharge Date: [**2153-3-19**]
Date of Birth: [**2094-3-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
1. Pseudoaneurysm of ascending aorta and arch
2. 2+ Aortic insufficiency
3. Respiratory failure
Major Surgical or Invasive Procedure:
[**2153-2-7**]
1. Ascending aorta hemiarch replacement with 26mm Gelweave graft
2. Aortic valve repair with 21mm pericardial tissue valve
[**2153-2-19**]
1. Tracheostomy
History of Present Illness:
58 year-old woman with hypertension, former tobacco use, and
Type B aortic dissection [**9-13**] with surgical repair. At that time
an ascending aortic hematoma was also noted. After several
missed appointments, she now presents with chest pain and
shortness of breath and a blood pressure of 200/100. She was
found to have an enlarging ascending aortic pseudoaneurysm on
CTA.
Past Medical History:
s/p type B aortic dissection repair [**9-13**]
Poorly controlled hypertension
Asthma
Obesity
COPD
s/p L frontal and R parietal lobe CVA
a fib
s/p retraoperitoneal hematoma
s/p repiratory failure with trach [**10-14**]
Social History:
Smoked 15 pk years until aortic dissection. No Etoh, No Drugs.
Family History:
Negative for aortic dissection; negative for CAD.
Physical Exam:
VS: P 60, BP 96/60 R-20 100% PS 0.4
GEN: [**Last Name (LF) 3584**], [**First Name3 (LF) 2995**]
HEENT: PERRLA EOMI
Neck: No Carotid Bruits
Heart: Distant, RRR w/o M
Chest: Bilateral Rhonchi, wheezes l>r
ABD: SNTND, no rebound
Vasc: Radial Femoral DP PT
R A-Line 2+ 2+ 2+
L 2+ 2+ 2+ 1+
Pertinent Results:
[**2153-2-23**] 04:17AM BLOOD WBC-10.4 RBC-3.22* Hgb-9.8* Hct-28.2*
MCV-88 MCH-30.4 MCHC-34.7 RDW-14.8 Plt Ct-185
[**2153-2-23**] 04:17AM BLOOD Plt Ct-185
[**2153-2-23**] 04:17AM BLOOD Glucose-94 UreaN-21* Creat-0.4 Na-142
K-4.0 Cl-106 HCO3-30* AnGap-10
[**2153-2-23**] 04:17AM BLOOD Mg-2.0
Cardiac catheter [**2154-2-6**]
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Moderate aortic regurgitation.
3. Mild systolic ventricular dysfunction.
4. Mild diastolic ventricular dysfunction.
5. Large aneurysmal dilation of the ascending aorta.
Brief Hospital Course:
After admission, Mrs. [**Known lastname 58041**] underwent a cardiac catheter.
Supravalvular aortography revealed a large aneurysmal (>7cm)
dilation arising from 2-3 cm above the aortic valve and
encroaching on the true lumen of the aorta. 2+ aortic
regurgitation was noted. On [**2-7**], she was taken to the
operating room for ascending aortic and hemiarch relacement as
well as aortic valve replacement with a tissue valve.
Postoperatively, she was admitted to the cardiac ICU. Her
postoperative course was complicated (again) by repiratory
failure. She weaned slowly off the vent but failed extubation
after successfully passing several breathing trials. She had to
be reintubated and underwent an open trachestomy by the thoracic
surgery team on [**2153-2-19**]. Her blood pressure was controlled on a
nipride drip initially. Later she could be controlled below 110
systolically on oral Antihypertensives. She was fed via a
Dobhoff tube and tube feedings. During the days she tolerated
several hours on trach mask in the chair but spend the night on
the ventilator on minimal settings. She was diuresed
appropriately until she reached preoperative weights. She was
ultimately weanod off the ventilator, and placed on trach
collar.
On [**2-23**], she was started on IV Vancomycin for MRSA on a central
line, and 1 positive blood culture. She should complete a 6
week course. Her trough levels have been approx. 17 (goal
trough per ID service is 15-20), on 1250 mg IV BID.
She has passed swallow studies, oral feedings have been
advanced, and her feeding tube was removed, as she is now eating
a regular diet without difficulty.
Her trach was downsized from a 6 to a 4, then subsequently
removed (on [**2153-3-16**]).
At discharge, she was in a good condition. Her wound was without
signs of wound infection.
Of note, during her hospitalization, she had a possible exposure
to a TB+ person. Since she had a previous +PPD, we can not use
this as a screening test to monitor sero-conversion. Ms. [**Known lastname 58041**]
therefore must be monitored for the next year for symptoms of
tuberculosis and worked up if these symptoms are found.
Medications on Admission:
Albuterol
Lopressor 50mg po bid
Amiodarone 200mg po qd
Norvasc 10mg qd
Lasix 40mg [**Hospital1 **]
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
3. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Vancomycin HCl 10 g Recon Soln Sig: 1250 mg Intravenous
twice a day for until [**4-6**] doses.
Disp:*17 doses* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
1. Pseudoaneurysm of ascending aorta and arch
2. 2+ Aortic insufficiency
3. Respiratory failure
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Of note, during her hospitalization, she had a possible exposure
to a TB+ person. Since she had a previous +PPD, we can not use
this as a screening test to monitor sero-conversion. Ms. [**Known lastname 58041**]
therefore must be monitored for the next year for symptoms of
tuberculosis and worked up if these symptoms are found.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.
[**Telephone/Fax (1) **]
Follow-up with PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 1300**] in [**2-11**]
weeks
Completed by:[**2153-3-19**]
|
[
"518.81",
"401.9",
"424.1",
"441.01",
"427.31",
"997.2",
"287.5",
"E878.8",
"493.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.45",
"97.37",
"88.42",
"96.04",
"88.72",
"96.72",
"88.56",
"37.22",
"38.93",
"35.21",
"31.1",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5408, 5463
|
2318, 4468
|
415, 586
|
5604, 5610
|
1747, 2071
|
5854, 6484
|
1333, 1384
|
4617, 5385
|
5484, 5583
|
4494, 4594
|
2088, 2295
|
5634, 5831
|
1399, 1728
|
280, 377
|
614, 993
|
1015, 1237
|
1253, 1317
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,616
| 190,070
|
562+563
|
Discharge summary
|
report+report
|
Admission Date: [**2131-6-1**] Discharge Date: [**2131-6-15**]
Service: CSU
CHIEF COMPLAINT: Increasing fatigue, decreasing appetite,
and weight loss.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is an 81-year-old woman
with multiple episodes of congestive heart failure with known
significant mitral regurgitation and chronic atrial
fibrillation (on Coumadin for her atrial fibrillation)
admitted preoperatively to come off of her Coumadin and be
placed on IV heparin while awaiting her INR to come back to
normal levels.
The patient underwent a cardiac catheterization in [**2131-6-20**] which showed a cardiac index of 1.4, 30% to 60% RCA
lesion, 4+ MR, with positive MAC. She had a TEE done also in
[**2131-4-20**] that showed mild aortic insufficiency, moderate
mitral regurgitation, mild mitral stenosis, moderate
tricuspid regurgitation, an EF of 35% to 40%, and a dilated
left atrium without any thrombus.
PAST MEDICAL HISTORY: Significant for hypertension, mitral
regurgitation, aortic insufficiency, COPD,
hypercholesterolemia, rheumatic heart disease, paroxysmal
atrial fibrillation, left retinal artery embolus,
cardiomyopathy, and pulmonary hypertension.
PAST SURGICAL HISTORY: Significant for hysterectomy
secondary to endometrial cancer.
MEDICATIONS PRIOR TO ADMISSION: Include Zocor 10 mg daily,
Coumadin, multivitamin 1 tablet daily, Lopressor 100 mg
b.i.d., calcium 3 tablets daily, aspirin 325 mg daily,
digoxin 0.125 mg daily, Lasix 20 mg daily, lisinopril 20 mg
daily, Remeron 15 mg daily, amiodarone 400 mg daily, Restoril
7.5 mg p.r.n., Protonix 40 mg daily, and Diamox (no dose or
schedule given).
ALLERGIES: The patient states no known drug allergies.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: She has a remote tobacco history; quit many
years ago. She lives alone; however, immediately prior to
admission to [**Hospital **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] she was in a
rehabilitation setting. The patient also denies alcohol use.
PHYSICAL EXAMINATION ON ADMISSION: Height of 5 feet 3
inches, weight of 112 pounds, heart rate of 54 (atrial
fibrillation), blood pressure of 104/56 on the right and
100/60 on the left, and respiratory rate of 20.
Neurologically, grossly intact. Pulmonary reveals clear to
auscultation bilaterally. Cardiac reveals irregularly
irregular. The abdomen is soft, nontender, and nondistended
with positive bowel sounds and no masses appreciated. The
extremities are warm and well perfused with no edema.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to the
cardiothoracic service and begun on heparin while awaiting
her INR to return to normal levels. Her last dose of Coumadin
prior to admission was on [**5-31**]. The patient was noted to
have an admission INR of 6.1. Therefore, the patient was
administered vitamin K on both the day of admission and on
hospital day 1. The patient has stated that she had a 3-week
history of diarrhea prior to admission to the [**Hospital **] [**Hospital **]
[**First Name (Titles) **] [**Last Name (Titles) **]. Therefore, the gastroenterology service was
consulted. Reportedly, the patient had been worked up by her
primary care physician with all culture data being negative
to date. She had recommended a lactose-free diet, additional
stool cultures, and an outpatient colonoscopy.
Over the next several days the patient remained
hemodynamically stable. Her blood work was followed daily,
and she was given p.r.n. vitamin K. Ultimately, on [**6-5**],
the patient was brought to the operating room where she
underwent mitral valve replacement with a #27 Mosaic valve.
Please see the OR report for full details. In summary, she
had mitral valve replacement. Her bypass time was 87 minutes
with a cross-clamp time of 66 minutes. She tolerated the
operation well and was transferred from the operating room to
the cardiothoracic intensive care unit. At the time of
transfer the patient was in atrial fibrillation at 76 beats
per minute, with a CVP of 6, and PA pressures of 30/15. She
had Neo-Synephrine at 0.5 mcg/kg/min and propofol at 20
mcg/kg/min.
In the immediate postoperative period the patient had a
somewhat [**Male First Name (un) 3928**] course with a labile blood pressure requiring
large volumes of fluid, and ultimately she was begun on
milrinone for a low cardiac index. Over the next 12 hours the
patient did extremely well. Her anesthesia was reversed. Her
sedation was discontinued. She was weaned from the ventilator
and successfully extubated. On postoperative day 1, she was
weaned from her milrinone infusion. However, she did require
a Nipride infusion to maintain a somewhat normalized blood
pressure.
On postoperative day 2, she was begun on an ACE inhibitor as
well as beta blockade and weaned from her Nipride infusion.
Additionally, the patient's PA catheter was removed.
Additionally, the patient had a swallow evaluation; and she
was transferred from the cardiothoracic intensive care unit
to [**Hospital Ward Name 121**] Two for continuing postoperative care and cardiac
rehabilitation.
On postoperative day 3, the patient remained hemodynamically
stable. However, she had dwindling urine output, and her
Foley catheter was re-placed. Additionally, the patient had a
swallow evaluation that did not demonstrate any signs of
aspiration, and she was restarted on her Coumadin.
On postoperative day 4, the patient remained hemodynamically
stable. Her temporary pacing wires were discontinued. Her
beta blockade and Lasix doses were adjusted, and her activity
level was gradually increased with the assistance of the
nursing staff and physical therapy.
On postoperative day 6, the patient was noted to have an INR
of 7; which was repeated and found to be accurate. She was
transferred from the floor back to the cardiothoracic
intensive care unit and treated with FFP and vitamin K;
following which her INR returned to 2. However, she continued
to be monitored in the cardiothoracic intensive care unit for
an additional 2 days.
On postoperative day 8, she was again transferred back to
[**Hospital Ward Name 121**] Two. She had an uneventful course throughout the
remainder of her hospitalization.
On postoperative day 9, it was felt that the following day
the patient would be stable and ready to be transferred to
rehabilitation for continuing care and recovery from her
cardiac surgery.
At this time the patient's physical exam reveals a
temperature of 96.6, heart rate of 85 (atrial fibrillation),
blood pressure of 139/91, respiratory rate of 18, and O2
saturation of 95% on room air. Weight is 60 kilograms.
Laboratory data reveals a white count of 8, hematocrit of 37,
and platelets of 172. PT is 15, PTT is 27, and INR is 1.5.
Sodium is 146, potassium is 5.5, chloride is 104, CO2 is 30,
BUN is 43, creatinine is 1.4, and glucose is 113. In general,
in no acute distress. Neurologically, alert and oriented.
Moves all extremities. Follows commands. A nonfocal exam.
Pulmonary reveals diminished at the bases without any rales
or rhonchi. Cardiovascular reveals irregularly irregular, S1
and S2, with no murmurs. The sternum is stable. Incision with
Steri-Strips, clean and dry, no drainage or erythema. The
abdomen is soft and nontender with normal active bowel
sounds. The extremities are warm and well perfused with 1+
edema.
DISCHARGE DISPOSITION: The patient is expected to be
discharged to an extended care facility.
CONDITION ON TRANSFER: Good.
DISCHARGE DIAGNOSES:
1. Status post mitral valve replacement with a #27 Mosaic
valve.
2. Mitral regurgitation.
3. Paroxysmal atrial fibrillation.
4. Hypertension.
5. Chronic obstructive pulmonary disease.
6. Hypercholesterolemia.
7. Left retinal artery embolus.
8. Cardiomyopathy.
9. Pulmonary hypertension.
10. Rheumatic heart disease.
11. Hysterectomy.
DI[**Last Name (STitle) 408**]E FOLLOWUP: The patient is to have followup in the
[**Hospital 409**] Clinic in 2 weeks, followup with Dr. [**Last Name (STitle) 1655**] in 2 to 3
weeks, and followup with Dr. [**Last Name (Prefixes) **] in 4 weeks.
MEDICATIONS ON DISCHARGE: Include Remeron 15 mg at bedtime,
amiodarone 400 mg daily, Protonix 40 mg daily, Lasix 20 mg
b.i.d. x 2 weeks and then 20 mg daily, Colace 100 mg b.i.d.,
aspirin 81 mg daily, warfarin as directed to maintain a
target INR of 2 to 2.5 (the patient received 1 mg on the [**6-14**]), Percocet 5/325 1 to 2 tablets every 4 to 6 hours as
needed (for pain), lisinopril 5 mg daily, Lopressor 50 mg
b.i.d., potassium chloride 20 mEq daily.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2131-6-14**] 18:03:31
T: [**2131-6-14**] 18:52:49
Job#: [**Job Number 4557**]
Admission Date: [**2131-6-1**] Discharge Date: [**2131-6-15**]
Service: CARDIOTHORACIC
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Mitral regurgitation
Major Surgical or Invasive Procedure:
1. Mitral valve replacement (#27 mosaic)
History of Present Illness:
81F c mitral regurgitation by TEE with symptoms of increasing
fatigue, decrease mobility, weight loss. Evaluated as
outpatient with echo showing mild AI, mod MR, mild MS, mod TR,
dilated LA, and EF 40%, and cardiac cath showing no significant
CAD. She was admitted for preop heparin gtt.
Past Medical History:
1. MR
2. AI
3. HTN
4. COPD
5. Hypercholesterolemia
6. Paroxysmal afib
7. h/o L retinal artery occlusion
8. Pulmonary HTN
9. s/p TAH for endometrial CA
Social History:
Noncontributory
Family History:
Noncontributory
Physical Exam:
Afebrile, VSS
NAD, alert
Neck: no bruits, no JVD
Heart: Irregular, [**2-25**] murmur
Lungs: CTAB
Abd: soft, NT, ND, + BS
Ext: no edema
Pertinent Results:
[**2131-6-9**] 06:20AM BLOOD WBC-9.3 RBC-4.27 Hgb-12.7 Hct-37.8 MCV-89
MCH-29.8 MCHC-33.7 RDW-17.3* Plt Ct-78*
[**2131-6-9**] 06:20AM BLOOD Glucose-120* UreaN-29* Creat-1.3* Na-141
K-4.0 Cl-103 HCO3-25 AnGap-17
Brief Hospital Course:
81F c mitral regurgitation by TEE with symptoms of increasing
fatigue, decrease mobility, weight loss. Evaluated as outpatient
with echo showing mild AI, mod MR, mild MS, mod TR, dilated LA,
and EF 40%, and cardiac cath showing no significant CAD. She was
admitted for preop heparin gtt.
She went to the OR [**2131-6-5**] for MVR (#27 Mosaic). For more
detailed account, please see operative note. Post-op, she was
transferred to the CSRU where she required dobutamine,
milrinone, and volume resuscitation for low cardiac index.
These issues rapidly resolved and she was extubated on POD 1.
She was tranferred to the floor on POD 2. She re-started her
coumadin on POD 4. PT recommended rehab placement.
Medications on Admission:
1. Zocor
2. Coumadin
3. Lopressor 100 mg PO BID
4. Calcium
5. ASA 325 mg PO QD
6. Digoxin 0.125 mg PO QD
7. Lasix 10 mg PO QD
8. Lisinopril 20 mg PO QD
9. Remeron 15 mg PO QD
10. Amiodarone taper
11. Protonix 40 mg PO QD
12. Diamox
Discharge Medications:
1. 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*
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. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
5. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
9. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for tonights dose.
Disp:*30 Tablet(s)* Refills:*2*
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
Disp:*120 neb* Refills:*2*
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
Disp:*120 neb* Refills:*2*
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
1. Mitral regurgitation
2. Paroxysmal atrial fib
3. HTN
4. COPD
5. Hypercholesterolemia
Discharge Condition:
Good
Discharge Instructions:
1. Medications as directed.
2. Follow up INR with PCP or cardiologist.
3. Call office or go to ER if fever/chills, discharge from
sternal incision, chest pain, dyspnea.
Followup Instructions:
PCP, 2 weeks, please call for appointment.
Cardiologist, 2 weeks, please call for appointment.
Dr[**Last Name (Prefixes) 4558**], 4 weeks, please call for appointment.
|
[
"398.91",
"V10.42",
"401.9",
"458.29",
"427.31",
"287.4",
"394.2",
"272.0",
"271.3",
"416.0",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"35.23",
"99.05",
"99.04",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
12612, 12684
|
10070, 10779
|
9063, 9106
|
12816, 12822
|
9835, 10047
|
13039, 13212
|
9648, 9665
|
7503, 8100
|
11061, 12589
|
12705, 12795
|
8127, 8986
|
10805, 11038
|
12846, 13016
|
1220, 1283
|
9680, 9816
|
2568, 7355
|
1316, 1711
|
9003, 9025
|
9134, 9425
|
2074, 2539
|
9447, 9599
|
9615, 9632
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,665
| 111,461
|
19104
|
Discharge summary
|
report
|
Admission Date: [**2185-10-6**] Discharge Date: [**2185-10-28**]
Date of Birth: [**2113-3-10**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Hayfever
Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
72 M s/p renal transplant and CRF, diastolic CHF EF 45-50%, s/p
CABG and [**First Name3 (LF) 1291**] on coumadin, DM2, vasculopath with L fem-[**Doctor Last Name **] bypass
and revisions, CHF, recently discharged from [**Hospital1 18**] [**2185-9-14**] after
a 2 month admission for osteomyelitis, ARF, and CHF
exacerbation. Today he was sent from NH to [**Hospital3 8544**] for
decreased responsiveness and AMS intermittantly over last week.
BG was found to be 34 with rapid recovery in responsiveness with
D50. Found him to be hyperkalemic in ARF, with TnT 0.367 (same
as Troponin here). Transferred to [**Hospital1 18**] today because of his 2
month admission here recently.
.
Family reported increasing full body swelling and worsening
dyspnea from baseline for the past week. EKG shows 1.5 mm STE in
V1-V3, 1mm on old EKGs for comparison. Patient is DNR/DNI,
patient and family did not wish to have cardiac cath performed.
Patient has never had CP, but has had intermittent dyspnea.
.
In the ED, HR60s, BP105-110, 99% 2L nc, BG108, received ASA,
plavix, did not give integrillin because of renal failure. INR
4.9 for anticoagulation for [**Hospital1 1291**], heparin gtt was not started.
For hyperkalemia of K 5.9 and 6.0, patient received calcium,
insulin, glucose, and he had received kayexylate at OSH. CXR
shows pulmonary edema and bilateral effusions. Trop 0.38, MB 8,
no CK drawn.
.
.
MICU course:
Found to be in oliguric renal failure with decreased urine
output for 5 days prior to admission. Started hemodialysis on
[**8-6**] for Uremia, volume overload. Supratheraputic INR on
admission, unable to biopsy kidney for diagnosis, given Vit K.
INR subtheraputic (with goal 2.5-3.5), restarted on coumadin and
Heparin GTT until coumadin theraputic. Also given solu-medrol
500mg x3 days to treat for rejection.
.
Past Medical History:
- IDDM
- PVD
- CAD (no MI)
- hyperlipid
- Hypertension
- CRI (baseline Cr 1.5-1.7)
- s/p L AK [**Doctor Last Name **]-DP spliced [**Doctor Last Name 5703**] BPG ([**2-4**])
- s/p LRKT ('[**79**])
- s/p CABG/Mech.[**Year (2 digits) 1291**]('[**77**])
- s/p Excise L metatarsal head
- s/p L AV fistula ('[**79**])
- s/p Excise colon polyp ('[**77**])
Social History:
non-contrib
Family History:
non-contrib
Physical Exam:
VS: 97.9 / 108/36 / 63 / 12 / 99% 2L nc
GENERAL: Alert, communicating, answering questions and directing
properly
HEENT: JVD to jawline, no LAD
LUNGS: Clear anteriorly but rales posteriorly, dull in bases bl
HEART: RRR, clear S1/S2, no m/r/g, CABG scar
ABDOMEN: Soft, dependent 4+ edema, thin, +BS
EXTR: 4+ edema on arms and legs, dopplerable pulses, larger R
arm than left, cellulitis and eschars in R and L feet
NEURO: Sensation present in legs and feet, cannot move legs well
SKIN: Skin breakdown areas
.
Pertinent Results:
[**2185-10-21**] Repeat Echocardiogram
Conclusions:
The left atrium is dilated. There is moderate symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. There
is moderate global left ventricular hypokinesis (LVEF = 30-40
%). Right ventricular chamber size and free wall motion are
normal. A bileaflet aortic valve prosthesis is present. The
aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. 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.] The tricuspid valve leaflets are mildly
thickened. There is a trivial/physiologic pericardial effusion.
Suboptimal image quality - patient unable to cooperate.
Compared with the findings of the prior study (images reviewed)
of [**2185-10-8**], the findings are similar (ejection
fraction overestimated on prior study).
.
[**2185-10-20**] Head CT
IMPRESSION:
1. No evidence of hemorrhage or mass effect.
2. Central involutional changes and evidence of small vessel
angiopathy.
.
[**2185-10-8**] Echocardiogram:.
Conclusions:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 0-5mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is mild global left ventricular hypokinesis (LVEF = 50 %), no
regionality seen. Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. Right ventricular systolic function
is borderline normal. There is
abnormal septal motion/position. A bileaflet aortic valve
prosthesis is present. The aortic valve prosthesis appears well
seated, with normal leaflet/disc motion and transvalvular
gradients. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2185-8-23**], no
significant change.
.
[**2185-10-7**] CXR -
IMPRESSION: New consolidation in the right lower lobe that may
reflect aspiration. Followup radiographs will help distinguish
atelectasis from pneumonia. Interval improvement in pulmonary
edema.
.
[**2185-10-6**] Renal Transplant U/S
Doppler examination of the main transplant renal artery and
interpolar arterials demonstrates normal systolic upstroke with
absent diastolic flow. The resistive index is 1.0. This is not
significantly chnaged. The transplant renal [**Month/Day/Year 5703**] is patent.
IMPRESSION:
1. Stable appearance of transplant kidney with elevated
resistive indeces. No
evidence of hydronephrosis or perinephric collection
[**2185-10-6**] 02:20AM WBC-6.1 RBC-3.88* HGB-10.5* HCT-34.1* MCV-88
MCH-27.0 MCHC-30.7* RDW-18.8*
[**2185-10-6**] 02:20AM NEUTS-77.1* LYMPHS-13.5* MONOS-7.8 EOS-1.4
BASOS-0.2
[**2185-10-6**] 02:20AM PLT COUNT-241
[**2185-10-6**] 02:20AM PT-43.0* PTT-44.0* INR(PT)-4.9*
[**2185-10-6**] 02:20AM ALBUMIN-2.3* CALCIUM-7.7* PHOSPHATE-5.5*#
MAGNESIUM-2.0
[**2185-10-6**] 02:20AM CK-MB-8 cTropnT-0.38*
[**2185-10-6**] 02:20AM LIPASE-9
[**2185-10-6**] 02:20AM ALT(SGPT)-10 AST(SGOT)-17 ALK PHOS-131*
AMYLASE-27 TOT BILI-0.2
[**2185-10-6**] 02:20AM GLUCOSE-88 UREA N-57* CREAT-4.8*# SODIUM-139
POTASSIUM-6.0* CHLORIDE-114* TOTAL CO2-13* ANION GAP-18
[**2185-10-6**] 06:00AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2185-10-6**] 06:00AM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.019
[**2185-10-6**] 06:00AM URINE HOURS-RANDOM UREA N-246 CREAT-176
SODIUM-25 POTASSIUM-56 CHLORIDE-17 TOT PROT-230 PROT/CREA-1.3*
[**2185-10-6**] 05:19AM LACTATE-1.1 K+-4.7
Brief Hospital Course:
72 yo M s/p renal transplant and CRF, systolic CHF s/p CABG and
[**Month/Day/Year 1291**] on coumadin, DM2, vasculopathy with L fem-[**Doctor Last Name **] bypass and
revisions admitted with mental status changes and acute renal
failure with volume overload admitted to the MICU.
.
MICU course:
Found to be in oliguric renal failure with decreased urine
output for 5 days prior to admission. Started hemodialysis on
[**8-6**] for Uremia, volume overload. Supratheraputic INR on
admission, unable to biopsy kidney for diagnosis, given Vit K.
INR subtheraputic (with goal 2.5-3.5), restarted on coumadin and
Heparin GTT until coumadin theraputic. Also given solu-medrol
500mg x3 days to treat for possibility of transplant rejection.
.
# Acute on chronic renal failure s/p renal transplant: He was
continued on dialysis MWF throughout admission to treat uremia
and volume overload secondary to acute renal failure. In
evaluating the cause of his renal failure, initially the concern
was for transplant rejection and he was given pulse steroid
treatment in the MICU. However, per report renal biopsy was
consistent with diagnosis of diabetic nephropathy, with
mod-severe scarring as well as ATN. Throughout the course of
the admission he did not regain any significant return of renal
function and continued to have a medical course complicated by
volumve overload between dialysis with hypotensive episodes
during dialysis. Tacrolimus was restarted approximately 2 weeks
in the admission and he was continued on mycophenolate and
prednisone which he had been taking all along. One week before
he expired he decided along with his family to be CMO. Dr.
[**Last Name (STitle) 4261**] was contact[**Name (NI) **] and spoke with the family.
Immunosupressants were initially left on his regimen for fear of
acute rejection which could be painful but were slowly taken
off. Morphine, Ativan and Ondansetron were used for comfort.
.
#Afib with RVR - On [**10-17**] he went into Afib with RVR following
dialysis thought most likely [**3-4**] to volume shifts. Initially
his rhythm was controlled with diltiazem however this was
changed over to digoxin for a brief time followed by metoprolol
for rate control. It was the feeling of the renal team that
diltiazem should be avoided as it effects tacrolimus levels. He
did not tolerated rapid atrial fibrillation and had associated
shortness of breath and tachypnea when his rate was poorly
controlled. Within one week of the development of Afib he
spontaneously returned to sinus rhythm. Lopressor 50mg po TID
was continued for rate control while BP tolerated. When he
was made CMO lopressor was discontinued.
.
#Altered mental status/delirium - Following the development of
atrial fibrillation he developed acute mental status change
characterized by fluctuating mental status, periods of confusion
and disorientation, visual hallucinations and inability to
speak. The etiology of this change was unclear however in
evaluation of this he was found to have suffered an NSTEMI with
troponins levle of 2.47 and trending down. Unclear when
original ischemic event occurred but was thought to be most
likely due to demand ischemia in the setting of rapid afib vs.
hypotension. Other likely contribution to delirium includes
medication effect with possible contributors including ativan
which he was taking prn for anxiety, digoxin which was given
briefly for afib and mirtazapine which was started for
depression and poor appetite. Infection was also a concern as
he is immunosuppressed and seriously ill. He was treated
empirically with vancomycin and levofloxacin. There was no
evidence of ICH on head CT and blood cultures remained negative.
One week before he expired, his mental status cleared and he
was awake, alert and oriented. It was at that point he made the
decision to be CMO.
.
#NSTEMI/CAD, s/p mechanical aortic valve replacement - as
discussed above in investigating his acute mental status change
he was found to have elevated troponin of 2.47 which was already
trending down. Unclear when original event occurred however it
was likely due to demand ischemia in the setting of episodic
hypotension or rapid atrial fibrillation. He was managed
medically as the family did not want any drastic intervention
given his multiple comorbidities. He was already on heparin gtt
to bridge until INR theraputic (goal 2.5-3.5 for [**Month/Day (2) 1291**]), statin
and metoprolol for rate control. Aspirin was restarted. He had
an echocardiogram to evaluate heart function following NSTEMI.
While the report shows decreased EF of 30-40% it was ready by
Dr. [**First Name (STitle) 437**] who stated that no significant change from prior
echocardiogram as he felt that EF was overestimated on prior
report.
.
#shortness of breath and periodic desaturation - multiple causes
of these symptoms throughout his admission including Afib with
RVR, increasing pulmonary edema associated with volume overload
in between dialysis sessions. In addition poor nutrition and
hypoalbuminemia likely contributing to his persistent pleural
effusions. He was treated with supplemental O2 via NC as
needed, dialysis for volume overload and rate control for Afib.
Dialysis was discontinued after his decision to be CMO,
supplemental O2 via NC and morphine were used for comfort.
.
# Systolic heart failure: EF 30-40% by most recent
echocardiogram with overal cardovascular status worsened by
volume overload associated with renal failure as well as
malnutrition and hypoalbuminemia. Not reponsive to lasix given
ARF. Treated for volume overload with hemodialysis.
.
#Constipation - treated with standing colace and senna, and
dulcolax suppository prn
.
#Yeast on UA/UC- foley catheter was removed and he was treated
with fluconzole
.
# Osteomyelitis: Recent 2 month admission for debridement of L
foot/amputation at level of metatarsals, also has R foot heel
eschar. Both appear as uninfected dry gangrene at this time. Has
had prior L fem-[**Doctor Last Name **] with revisions [**5-6**]. Seen by podiatry during
this admission with reccs for wound care as well as non weight
bearing on L foot. He should follow up with Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) 543**] within 1 wk of discharge
.
# DM2, insulin-dependent: he was continued on insulin sliding
scale, which was discontinued after he was made CMO
.
# Cdiff: completed course of flagyl
.
# Anemia: stable HCT throughout admission, Likely due to renal
failure and chronic disease.
.
# History of depression/anxiety/panic: pt reports occasional
anxiety, has been assessed by psychiatry in past admission, had
recommended ativan regimen. He was intially treated with ativan
0.5mg prn which helped his symptoms however ativan was
discontinued upon development of acute mental status change. In
addition he was started on remeron to treat symptoms of
depression and anorexia however this was also stopped in
evaluating cause of acute mental status change.
.
#Hypoalbuminemia/malnutrition - he had a very poor appetite and
limited oral intake throughout admission with low albumin and
malnutrition likely due to combination of chronic illness and
depression. Ntrition was consulted and he was started on liquid
meal supplements however he took in very little of this. Given
the severity of his illness and families resistance to invasive
treatment measures and consideration of CMO status tube feeding
was not started.
.
PPX: PPI, on heparin gtt while waiting for INR be 2.5-3.5 (goal
INR 2.5-3.5 for [**Telephone/Fax (1) 1291**])
.
CODE: DNR/DNI, family does not want pt transferred to ICU, made
CMO
Medications on Admission:
MEDICATIONS:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Mycophenolate Sodium 180 mg Tablet, Delayed Release (E.C.)
Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a
day).
6. insulin
take as directed by your PCP
7. glargine
take 13 units at night / if you are on SS please take as
directed by your PCP
8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime:
have your INR followed. you must get this done beginning
tomorrow. Tablet(s)
9. Cefepime
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 weeks: last dose 9/18.
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
16. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
17. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
18. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
19. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Mycophenolate Sodium 180 mg Tablet, Delayed Release (E.C.)
Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a
day).
21. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
22. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
23. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) mL
Injection QM-W-F ().
24. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
25. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
respiratory failure
acute on chronic renal failure
insulin dependant diabetes mellitus
- IDDM (may be DM2 insulin-dependent)
- PVD- CHF (EF 40-50% by [**8-9**] echo)
- CAD s/p CABG + [**Month/Year (2) 1291**] ('[**77**])
- hyperlipidemia
- Hypertension
- CRI (baseline Cr 1.5-1.7)
- s/p L [**Doctor Last Name **]-DP bypass followed by L TMA [**2-5**] with revision [**5-6**]
- s/p LRKT ('[**79**])
- s/p CABG/Mech.[**Year (2 digits) 1291**]('[**77**])
- s/p Excise L metatarsal head
- s/p L AV fistula ('[**79**])
- s/p Excise colon polyp ('[**77**])
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
Completed by:[**2185-10-28**]
|
[
"410.71",
"276.7",
"285.21",
"427.31",
"403.90",
"584.9",
"V43.3",
"263.9",
"996.81",
"585.9",
"112.2",
"414.00",
"428.0",
"428.20",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"55.23"
] |
icd9pcs
|
[
[
[]
]
] |
17200, 17209
|
7411, 15038
|
306, 312
|
17804, 17813
|
3170, 7388
|
17866, 18030
|
2610, 2624
|
17171, 17177
|
17230, 17783
|
15064, 17148
|
17837, 17843
|
2639, 3151
|
245, 268
|
368, 2192
|
2214, 2564
|
2580, 2594
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,544
| 115,263
|
16984
|
Discharge summary
|
report
|
Admission Date: [**2162-3-2**] Discharge Date: [**2162-3-12**]
Service: MEDICINE
Allergies:
Ceftriaxone Sodium / Cefotaxime / Ace Inhibitors
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Renal failure
Major Surgical or Invasive Procedure:
central line placement
respiratory mechanical ventilation
IV pressors
thoracentesis of pleural effusion
History of Present Illness:
[**Age over 90 **] year old female with exquisitely complex medical history,
transferred from [**Hospital **] rehab for evaluation of renal failure
and consideration for dialysis.
.
Of note, pateint was recently discharged from [**Hospital1 18**] in [**12-5**]
after a very complicated MICU stay. She was initially admitted
for respiratory distress likely from decompensated CHF and ?MRSA
pneumonia. SHe was treated with vancomycin for pneumonia. She
was also diurese and had afterload reduction. She also had
multiple thoracentesis with transudative effusion and rapid
reaccumulation. She was eventually intubated and trach on
[**2161-12-30**]. Weaning has been mainly unsuccessful.
.
Patient was transferred to rehab on pressure support but was
switched to AC becuase of intolerance. Weaning attempts were
unsuccessful.
She actually was admitted to ICU at [**Hospital1 **] becuase of
arrhythmia. Her SVT was controlled with increasing doses of
metoprolol and digoxin but she became bradycardic. Patient went
into monomorphic VTs that resolved spontaneouly. Patient was
given amiodarone 150mg IV 2 weeks ago. Serial CKs and troponin
were negative
Her course was also complicated by hemoptysis and [**Hospital1 4532**],
aspirin and coumadin has been d/c'd.Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1726**] [**Last Name (NamePattern1) 47786**] her
and did not find source of bleeding.
Patient was also started on imipenem for presumed ventilator
associated pneumonia([**1-25**]- [**2162-2-4**]). SHe was also on Bactrim for
anterobacter on her sputum.
Her BUn and creatinine begin to climb around [**2-17**] t0 1.9 and 3.3
on day of admission. Renal consult suggested dialsysis. Family
meeting was held with son on [**2-19**] who insisted everything to b
done
Past Medical History:
CAD s/p bare metal stent to OM1 [**7-5**]
gallstone pancreatitis
cholecystitis
s/p percutaneous cholecystostomy tube
h/o CVA
anemia
CRI
hemorrhoids
AF
junctional arrhythymias
htn
h/o pna
s/p PEG tube placement feeds d/c [**2161-6-25**]
tracheostomy
s/p bilateral thoracentesis
s/p hip replacement
necrotic right foot
CHF, hx of diastolic dysfxn
R foot dry gangrene s/p AKA [**9-4**]
Social History:
Lives with son (healthcare proxy) in [**Hospital1 **], but has been in
rehab for many months.
Family History:
non contributory
Physical Exam:
PHYSICAL EXAMINATION:
Gen- frail looking elderly female lying in bed, only responsive
to noxious stimuli
HEENT- anicteric, flushed and swollen looking face, oral mucosa
dry, neck supple, trach site looks clean
CV- 2/6 SEM at apex, irregular heart sound
resp- decreased breath sound right more than left
abdomen- PEG site clean, no distension, unable to assess
tenderness
ext- 3+ pitting edema in all extremity, right AKA noted.
skin- multiple bruises and also excoriation from anasarca, clean
ulcer noted on left foot.
Pertinent Results:
Please refer to OMR records for CXR, abdominal U/S, ECG,
echocardiogram, and lab results.
Blood Cx with ENTEROBACTER CLOACAE
Urine Cx with pseudomonas
Sputum Cx with pseudomonas and proteus
Brief Hospital Course:
[**Age over 90 **] year old female with extensive cardiac history, AF, sick
sinus syndrome, presents with acute renal failure to be
considered for dialysis.
.
# Code Status / Overall Goals of Care: Patient was initially
"Full code," confirmed with son. Over the course of her
hospitalization, the patient's very grave prognosis and very
limited potential quality of life (even if all acute issues were
effectively treated) led to frequent discussions between the ICU
team and the patient's family (son). Given the patient's
deteriorating status and grave prognosis, the patient's code
status was changed to DNR/I, CPR not indicated. The patient's
son and ICU team decided to discontinue Levophed on [**3-12**] and
the patient passed away within 1-2 hours.
.
# ID: The patient's clinical picture at admission very
consistent with sepsis (including WBC 16 with 39% bands) and pt
was started empirically on vancomycin and meropenem and given
aggressive IVF resuscitation. Two out of two blood Cx bottles
drawn on day of admission grew ENTEROBACTER CLOACAE, sensitive
to meropenem, which pt was continued on for the remainder of her
hospital stay. Patient was apparently on Flagyl 250 Q6
prophylactically at rehab facility, although C diff was negative
on [**2162-2-1**]. Flagyl was not continued in the hospital. Stool
studies were negative for C.diff here as well. Thoracentesis was
performed and revealed a transudative process. [**Last Name (un) **] stim test
was WNL.
.
# Acute Renal Failure: Creatinine was increased at admission but
urine output was initially WNL. Pt's renal function continued to
deteriorate and she became anuric. Work-up was entirely
negative, including abdominal ultrasound (no hydronephrosis
seen), urine eosinophils negative. Pt had history of renal
artery stenosis (angiography showed high grade stenosis of the
left renal artery but with normal perfusion and moderate
stenosis of the right renal artery which previously had been
demonstrated to be atrophic with flow studies indicative of
significant stenosis too diffuse to intervene). Renal followed
the patient throughout her hospitalization. The possibility of
initiating dialysis was discussed at length with the patient's
family (son) and the renal team and in view of the patient's
grave overall prognosis and very limited potential quality of
life even with dialysis, the decision was made not to pursue
dialysis.
.
# Hypotension: was likely from sepsis. Pt required levophed for
BP support despite aggressive IVF.
.
# CAD: Patient had a trop of 0.21, MB 22. ECG revealed Afib,
nonspecific St-T changes, poor RWP(not new); likely demand
ischemia. Patient was maintained on aspirin and lipitor. Cardiac
enzymes
- cycle cardiac enzymes
- cardiology consult
- bare metal stent placement in [**Month (only) **] to OM #1, doubt it is in
stent thrombosis, no acute EKG a changes and completed at least
3 month of [**Month (only) 4532**]
.
# Diastolic heart failure; echo [**12-5**]:EF>55%, 2+MR, 1+TR.
Patient was discharged on daily laisx and mitolazone; this is
probably now complicated by acute renal failure
- d/c afterload reduction(isordil, metoprolol and Hydralazine)
until sure that BP is stable, Losartan was d/c on last admission
due to ARF
.
# Anasarca: from admission, pt was grossly edematous with weepy
skin. This was likely from low albumin state, diastolic heart
failure, and complicated by acute renal failure. Pt received
aggressive skin care.
.
# Afib with history of junctional arrythymias. EP felt that
there was no indication for amiodarone during past admission,
however, given one time dose of amiodarone at NH (last dose 2
weeks ago). Patient intermittently was in NSR and Afib
throughout hospitalization. Anticoagulation was not initiated
given recent report of hemoptysis.
.
# Respiratory failure: combination of pleural effusion, ?PNA. Pt
was continued on ventilatory support via her trach throughout
her hospitalization.
.
# Thrombocytopenia: stable throughout admission but lower than
her plt count in [**2161-12-31**]. Could have been from low-grade
DIC (high LDH, high Ddimer), although fibrinogen was high.
.
# Hypothyroidism - the patient was continued on her outpatient
regimen of levothyroxine.
.
# Hemoptysis at [**Hospital1 **], apparently broch'd by Dr. [**First Name (STitle) 1726**] and
was negative. Held [**Last Name (LF) 4532**], [**First Name3 (LF) **] and coumadin.
.
# Psych: pt had very minimal mental status throughout her
hospitalization, only wincing to noxious stimuli but otherwise
not interactive.
.
# CVA: pt had a history of a subacute right occipital infarct
and was on [**First Name3 (LF) **].
.
# Anemia: Work up consistent with ACD and iron deficiency
.
# Diabetes- on RISS and lantus
.
# Prophylaxis: Pt was initially on SC heparin prophylaxis but
this was discontinued due to skin weeping (from anasarca). Pt
was maintained on a PPI throughout her hospitalization.
*
# FEN: pt tolerated tubefeeds via PEG (placed [**2161-12-18**]).
.
# Access: a right-subclavian line was placed on [**2162-3-3**] and PICC
line was removed.
.
# Communication: the patient's only son, [**Name (NI) **] [**Name (NI) **]
[**Telephone/Fax (1) 47781**], was updated on the patient's status on a daily
basis by the ICU attending and team.
Medications on Admission:
flagyl 250 Q6
diphenhydramine 50mg Q8
ativan 2mg Q4
lopressor 12.5mg Q12
RISS
morphine Q1 prn
hydralazine 40 Q6
lipitor 10
MVI
synthroid 0.088 mg
lansoprazole 30
isosorbide 10 Q8
ascorbic acid 250 every 12h
artificial tears
docusate and senna
[**Last Name (LF) 4532**], [**First Name3 (LF) **] and coumadin held becuase of hemoptysis through
trach
Discharge Medications:
(deceased)
Discharge Disposition:
Expired
Discharge Diagnosis:
sepsis, bacterial
acute renal failure
respiratory failure
atrial fibrillation
coronary artery disease, stable
thrombocytopenia
pleural effusion, transudative
Discharge Condition:
(deceased)
Discharge Instructions:
(deceased)
Followup Instructions:
(deceased)
Completed by:[**2162-3-12**]
|
[
"428.0",
"410.71",
"995.92",
"V45.82",
"414.01",
"518.81",
"397.0",
"V49.76",
"038.49",
"584.9",
"287.5",
"511.9",
"V43.64",
"427.31",
"280.9",
"250.00",
"V44.1",
"486",
"424.0",
"428.33",
"V44.0",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"96.04",
"96.6",
"96.72",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
9201, 9210
|
3508, 8768
|
269, 374
|
9411, 9423
|
3293, 3485
|
9482, 9523
|
2721, 2739
|
9166, 9178
|
9231, 9390
|
8794, 9143
|
9447, 9459
|
2754, 2754
|
2776, 3274
|
216, 231
|
402, 2187
|
2209, 2594
|
2610, 2705
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,233
| 139,373
|
7672
|
Discharge summary
|
report
|
Admission Date: [**2141-6-6**] Discharge Date: [**2141-6-14**]
Date of Birth: [**2087-3-27**] Sex: M
Service: MEDICINE
Allergies:
Percocet / Labetalol / Felodipine
Attending:[**First Name3 (LF) 8790**]
Chief Complaint:
Refractory right hip pain
Major Surgical or Invasive Procedure:
Intramedullary nail stabilization of right femur [**6-8**]
History of Present Illness:
This is a 54 year old male with pancreatic cancer diagnosed in
[**2136**] s/p total pancreatectomy, CCY, splenectomy; solitary
recurrence in liver in [**2137**] s/p RFA/hemihepatectomy; second
liver recurrence in [**2139**] s/p RFA; T5 metastasis induced cord
compression in [**2139**] s/p partial vertebrectomy and XRT;
refractory to treatment with cycles gemcitabine, erlotinib, and
capecitabine; presenting now with severe refractory right hip
pain related to a right femur met. He was scheduled to have an
outpatient right femur stabilization procedure to help his pain
on [**6-7**] but the pain became too much to bear at home and he
required admission for pain control. At home he takes oxycontin
140mg TID and Dilaudid 8mg q3 PRN pain which has not been enough
to maintain his comfort. He says the pain starts in his upper
right leg/hip and radiates to his coccyx. He has no other
complaints and is clearly uncomfortable precluding a thorough
history. He had a recent admission for similar hip pain from
[**Date range (1) 27916**] during which time his pain meds were titrated up. He
remains weak, but denies any bowel/bladder incontinence or
saddle anesthesia. He denies fever, rash, URI symptoms, cough,
new abdominal pain, or vomiting/diarrhea.
.
In the ED his initial vitals were 99.1, 93, 153/80, 16, 100% RA.
He was clearly uncomfortable and given IV Dilaudid with minimal
effect on his pain. Leukocytosis to 20 was noted on laboratory
studies, with a negative infectious review of systems. It was
felt that this represented stress demargination from severe
pain. Blood cultures were drawn and a chest x-ray obtained. He
was transferred without any further intervention to the floor
for further pain management.
Past Medical History:
Past Oncologic History: Incidental finding of dilated pancreatic
duct
in [**3-/2136**] after undergoing routine CT imaging for work-up of
myeloproliferative disorder. He underwent pancreatectomy,
cholecystectomy and splenectomy on [**2136-6-26**] by Dr. [**Last Name (STitle) **].
Pathology demonstrated an intraductal carcinoma with an invasive
component measuring 8mm, T1N0Mx, without lymphovascular invasion
or positive surgical margins. % lymph nodes were removed and did
not involve carcinoma.
-In [**11/2137**], he developed recurrent disease in segment VI of the
liver, which was treated with radiofrequency ablation. In
[**7-/2138**], he underwent right hepatectomy pathology demonstrated
almost completely necrotic 2.8 cm focus of metastatic
adenocarcinoma.
-In [**6-/2139**], he developed recurrence disease at the resection
site within the right lobe of the liver and underwent
radiofrequency ablation again.
-In [**11/2139**], he developed upper back pain and was found to have
large destructive metastatic disease at T5 causing compression
of
the spinal cord. Biopsy confirmed metastatic adenocarcinoma of
pancreatic origin.
-In [**12/2139**], he underwent T5 vertebrectomy and posterior lateral
arthrodesis T2 through T8 with local autograft and completed
radiation therapy in [**1-/2140**] involving the T3 through T7 area.
-In [**2-/2140**], PORT was placed and he was started capecitabine and
oxaliplatin on clinical protocol which was complicated by
development of severe enteritis and colitis.
-In [**5-/2140**], he started gemcitabine and erlotinib and completed
a
total of eight cycles until new disease was demonstrated in the
twelfth rib with increased FDG avidity of widespread osseous
metastatic disease. Monthly Zometa infusion was added to his
regimen on [**2141-1-20**]. The patient continued to have evidence
of
worsening metastatic disease involving the bones.
-He underwent radiation therapy of the right clavicle, right
iliac bone and left hip, which was completed on [**2141-3-3**]. The
patient has not received further Zometa in the setting of renal
insufficiency.
.
Other Past Medical History:
-Metastatic pancreatic cancer
-Coronary artery disease -- stent implanted [**8-/2131**] for "blocked
secondary artery"
-HTN -- baseline BPs 130s/80s
-hypercholesterolemia
-Diabetes mellitus [**2-14**] total pancreatectomy
-Polycythemia [**Doctor First Name **] -- Pseudohyperkalemia caused by
myeloproliferative syndrome with thrombocythemia
-Kidney stones
-GERD
-Liver abscess, enterococcal bacteremia in [**7-20**]
-Small secundum ASD on ECHO.
Discharge Summary Past Medical History Signed [**Last Name (LF) **],[**First Name3 (LF) **] D
WED [**2141-5-31**] 2:22 PM
PAST MEDICAL HISTORY:
====================
Metastatic pancreatic cancer (see below)
Coronary artery disease -- stent implanted [**8-/2131**] for "blocked
secondary artery"
HTN -- baseline BPs 130's/80)
hypercholesterolemia
Diabetes mellitus [**2-14**] total pancreatectomy
Polycythemia [**Doctor First Name **] -- Pseudohyperkalemia caused by
myeloproliferative syndrome with thrombocythemia
Kidney stones
GERD
Liver abscess, enterococcal bacteremia in [**7-20**]
small secundum ASD on ECHO.
.
PAST SURGICAL HISTORY:
elbow surgery on nerve [**8-/2125**]
basal cell ca (R cheek) surgery [**11/2131**]
total pancreatectomy [**2137**]
Vental hernia surgery [**12-18**]
right hemihepatectomy [**2138**]
VATS [**8-19**]
T5 vertebrectomy [**12-20**]
Social History:
Lives w/ wife and two sons. [**Name (NI) 1403**] as a contractor. No EtOH
since pancreatectomy. Smoked 2 packs per day, quit many years
ago. No history of IV drug use or other illicits.
Family History:
-Father died of metastatic carcinoma to the liver, age 59.
-Paternal Grandfather thought to have stomach cancer.
-Mother had a GI tumor removed early in her life, but lived for
many years afterwards.
Physical Exam:
ADMISSION:
Constitutional: Uncomfortable male lying in bed
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Oropharynx within normal limits, supple neck
Chest: Clear to auscultation, left chest port
Cardiovascular: RRR
Abdominal: Soft, Nontender
GU/Flank: No costovertebral angle tenderness
Extr/Back: 2+ radial/DP pulses, No cyanosis, clubbing or
edema
Skin: Warm and dry
Neuro: Speech fluent, alert and oriented x3, normal
sensation
.
DISCHARGE:
Constitutional: Comfortable appearing male lying in bed in NAD
HEENT: Normocephalic, atraumatic, EOMI, small but reactive
pupils, Oropharynx clear, supple neck
Chest: Clear to auscultation, left chest port
Cardiovascular: RRR
Abdominal: Soft, Nontender, mild bowel distention, hypoactive
bowel sounds
GU/Flank: No costovertebral angle tenderness
Extr/Back: 2+ radial/DP pulses, No cyanosis or clubbing,
trace-1+ pedal edema
Skin: Warm and diaphoretic
Neuro: Speech fluent, alert and oriented x3, noted to have
difficulty with dorsiflexion of right foot and left foot drop,
otherwise motor strength and sensory equal and intact
bilaterally
Pertinent Results:
[**2141-6-6**] 01:52PM GLUCOSE-192* UREA N-27* CREAT-1.2 SODIUM-134
POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-29 ANION GAP-13
[**2141-6-6**] 01:52PM WBC-20.1* RBC-3.76* HGB-9.5* HCT-29.1*
MCV-78* MCH-25.3* MCHC-32.7 RDW-19.3*
[**2141-6-6**] 01:52PM NEUTS-85* BANDS-1 LYMPHS-2* MONOS-12* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2141-6-6**] 04:46AM LACTATE-1.0
.
[**6-6**] femur AP/lat:
FOUR VIEWS OF THE RIGHT FEMUR: Again seen are numerous lytic
lesions, with slightly dense internal components seen in the
right inferior pubic ramus and ischium, the intertrochanteric
region of the right femur, and the right iliac [**Doctor First Name 362**]. These do
not appear significantly changed since the prior study. There is
no evidence of pathologic fracture. The distal femur
demonstrates no definite metastatic lesion.
IMPRESSION: Multiple metastatic lesions, without evidence of
pathologic
fracture.
.
[**6-8**] CXR: IMPRESSION:
No evidence of focal lung opacities.
.
[**6-8**] CT head:
IMPRESSION: No acute intracranial process. If there is clinical
concern for ischemia or infarction, an MRI may be obtained for
further evaluation.
Brief Hospital Course:
This is a 54 year old male with pancreatic cancer diagnosed in
[**2136**] s/p total pancreatectomy, CCY, splenectomy; solitary
recurrence in liver in [**2137**] s/p RFA/hemihepatectomy; second
liver recurrence in [**2139**] s/p RFA; T5 metastasis induced cord
compression in [**2139**] s/p partial vertebrectomy and XRT;
refractory to treatment with cycles gemcitabine, erlotinib, and
capecitabine; presenting now with severe refractory right hip
pain related to a right femur met.
.
#. Right hip/back pain. The patient has a known right femur met
that is the likely cause of his pain. He was scheduled to have
an orthopedic procedure as an outpatient on [**6-7**] to help
stabilize the femur with the goal of helping to improve his
pain; however, his pain became too much to bear at home on his
oral pain regimen and he required admission for IV pain control.
He was recently admitted from [**Date range (1) 27916**] for pain control related
to this same pain in his right leg/back which required Dilaudid
PCA. This admission, his Dilaudid PCA was titrated up to 0.5mg
q6 minutes, but mental status changes were noted and he was
titrated back to 0.37mg q6 minutes. The ortho/oncology service
was consulted and recommended right femur plain films which
ruled out pathologic fracture. He was taken to the OR on [**6-8**]
for intramedullary nail to stabilize his femur with a goal of
improving pain and preventing pathologic fracture. His post-op
course was complicated by delirium in the PACU secondary to poor
pain control which required a brief ICU stay. He was started on
a Dilaudid drip in the ICU and his delirium quickly resolved.
He was then transitioned from a Dilaudid drip back to Dilaudid
PCA at 0.37mg q6min and then to 4-8mg of PO Dilaudid q3 hours
PRN. Lovenox 40 mg SC QD was started for DVT ppx starting [**6-9**]
which was one day post-op. He was continued on his home
oxycontin 140mg TID and baclofen 5-10mg PRN spasms. His home
anagrelide for essential thrombocytosis was held during his
hospitalization for pre- and post-op prevention of bleeding, but
the surgery service recommended restarting it on day of
discharge. He will need to remain on anagerlide given his high
risk for clot with essential thrombocytosis. Pt was also on
Lovenox for DVT ppx, which needs to be continued for 1 month
post-op. Pt's pain regimen was ultimately titrated up to
Oxycontin 180mg TID plus Dilaudid 12-20mg q4h PRN which gave
adequate control, ensuring that the pt does not require any IV
Dilaudid. Pt was also given bowel regimen.
.
#. HTN. The patient's verpamil was uptitrated to 240mg daily
during his last admission. His blood pressure remained elevated
up to 190s systolic likely secondary to acute pain. He was
continued on verapamil 240mg daily and hydralazine 25mg was
administered q6 PRN for BP>180 as the patient had an allergy
documented to labetalol. Pt was also started on Lisinopril 10mg
daily for better BP control.
.
#. Leukocytosis. Likely due to stress reaction from acute pain
as patient has no signs of underlying infection. He also has
essential thrombocytosis which is associated with increased WBC
counts in situations of inflammatory stress. Blood and urine
cultures remained negative and several CXRs showed no evidence
of pneumonia. No antibiotics were initiated.
.
#. Diabetes. Continued home ISS and glargine.
.
#. Hyperlipidemia. Continued home simvastatin.
.
#. Depression. Continued home citalopram.
.
#. Pt was on a regular diet, on Lovenox for DVT ppx. Pt was
full code.
Medications on Admission:
-Verapamil 240mg PO QAM
-Agrylin 3mg QAM and 4mg qPM (on hold prior to surgery)
-Zocor 40mg QPM
-Celexa 20mg QAM
-Pancrease 4500mg 7 capsules with meals
-Humalog 5-15 units sliding scale with meals
-Lantus 15 units QPM
-Trazodone 50mg QHS PRN
-Baclofen 5-10mg TID PRN muscle spasms
-Dilaudid 8mg q3 PRN pain
-Oxycontin 140mg TID
-Zofran 8mg PO TID PRN nausea
-Compazine 10mg PO q6 PRN nausea
-Lorazepam 1-2mg q6 PRN nausea
-Omeprazole 20mg QD
-Penicillin 500mg QID PRN open wounds
-Multivitamin QAM
Discharge Medications:
1. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily) for 25 days.
Disp:*25 * Refills:*0*
2. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
6. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for muscle spasms.
Disp:*15 Tablet(s)* Refills:*0*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold for diarrhea.
Disp:*60 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily): hold for
diarrhea.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. OxyContin 60 mg Tablet Sustained Release 12 hr Sig: Three
(3) Tablet Sustained Release 12 hr PO every eight (8) hours.
Disp:*90 Tablet Sustained Release 12 hr(s)* Refills:*0*
12. Hydromorphone 4 mg Tablet Sig: 3-5 Tablets PO Q2H (every 2
hours) as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
13. Lipase-Protease-Amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
14. Agrylin 0.5 mg Capsule Sig: Six (6) Capsule PO every
morning.
15. Agrylin 0.5 mg Capsule Sig: Eight (8) Capsule PO every
evening.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]/[**Hospital1 8**] VNA
Discharge Diagnosis:
Primary diagnosis:
-Right femur pain secondary to bony metastasis s/p
.
Secondary diagnoses:
-Metastatic pancreatic cancer
-Coronary artery disease
-Hypertension
-Diabetes mellitus
-Essential thrombocytosis
-GERD
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
pain control related to refractory right hip pain from known
metastases. Pain control was established with Dilaudid and
Oxycontin. You were subsequnetly taken to surgery for
stabilization of your right thigh bone with the goal of
preventing future fractures and helping control your pain. You
developed some altered mental status after the procedure which
required a brief stay in th ICU for more aggressive pain
control. All in all, you tolerated the procedure well and are
now back to an oral pain control regimen.
.
The following changes have been made to your home medication
regimen:
START Enoxaparin 40 mg Subcutaneous daily for 25 days
START Acetaminophen 500 mg Tablet Two Tablets every 6 hours
START Baclofen 10 mg 3 times a day as needed for muscle spasms
START Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day), hold for diarrhea
START Docusate Sodium 100 mg PO 2 times a day, hold for
diarhhea
START Bisacodyl 10 mg Delayed Release Daily, hold for diarrhea
START Lisinopril 10 mg daily
START OxyContin 60 mg Sustained Release 3 Tablets every eight
hours
START Hydromorphone 4 mg 3-5 Tablets every 2 hours as needed
for pain
CONTINUE your other medications as before, including Agrylin
If you find yourself using the Hydromorphone more than four
times a day for breakthrough pain, please call Dr. [**Last Name (STitle) 4613**]/Dr.
[**Last Name (STitle) **] so that they can readjust your long-acting pain
medication.
Followup Instructions:
Please keep the following appointments:
Provider ORTHO XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2141-6-16**] 11:25
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6214**], MD Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2141-6-16**] 11:45
Provider [**First Name11 (Name Pattern1) 4224**] [**Last Name (NamePattern4) 4225**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2141-6-19**] 4:00
Please also call Dr. [**Last Name (STitle) 4613**]/Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 27917**] to make
a follow-up appointment next week.
Please also call Dr. [**Last Name (STitle) 3929**] at [**Telephone/Fax (1) 8082**] to make a
follow-up appointment with him.
Completed by:[**2141-6-14**]
|
[
"414.01",
"401.9",
"530.81",
"276.1",
"198.5",
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"412",
"251.3",
"745.5",
"288.60",
"238.79",
"V10.09",
"338.3",
"V45.82",
"564.09",
"736.79",
"293.0"
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icd9cm
|
[
[
[]
]
] |
[
"78.55"
] |
icd9pcs
|
[
[
[]
]
] |
14113, 14184
|
8351, 11885
|
319, 379
|
14441, 14441
|
7190, 8170
|
16154, 16912
|
5838, 6039
|
12435, 14090
|
14205, 14205
|
11911, 12412
|
14624, 16131
|
5386, 5615
|
6054, 7171
|
14298, 14420
|
254, 281
|
407, 2145
|
8179, 8328
|
14224, 14277
|
14456, 14600
|
4891, 5363
|
5631, 5822
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
117
| 140,784
|
18180
|
Discharge summary
|
report
|
Admission Date: [**2133-4-7**] Discharge Date: [**2133-4-12**]
Date of Birth: [**2083-12-28**] Sex: F
Service: [**Doctor Last Name 1181**]
HISTORY OF PRESENT ILLNESS: The patient is a 49 year old
woman with a history of end stage liver disease secondary to
hepatitis C complicated by esophageal varices as well as a
history of encephalopathy and prior spontaneous bacterial
peritonitis who was recently discharged from [**Hospital1 18**] for
management of her ascites. On that hospitalization multiple
attempts were made to manage her fluid overload with
diuretics, but she was ultimately refractory to them. She
was referred for TIPS procedure for improved fluid
management. The patient was readmitted on the day of
admission on [**4-7**] for TIPS. The procedure was notable for
having somewhat difficult access, but no complications with
an estimated blood loss of 100 cc. At the procedure she
received 4 mg of Versed, 600 of propofol, 150 of fentanyl.
She had been hemodynamically stable for several hours post
procedure, but then her blood pressure dropped from 100/40 to
70s to 80s over 30s and her heart rate remained sinus tach.
At the time, although her urine output remained strong, she
was transferred to the medical ICU for further management.
PAST MEDICAL HISTORY: Hepatitis C genotype 1A complicated by
cirrhosis, esophageal varices, encephalopathy and presumptive
SBP. Type 2 diabetes. Obesity. Hypertension. Asthma.
Esophageal candidiasis. Gastroparesis. Depression. Status
post cholecystectomy. Status post seven spur surgeries.
Hypothyroidism. Amenorrhea. Migraines.
MEDICATIONS ON ADMISSION: Protonix 40 mg q.d., Synthroid 100
mcg q.d., Reglan 10 q.i.d., Flovent two puffs b.i.d.,
lactulose 45 ml q.i.d., Ambien 5 mg q.h.s. p.r.n., Levaquin
250 mg q.d., Lasix 60 mg b.i.d., spironolactone 100 mg
b.i.d., morphine p.r.n., albuterol one to two puffs q.six
p.r.n., Serevent one puff b.i.d.
SOCIAL HISTORY: The patient is a prior machine operator on
disability. She is not married. She lives with her son.
She has a 15 pack year tobacco history, she quit in [**Month (only) 359**].
She has a history of alcohol use, particularly heavy in the
mid-[**2109**]. She has a history of IV drug abuse, none since
the [**2109**].
FAMILY HISTORY: Noncontributory. It does not include liver
disease or bleeding disorder.
PHYSICAL EXAMINATION: The patient's temperature was 98.5,
pulse 96, BP 95/48, respiratory rate 16, sating 98 percent on
3 liters. In general, she was a pleasant, middle aged woman
lying in no acute distress. Head and neck exams showed
normocephalic, atraumatic head with pupils equal, round, and
reactive to light and accommodation. Extraocular movements
intact. Oropharynx was slightly dry. On neck exam she had a
right central venous line with mild ooze. Heart was
tachycardiac with regular rhythm, no murmurs. Lungs were
clear to auscultation bilaterally anteriorly. Abdomen was
soft, nondistended, nontender with active bowel sounds. She
had guaiac positive stool. Extremities had 2+ edema to the
knees. On neuro exam she was alert and oriented times three.
Cranial nerves II-XII were grossly intact. Strength and
sensation were grossly intact.
LABORATORY DATA: White count 3.7, hematocrit 26.8, platelets
43. PTT 39.5, INR 1.5. Sodium 126, potassium 4.4, chloride
94, bicarb 26, BUN 31, creatinine 1.2, glucose 136. Calcium
7.5, mag 1.2, phos 3.7. AST 174, ALT 80, alka phos 126,
t-bili 3.1, LDH 255.
HOSPITAL COURSE:
1. Hypotension. The patient was admitted to the MICU for
hypotension. The underlying etiology was not initially
clear, although the differential included excess anesthesia
from the procedure, particularly given her liver disease
versus hypovolemia from a hemorrhage, either around the liver
into the abdomen or within the GI tract versus sepsis. She
was started empirically on antibiotics with levo and Flagyl.
She had an abdominal ultrasound to evaluate for ascites for
possible paracentesis. There was no ascites. She was
maintained on antibiotic prophylaxis for several days. She
was transfused one unit of packed cells and given fluids to
improve her blood pressure and it responded appropriately.
She was started on Neo-Synephrine to keep her MAPS greater
than 55. It took several days, but this was ultimately
weaned. The entire time she had excellent urine output. As
cultures continued to be negative and the patient had no
fever or white count, she was not maintained SBP antibiotic
coverage and once she was maintained on pressors, she was
able to be transferred out to the floor. She had no further
evidence of hypotension while on the medicine floor.
2. Hypoxia/congestive heart failure. The patient was given
vigorous IV fluids hydration and blood during her MICU stay.
She subsequently became progressively hypoxic with diffuse
wheezing and a chest film that was consistent with fluid
overload. She was started with diuresis once she was on the
medicine floor with rapid improvement in her hypoxia and her
lung exam. Once the pulmonary edema was improved, her
exercise tolerance improved dramatically.
3. Pulmonary. The patient does have a history of asthma and
she was wheezing significantly when she hit the floor. She
responded well to IV Lasix and frequent nebulizer treatments.
These will be continued as an outpatient per her
prehospitalization regimen.
4. Status post TIPS. The patient did not have any evidence
of encephalopathy and her abdominal distention improved
significantly over the course of her admission. She was
between 2 and 3 liters negative per day and did not have an
untoward effects with respect to her renal failure.
5. Renal. The patient's creatinine slightly increased on
admission to the ICU. However, over the course of her
admission, her creatinine went down to 1.0 by discharge which
is as good, if not better, than her typical baseline.
6. Infectious disease. When the patient was out on the
floor, she did not show any evidence of infection. She was
continued on SBP prophylaxis regimen of Levaquin q.day.
7. Endocrine. The patient was continued on her diabetes
regimen with glargine and a sliding scale.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home with VNA for home safety
evaluation.
DISCHARGE DIAGNOSES:
1. End stage liver disease.
2. Hepatitis C.
3. Anasarca.
DISCHARGE MEDICATIONS:
1. Flovent two puffs b.i.d.
2. Albuterol one to two puffs q.six hours p.r.n.
3. Serevent one puff b.i.d.
4. Synthroid 100 mcg q.d.
5. Protonix 40 mg q.d.
6. Levaquin 250 mg q.d.
7. Lactulose 30 ml p.o. t.i.d.
8. Lasix 40 mg p.o. q.d.
9. Reglan 10 mg p.o. q.i.d.
10. Aldactone 25 mg p.o. b.i.d.
FOLLOWUP: The patient will call the liver center to make an
appointment with Dr. [**Last Name (STitle) 497**] in two weeks. She will contact
her PCP to make an appointment within the next one to two
weeks.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 13467**]
Dictated By:[**Last Name (NamePattern1) 7693**]
MEDQUIST36
D: [**2133-4-12**] 16:20
T: [**2133-4-12**] 16:54
JOB#: [**Job Number 50266**]
|
[
"276.5",
"285.1",
"428.0",
"401.9",
"287.5",
"789.5",
"070.54",
"571.5",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.1",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
2295, 2370
|
6322, 6383
|
6406, 7164
|
1647, 1943
|
3513, 6202
|
2393, 3496
|
185, 1279
|
1302, 1620
|
1960, 2278
|
6227, 6301
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,810
| 154,569
|
10265
|
Discharge summary
|
report
|
Admission Date: [**2142-8-30**] Discharge Date: [**2142-9-5**]
Date of Birth: [**2071-12-30**] Sex: M
Service: CT Surgery
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 34164**] is a 70 year old
male with no cardiac history prior to [**2138-7-29**], when he
had an acute myocardial infarction while on a hunting trip in
[**State 1727**]. He was admitted to a local hospital and received TPA.
He was subsequently discharged to home. An echocardiogram at
that time showed inferior and posterior as well as basal and
septal ischemia and he was referred for cardiac
catheterization. He then received two crown stents to the
right coronary artery and an [**Doctor First Name 10788**] stent to the left anterior
descending artery.
The patient did well after the intervention and was scheduled
for an elective knee surgery in [**2141-1-26**] but, before his
surgery, he began to develop symptoms of chest discomfort.
He consequently underwent another cardiac catheterization in
[**2140-12-29**], which showed branch vessel coronary artery
disease, mild mitral regurgitation and mild diastolic
ventricular dysfunction with an estimated left ventricular
ejection fraction of 55%. He was medically managed since
then.
The patient is active daily. For the past few months prior
to admission, he noticed increasing mild chest burning when
he is exerting himself. This discomfort is relieved with
rest. He sometimes needs to use nitroglycerin spray to
relieve his symptoms. The patient's most recent
echocardiogram was in [**2142-5-28**]. He exercised 15 minutes of
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol. He did experience chest discomfort with
exercise, but his electrocardiogram was nondiagnostic.
Imaging at the time revealed a mild fixed inferior defect but
no areas of ischemia, with an estimated left ventricular
ejection fraction of 45%.
Given the increasing symptoms of chest pain on exertion, the
patient underwent another cardiac catheterization prior to
admission, on [**2142-8-30**]. This cardiac catheterization
showed three vessel disease and left main coronary artery
disease with normal left ventricular function and moderate
diastolic dysfunction. Specifically, the left main coronary
artery showed a 70% to 75% stenosis of the distal segment.
The left anterior descending artery showed a 50% proximal
stenosis and the circumflex artery had minimal irregularities
without significant flow limited lesions. The right coronary
system had a 30% stenosis of the proximal segment.
REVIEW OF SYSTEMS: The patient denied any symptoms of
orthopnea, paroxysmal nocturnal dyspnea, claudication, edema
or lightheadedness.
PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2.
Diabetes mellitus. 3. History of smoking. 4. Myocardial
infarction in [**2138-7-29**], treated with TPA. 5. Left
anterior descending artery stents and right coronary artery
stent in [**2137**]. 6. Severe degenerative joint disease. 7.
Prostate cancer treated with Lupron.
PAST SURGICAL HISTORY: [**2141-1-26**], bilateral knee
replacements.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: Toprol XL 100 mg p.o.b.i.d.,
Lipitor 60 mg p.o.q.d., aspirin 325 mg p.o.q.d., Motrin 800
mg p.o.q.d., iron 325 mg p.o.b.i.d., multivitamins one
p.o.q.d., Zestril 10 mg p.o.q.a.m. and 5 mg p.o.q.p.m.,
Glucovance as per instructions.
SOCIAL HISTORY: The patient works as a plumber. He is
married. The patient has a history of smoking.
PHYSICAL EXAMINATION: On physical examination, the patient
was awake, alert and oriented times three, in no acute
distress, healthy looking elderly male. He was afebrile with
a heart rate of 60, blood pressure 132/72, and oxygen
saturation 99% in room air. Head, eyes, ears, nose and
throat: No bruits, no jugular venous distention. Lungs:
Clear to auscultation bilaterally. Cardiovascular: Regular
rate and rhythm, II/VI systolic ejection murmur at the apex,
normal S1 and S2 sounds. Abdomen: Soft, nontender,
nondistended, right groin without hematoma, no oozing, no
bruits status post cardiac catheterization. Extremities: No
edema, pulses palpable bilaterally.
LABORATORY DATA: Admission hematocrit was 31.6, white blood
cell count 6.7, platelet count 179,000, prothrombin time
12.6, partial thromboplastin time 27.7 and INR 1.1.
Urinalysis: Negative. Glucose was 174, BUN 27, creatinine
0.7, sodium 136, and potassium 4.6.
HOSPITAL COURSE: The patient was admitted to the cardiac
surgery service. His last cardiac catheterization performed
on the day of admission showed 70% stenosis of the left main,
50% stenosis of the left anterior descending artery and 30%
stenosis of the right coronary artery with an estimated left
ventricular ejection fraction of 60%.
At the time, it was decided that a surgical intervention
would be appropriate given three vessel coronary artery
disease. On [**2142-8-31**], the patient underwent coronary
artery bypass grafting times two with a left internal mammary
artery to the left anterior descending artery and reverse
saphenous vein graft from the aorta to the obtuse marginal
coronary artery. The procedure was without any
complications. Please see the full operative report for
details.
The patient remained intubated and tolerated the procedure
well. He was transferred to the Intensive Care Unit in good
condition. The patient remained in sinus rhythm with
occasional premature ventricular contractions. He continued
to make adequate urine. He was originally put on an insulin
drip given his history of diabetes. The patient was started
on a diuretic regimen, to which he responded well.
Physical therapy was consulted, who followed the patient
throughout his hospitalization. On postoperative day number
two, the patient had a fever of 101.3. His physical
examination remained unremarkable. His incision was clean,
dry and intact. He was started on Lopressor. His hematocrit
was 26.8 on postoperative day number two. His chest tube had
a small air leak. The patient's insulin regimen was
tightened to gain better control of blood sugar levels.
On postoperative day number two, the patient was transferred
to the regular floor in stable condition. He remained
afebrile with a stable heart rate and blood pressure and
adequate oxygenation. The patient was ambulating with
assistance. His chest tube and pacing wires were removed as
was his urine catheter. The patient was cleared by physical
therapy to go home when medically ready. The patient
remained in sinus rhythm without any events. He was
discharged to home on [**2142-9-5**] in stable condition.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, coronary artery bypass grafting
times two.
2. Diabetes mellitus.
3. Hyperlipidemia.
4. Degenerative joint disease.
5. Hypertension.
DISCHARGE MEDICATIONS:
Aspirin 325 mg p.o.q.d.
Toprol XL 100 mg p.o.b.i.d.
Lipitor 60 mg p.o.q.d.
Motrin 800 mg p.o.q.d.p.r.n. pain.
Iron 325 mg p.o.b.i.d.
Multivitamins one p.o.q.d.
Zestril 10 mg p.o.q.a.m. and 5 mg p.o.q.p.m.
Glucovance as per instruction.
Lasix 20 mg p.o.b.i.d. times seven days.
Potassium chloride 20 mEq p.o.b.i.d. times seven days.
Percocet one to two tablets p.r.n. pain.
Colace 100 mg p.o.b.i.d.p.r.n. constipation.
DISCHARGE INSTRUCTIONS: The patient is to follow up with his
surgeon, Dr. [**Last Name (STitle) 70**], in approximately six weeks. The
patient is to follow up with his cardiologist, Dr. [**Last Name (STitle) 1016**], in
approximately four weeks. The patient is to follow up with
his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in approximately one
to two weeks. The patient is to follow up with the diabetes
specialist at the [**Hospital **] Clinic in approximately two weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2142-9-10**] 11:50
T: [**2142-9-10**] 12:15
JOB#: [**Job Number 26584**]
|
[
"414.01",
"272.0",
"250.00",
"V45.82",
"401.9",
"411.1",
"185",
"428.30",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"39.61",
"88.56",
"36.11",
"36.15",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
6742, 6908
|
6931, 7350
|
3180, 3413
|
4479, 6660
|
7375, 8176
|
3052, 3153
|
3541, 4461
|
2576, 2693
|
172, 2556
|
2716, 3028
|
3430, 3518
|
6685, 6721
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,184
| 132,046
|
22252
|
Discharge summary
|
report
|
Admission Date: [**2109-7-21**] Discharge Date: [**2109-8-15**]
Date of Birth: [**2029-12-24**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Lithium / Levaquin / Gatifloxacin /
Reglan
Attending:[**First Name3 (LF) 2074**]
Chief Complaint:
Transfer to [**Hospital1 18**] s/p Vtach/torsades [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 29185**]/arrest with
prolonged QT interval s/p admission to [**Hospital 1474**] hospital for
SOB/Cough/fever after witnessed aspiration event
Major Surgical or Invasive Procedure:
Arterial line placement [**2109-7-21**]
Right internal jugular central line placement [**2109-7-21**]
cardiac catheterization with Left circumflex artery stent
placement [**2109-8-5**]
History of Present Illness:
79 y/o female with h/o bipolar disorder, paranoia, DM2, [**Hospital 2754**]
transferred from [**Hospital 1474**] Hospital after VT/VF arrest.
Defibrillated to NSR- SB (HR 30), later alternating between SR
and polymorphic VT, which required more shocks. Pt given
magnesium, and amiodarone 150mg X2--amio gtt during code at
[**Hospital1 1474**].
Pt initally was admitted to OSH for fever/nonproductive
cough/increasing SOBX 2days. Family reports witnessed
aspiration event at home. CXR at OSH revealed aspiration PNA
and pt tx with Vancomycin and Gatifloxacin. Pt reported CP this
AM and found to have EKG with anterior TWI. Troponin 2.9/CK
250/MB 4.9 yesterday. Pt started on Lovenox/plavix/ASA/BB. Of
note, pt with report of interior/posterior MI on ECHO and
Myoview. Pt seen by cardiologist at [**Hospital1 1474**], who offered cath,
but pt refused. Psychiatry was consulted and deemed pt without
capacity to make medical decisions. [**Name (NI) 1094**] HCP is her daughter,
and she would like cardiac cath to be done--plans made to
transfer to [**Hospital1 18**] for further care. Prior to transfer, pt
sustained VT arrest.
--CCU resident over at [**Hospital1 1474**] said QT was normal "440". Here,
QTc is 920 and was same before code. TWI still present and are
diffuse may be ischemic but would also worry about head bleed
given delta MS [**First Name (Titles) **] [**Last Name (Titles) **] patient on lovenox. Arrived with ETT
(intubated for airway protection). EP notified. Now febrile.
.
Of note, admission at [**Hospital1 1474**] 2 weeks ago for projectile
vomiting, nausea. At this time, she was not taking lithium.
During this admission, she had a GI workup, with EGD on [**2109-7-9**]
showing a paraesophageal hernia (with almost [**1-24**] of her stomach
above the diaphragm) and hiatal hernia, with multiple
wide-mouthed duodenal diverticula. It was felt that this large
paraesophageal hernia made it difficult for the pt to tol po,
including her lithium/meds. Further workup was planned,
includeing 24 hour pH monitoring, and esophageal manometry to
study motility. Her upper GI and barium swallow study showed
the type II paraesophageal herniaShe was offered a laparoscopic
paraesophageal hernia repair, but declined. Her family felt
that this was due to a decline in mental capacity/decision
making given that she was not on her psych meds.
Past Medical History:
PSH: uterine suspension, appendectomy
PGYNH: nl Pap [**2109-2-8**]
POBH: FTND x 5
PMH:
1. s/p I/P MI, CAD
2. Type II DM
3. HTN
4. CHF by echo at OSH EF 47% 7/05
5. Bipolar disorder/paranoia
6. h/o urinary incontinence
7. hiatal hernia
Social History:
no tobacco/EtOH
widowed; lives alone in [**Hospital1 1474**]
daugher is HCP [**First Name8 (NamePattern2) 6480**] [**Name (NI) **])
Family History:
both parents w/ heart disease (deceased)
Physical Exam:
HR 60, BP 110/71, RR 30, ox sat: 99% on vent SIMV TV 600, [**9-25**],
FiO2 0.3, PIP 24 (plt 18), RR set 10, RRt 30
HEENT: PERRL, chipped teeth
Neck: No JVD, supple
Lungs: Coarse breath sounds bilaterally. Intubated.
CV: PMI WNL. S1 and S2 audible. RRR, no murmur/rub/gallop
Abd: Obese, NT, ND, NABS, No masses.
Peripheral: 2+ symm pulses bilaterally.
Pertinent Results:
[**2109-7-21**] 09:51PM BLOOD
WBC-11.4*# Hgb-10.6*# Hct-30.3*# MCV-86 Plt Ct-188
Neuts-89.2* Bands-0 Lymphs-8.7* Monos-1.8* Eos-0.1 Baso-0.2
PT-15.0* PTT-49.7* INR(PT)-1.5
Na-134 K-3.2* Cl-105 HCO3-18* UreaN-18 Creat-1.0 Glucose-165*
AnGap-14
ALT-51* AST-65* LD(LDH)-377* AlkPhos-43 Amylase-69 TotBili-0.5
CK(CPK)-223* CK-MB-2 cTropnT-0.10* (PEAK)
[**2109-7-24**] 04:08AM BLOOD CK(CPK)-364* PEAK
Triglyc-187* HDL-22 CHOL/HD-4.6 LDLcalc-43
.
ECHO [**2109-7-22**]
1. The left atrium is normal in size. The left atrium is
elongated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. While views are limited, suspect overall left
ventricular
systolic function is severely depressed. Resting regional wall
motion
abnormalities include mid and distal septal, inferior akinesis
with
inferolateral hypo/akinesis.
3.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets appear structurally normal with good
leaflet
excursion. No aortic regurgitation is seen. 5.The mitral valve
leaflets are
mildly thickened. No mitral regurgitation is seen.
6.There is no pericardial effusion.
.
[**2109-7-21**]: EKG: Sinus rhythm with PACs
Markedly long Q-Tc interval
Extensive ST-T changes are probably due to metabolic
Changes and/or ischemia or central nervous system event disease
- clinical
correlation is suggested
Since previous tracing of [**2109-4-4**], anterior T wave inversions
and long Q-T
interval seen
.
CXR [**2109-8-1**]
IMPRESSION:
1. Continued right upper lobe consolidation and bibasilar
opacities, with slight improvement in aeration of the right
upper lobe.
2. No definite evidence of congestive heart failure.
.
CARDIAC CATHETERIZATION WITH STENT PLACEMENT [**2109-8-5**]
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Normal left and right sided filling pressures. Mild pulmonary
hypertension.
3. Mild LV systolic dysfunction with LVEF of 42%.
4. Successful placement of drug-eluting stent in proximal LCx.
5. Successful balloon angioplasty of distal LCx.
6. Successful placement of Angioseal in right femoral
arteriotomy.
.
ECHO [**2109-8-6**]
The left atrium is elongated. There is mild symmetric left
ventricular
hypertrophy. There is moderate regional left ventricular
systolic dysfunction with inferior hypokineisis and
infero-lateral akinesis/dyskinesis. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. There is no aortic valve stenosis. The mitral
valve leaflets are mildly thickened. Mild to moderate ([**12-23**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
Compared with the findings of the prior report (tape unavailable
for review) of [**2109-7-22**], the overall LVEF has improved while the
degree of mitral regurgitation detected has increased (intrinsic
LVEF may be less given the severity of mitral regurgitation).
The degree of pulmonary hypertension is similar.
Brief Hospital Course:
Impression:
79 y/o woman s/p Vtach/torsades arrest with prolonged QT,
elevated troponins.
1. Coronary:
Pt has a history of coronary ds based on EKG findings, who
presented to an OSH with elevated troponins, and report of
inferior posterior MI on Myoview. We continued
ASA/plavix/statin throughout her stay. We initially held beta
blocker given her low BP and HR, however this was re-introduced
when tolerated. We did not feel the need for cath emergently,
as pt's inferior posterior MI was nonacute in nature, was noted
hypokinesis/akinesis of inferior segment on echo per OSH records
2 weeks ago. Pt likely went into torsades from prolonged QT,
superimposed on prior MI. She went for cardiac catheterization
on [**2109-8-5**], with successfull placement of a stent in her LCX
artery. Her post-cath echo demonstrated an EF of 35-40%, and
moderate regional left ventricular systolic dysfunction with
inferior hypokineisis and infero-lateral akinesis/dyskinesis.
.
2. PUMP- Echo with new wall motion abnormality apex and septum
on [**2109-7-22**]. It is thought that this likely a recent cardiac event
resulting in this new depressed LV function. Pt initially had
evidence of mild CHF on CXR and she was diuresed with Lasix with
good response. As stated above, she went for cardiac cath with
placement of stent and subsequent echo showing EF 35-40%. She
was euvolemic at discharge, with no evidence of CHF on CXR.
.
3. ELECTRICAL: likely Vtach/torsades/Vfib/arrest [**1-23**] prolonged
QT interval secondary to several medications that can cause
prologed QT (lithium, amiodarone gtt, haldol, gatifloxacin), now
discontinued. QT here: .92 sec on arrival. No acute need for
ICD. Electrolytes were aggressively repleted with K>4.5, Mg>2.
We slowly introduced some of her psychiatric medications, such
as Prozac, Zyprexa (which was switched to Haldol), and obtained
serial EKGs. Her QT at discharge was around .5 sec. Based on
an EKG obtained in [**2-23**], her QT interval appears at baseline to
be prolonged at .48 to .5. Her family was notified that they
would need to see their primary care physicians for baseline
EKGs, as prolonged QT syndrome may be congenital.
.
4. [**Name (NI) 58022**]
The pt was admitted to OSH with aspiration pneumonia, completed
10 day course of Zosyn while here. She was intubated for airway
protection peri-code. We attempted extubation on Hospital day
2, but pt required re-intubation for respiratory distress. She
was finally successfully extubated on Hospital day 6.
.
5. ID
Pt with evidence of asp PNA on CXR. All blood cx, urine cx
negative. UA negative. Completed 10 day course of Zosyn.
.
6. GI
- h/o severe paraesophageal hiatal hernia by OSH records,
offered surgery at OSH but declined, however, this was felt to
be in the setting of decreased mental capacity, when she was off
meds. Family feels she would be ammenable to interventions if
she was on her meds. [**Month (only) 116**] follow up as an outpatient.
.
7. NEURO/PSYCH:
Given the long QT interval, we held lithium, prozac, avoided
ativan and haldol for agitation. Psychiatry was consulted,
recommended titrating up Zyprexa. But on Zyprexa 2.5po [**Hospital1 **], with
Zyprexa 2.5 prn [**Hospital1 **], she developed chest pain with EKG showing
increased QT interval at .550 sec. Zyprexa was discontinued,
and psychiatry recommended haldol 1mg tid with prozac 20mg po
qd. Her QT stabilized on this regimen, and her mental status is
at baseline. Given concern for long QT interval, would
recommend outpatient psychiatrist try to avoid lithium if
possible or use alternative medication. Head CT performed on
admission for AMS, ruled out for bleed. She was stable on Haldol
1 mg QAM and 2 mg QPM, and prozac 20mg po qd. She should have a
weekly EKG to follow her QT interval.
.
8.Dental: - Dental consult was obtained because 2 teeth are
loose and 1 knocked out after intubation at OSH. She should
follow up as an outpatient.
Medications on Admission:
ASA 81mg po qd, Lipitor 10mg po qd, Prozac 20mg po bid, Protonix
40mg po bid, Lovenox, Haldol PRN, Plavix 75mg po qd, Lithium
150mg po bid, Metoprolol 25mg po qd, Simvastatin 20mg po qd,
Gatifloxacin 400mg po qd, Vancomycin 1gIV q24, Zyprexa 2.5mg po
bid
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
1.5 Tablet Sustained Release 24HRs PO DAILY (Daily).
Disp:*45 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
8. Haloperidol 1 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
9. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
10. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
Baypointe - [**Hospital1 1474**]
Discharge Diagnosis:
1. Ventricular tachycardia/torsades [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 29185**]/Cardiac Arrest
secondary to prolonged QT interval
2. Aspiration Pneumonia
3. Type II Diabetes Mellitus
3. Coronary Artery disease
4. Paraesophageal gastric hernia
5. Hypertension
6. Depression with psychotic features/paranoia
7. Congestive Heart Failure (ejection fraction 25-30%)
Discharge Condition:
Stable
Discharge Instructions:
If you experience any chest pain, shortness of breath, or
sweating, report to the emergency room immediately. If you
experience palpitations, come to the ER. Please do not take any
medications that will prolong your QT interval (Haldol,
Gatifloxacin, Lithium). You can remind your primary care
physician.
[**Name10 (NameIs) 357**] follow up with your doctors (see information below).
Please check EKG weekly to evaluate his QT interval.
You must take Plavix for your coronary artery stent until you
are told to stop by your cardioliogist.
Followup Instructions:
You have a a follow up appointment with a cardiologist Dr. [**Last Name (STitle) 2262**]
on Thursday, [**8-29**] at 2:15 pm. If you have any questions
or need to change the appointment you can call [**Telephone/Fax (1) 3183**].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2109-9-26**] 9:00
Completed by:[**2109-8-16**]
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icd9pcs
|
[
[
[]
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12606, 12665
|
7147, 11099
|
573, 760
|
13097, 13105
|
4030, 5810
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3598, 3640
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11125, 11382
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5827, 7124
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13129, 13673
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3655, 4011
|
288, 535
|
788, 3167
|
3189, 3433
|
3449, 3582
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,407
| 189,576
|
21842
|
Discharge summary
|
report
|
Admission Date: [**2153-7-27**] Discharge Date: [**2153-8-5**]
Date of Birth: [**2075-3-1**] Sex: F
Service: SURGERY
Allergies:
Benzocaine / Bactrim / Novocain
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
1. Carcinoma of the right colon.
2. Multiple polyps, colon.
3. Recurrent incisional hernia.
Major Surgical or Invasive Procedure:
1. Abdominal colectomy.
2. J-pouch to rectal anastomosis, and
3. Repair of recurrent incisional hernia using component
separation technique and Vicryl mesh.
History of Present Illness:
A 78-year-old female newly diagnosed with right
colon cancer and other polyps deemed unsuitable for
endoscopic removal, as well as recurrent incisional hernia.
She was status post a left colectomy for diverticulitis 4
years ago.
Past Medical History:
Atrial fibrillation s/p converstion: on coumadin
HTN
CHF (recently diagnosed in [**6-20**], unknown EF)
Social History:
Lives in [**Location **] in an adjoining apartment with her daughter.
[**Name (NI) 1403**] as a book-keeper at [**Hospital1 392**] Courthouse. Denies current
tobacco use, quit 24 yrs ago. Social EtOH use. Denies IVDU or
illicit drugs. Last hospitalization at [**Hospital3 **] one year ago
for cough + in [**2152-10-14**] (low Hct requiring blood
transfusions.) No nursing facility exposures. No pets at home.
.
Family History:
mother died of old age in her 90s. Father died of MI at 69.
Brother died of heart problems at 58. Children in good health.
Pertinent Results:
[**2153-7-27**] 01:39PM HCT-30.6*
[**2153-7-27**] 01:39PM MAGNESIUM-1.6
[**2153-7-27**] 01:39PM GLUCOSE-123* UREA N-10 CREAT-0.8 SODIUM-137
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14
Brief Hospital Course:
Mrs. [**Known lastname 1356**] is a 78 year who was admitted to the surgical service
on [**2153-7-27**] for elective total colectomy and hernia repair. She
was seen by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3549**], her cardiologist, prior to surgery who
recommended restriction of IV fluids given history of diastolic
failure with aggressive fluid resuscitation in the past. The
surgery was tolerated well. She received 1700 cc crystalloid
intraoperatively and made 350 cc urine. Estimated blood loss was
100 cc. Blood pressures during the procedure ranged from the 90s
to 130s systolic.
She was noted to be hypotensive in the PACU to 87/30s with urine
output less than 15 cc/hr. She was given only 250 cc fluid out
of concern for her tenuous cardiac status given her history of
diastolic heart failure with improvement in her blood pressure
to the 110s systolic with urine output of 15 cc/hr.
She triggered on the floor at 2215 for decreased urine output
and hypotension. She received another 250 cc fluid bolus and
albumin 500 cc x 1. Oxygen saturations were stable in the mid
90s on 2L nasal cannula without dyspnea. Hematocrit was noted to
be decreased to 23.8 from 30.6 preoperatively and she was
transfused two units PRBCs. Her urine output continued to be
poor. She is transferred to the [**Hospital Unit Name 153**] for central line placement
to monitor CVP to guide fluid management.
On arrival the [**Hospital Unit Name 153**] she is alert, oriented and conversant. She
has no complaints but does note that she has pain when taking a
deep breath in. No lightheadedness, dizziness, chest pain,
shortness of breath, nausea, vomiting, leg pain. She has mild
lower extremity edema which is unchanged over the past year. She
does have mild pain over incision. All other review of systems
negative in detail. Plan per surgery to place central line for
CVP monitoring. Initial right subclavian line noted to be
misplaced in the neck. Line removed and replaced with left
subclavian line which is now in good position. CXR with minimal
volume overload compared to prior films in [**2152-12-14**].
The patient was transferred to general surgery floor from the
PACU. She was maintained NPO with IVF/PCA/EPIDUAL/FOLEY/MEDS.
The pt c/o of right arm pain & decreased range of
motion/strength. An x-ray was done showing no acute fractures or
alignment abnormalities, mild DJD is noted at the AC joint.
With the return of bowel function and flatus her diet was slowly
advanced from sips to regular, tolerated well. Medications were
changed to oral and home meds were restarted. Her epidural was
d/c'd and foley removed. She had a few loose BM on POD 6 so whe
was started on Metamucil wafers [**Hospital1 **]. On [**8-5**], her stools were
more formed and she was discharged home in stable condition.
Medications on Admission:
amio 200, amlodpine 5, asa 81, folic acid 1, lasix 40,
lisinopril 5, protonix 40, toprol xl 100, previously on coumadin
(held for anemia)
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain for 2 weeks.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 2 weeks.
Disp:*30 Tablet(s)* Refills:*0*
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Psyllium 1.7 g Wafer Sig: [**12-15**] Wafers PO BID (2 times a day).
Disp:*120 Wafer(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
1. Carcinoma of the right colon.
2. Multiple polyps, colon.
3. Recurrent incisional hernia.
Discharge Condition:
Stable.
Tolerating regular diet.
Pain well controlled with oral medications.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your staples will be removed at your follow up appointment
-Steri-strips will be applied and will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
1. Please call Dr.[**Name (NI) 10946**] office, [**Telephone/Fax (1) 9**], to make a
follow up appointment in [**12-15**] weeks.
Completed by:[**2153-8-5**]
|
[
"427.31",
"401.9",
"584.9",
"276.52",
"428.32",
"153.6",
"428.0",
"V58.61",
"492.8",
"553.21",
"458.29",
"211.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.82",
"45.95",
"53.61"
] |
icd9pcs
|
[
[
[]
]
] |
5698, 5749
|
1739, 4564
|
378, 541
|
5885, 5964
|
1516, 1716
|
7566, 7725
|
1373, 1497
|
4753, 5675
|
5770, 5864
|
4591, 4730
|
5988, 7130
|
7145, 7543
|
247, 340
|
569, 800
|
822, 928
|
944, 1357
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,244
| 118,788
|
20798
|
Discharge summary
|
report
|
Admission Date: [**2169-9-22**] Discharge Date: [**2169-9-28**]
Date of Birth: [**2103-1-12**] Sex: M
Service: CSURG
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
Coronary artery disease, acute chest pain and left circumflex
dissection s/p cardiac catheterization.
Major Surgical or Invasive Procedure:
CABG x3(LIMA-LAD, SVG-PDA, OM)
History of Present Illness:
66 yo man with h/o CAD c stent placement who p/w for re-cath
after onset of jaw pain.
Past Medical History:
1. HTN
2. Hyperlipidemia
3. varicose veins
4. CAD s/p RCA stent ([**6-16**])
Social History:
Unremarkable
Family History:
Father: CHF
Physical Exam:
Gen: NAD, alert
Neck: no JVD, no bruit
CV: RRR, no murmur
Pulm: CTAB
Abd: soft, NT, ND
Ext: no C/C/E
Neuro: grossly intact
Brief Hospital Course:
66M who presented for re-cath after onset of jaw pain. Pt had L
circumflex dissection and new onset chest pain in cath lab. He
had an emergent IABP placement and was referred for emergent
CABG. Pt. was takent to the OR on [**2169-9-22**] for emergent CABG x3
(LIMA-LAD, SVG-PDA, SVG-0M). To the CSRU post-op where IABP was
removed on POD1. All tubes and drains were removed per protocol
and diuresis occured according to protocol. Pt. was transferred
to floor on POD3 where pt experience atrial fibrillation treated
with amiodarone and he converted to normal sinus rhythm. Pt.
was deemed well enough to go home on POD6 c VNA.
Medications on Admission:
1. Plavix
2. Toprol
3. ASA
4. Lipitor
5. Imdur
6. Lisinopril
7. Ditropan
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day) for 3 months.
Disp:*90 Tablet(s)* Refills:*0*
6. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
9. Metformin HCl 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
10. Glipizide 10 mg Tab, Sust Release Osmotic Push Sig: One (1)
Tab, Sust Release Osmotic Push PO QD (once a day).
Disp:*30 Tab, Sust Release Osmotic Push(s)* Refills:*2*
11. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
1. CAD, dissection of L circumflex s/p cardiac cath
2. HTN
3. Hyperlipidemia
4. post-op AFib
status post CABG x3
EF 45%
hypertension
coronary artery disease
status post RCA stent [**6-16**]
status post LLE vein stripping
status post left knee arthroplasty
right achilles tendon rupture
Discharge Condition:
Good
Discharge Instructions:
If you experience any fevers/chills, nausea/vomiting, shortness
of breath, difficulty breathing, chest pain, or bleeding, please
seek medical attention.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 70**] for a follow up appointment in 6
weeks: [**Telephone/Fax (1) 170**]
Please follow up with your PCP as needed
Please follow up with [**Last Name (un) **] as directed.
|
[
"414.12",
"998.2",
"997.1",
"401.9",
"414.01",
"E879.0",
"413.9",
"427.31",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"36.15",
"36.12",
"89.68",
"97.44",
"88.72",
"99.04",
"37.22",
"39.61",
"88.56",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
3034, 3085
|
884, 1518
|
415, 448
|
3415, 3421
|
3622, 3837
|
709, 722
|
1641, 3011
|
3106, 3394
|
1544, 1618
|
3445, 3599
|
737, 861
|
274, 377
|
476, 563
|
585, 663
|
679, 693
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,019
| 125,484
|
42431
|
Discharge summary
|
report
|
Admission Date: [**2201-1-14**] Discharge Date: [**2201-1-14**]
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
inferior STEMI
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
[**Age over 90 **]F with PMH of hypertension and aortic stenosis presents to OSH
with severe epigastric pain, found by EKG to have inferior
[**Hospital **] transferred to [**Hospital1 18**] for cath lab. Patient was last seen
well by family yesterday morning and was at baseline. Family
became concerned when they did not hear from her later in the
day and went to check on her at 6:30pm and found her doubled
over in severe abdominal pain and with altered mental status.
She had not picked up her morning paper, so acute event likely
occurred in AM.
.
At OSH, she was found by EKG to have an inferior STEMI. Labs
showed WBC 15.9, Hct 40.9, Platelets 309. INR 1.8, BUN 28, Cr
2.3, Sodium 140, K 4.4, Cl 98. CK 516, troponin 1.58. She was
transferred to [**Hospital1 18**] for further management of STEMI and cath
lab.
.
At [**Hospital1 18**] ED, she was initially hemodynamically stable on
arrival. On her way to radiology, sbp dropped to 50s and she was
started on dopamine, after which her sbp came up to 100s-130s. A
head CT was also obtained due to AMS, and was negative for acute
intracranial abnormalities. She was transferred to the cardiac
cath lab.
.
In the cath lab, patient was found to have elevated RA pressure
20/24/21, PCWB 16/15/16, LV 186/20, aortic valve gradient 30
(consistent with severe AS), O2 sats - no evidence of shunts, [**MD Number(3) 91869**] venous sat - 70, IVC sat lower than SVC 60 vs 81 (possibly
indicates an inflammatory process in lower torso). LV gram
showed hyperdynamic LV. Systemic vascular resistance is elevated
at 1149. Coronary perfusion shows LMCA ostial 90% lesion,
proximal LAD 70% stenosis. The RCA is proximally totally
occluded, however, this was not thought to be acute because LV
EF was good and LV wall motion was hyperdynamic. Curiously,
however, no collateral vessels were seen, which would be
expected if RCA lesion was thought to be chronic. The patient
was judged to not necessarily benefit from stenting, so an
intra-aortic balloon pump was put in for supportive measures.
.
Patient is intubated and unable to complete a review of systems,
but per family, she does not have hx of prior stroke, TIA, deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, hemoptysis, black stools
or red stools. She has had no recent fevers, chills or rigors.
She denies exertional buttock or calf pain. All of the other
review of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY: moderate aortic stenosis
3. OTHER PAST MEDICAL HISTORY:
- anxiety
- s/p carotid endarterectomy
- divertulitis
- s/p hysterectomy
Social History:
Lives alone, independent and walks with cane, has dementia and
is sometimes confused.
Family History:
Son with CAD. Brother has valve replacement and pacemaker.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T= [**Age over 90 **]F (rectal) BP=126/91 HR=92 RR=14 O2 sat= 95% (CMV
ventilation with TV 450, RR 14, FiO2 50%, PEEP 5)
GENERAL: intubated, sedated, no acute distress
HEENT: NCAT. Sclera anicteric. PERRL 3mm to 2mm.
CARDIAC: bradycardic, somewhat irregular, normal S1, S2.
systolic murmur best heard at LUSB radiating to left carotid>
right carotid.
LUNGS: No chest wall deformities, scoliosis or kyphosis. CTAB,
no crackles, wheezes or rhonchi.
ABDOMEN: hypoactive bowel sounds, soft, nondistended. No HSM or
tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: multiple sebhorreic [**Last Name (LF) 91870**], [**First Name3 (LF) **] stasis dermatitis,
ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION LABS:
[**2201-1-13**] 11:40PM BLOOD WBC-16.1* RBC-4.21 Hgb-12.6 Hct-40.7
MCV-97 MCH-29.9 MCHC-31.0 RDW-13.5 Plt Ct-312
[**2201-1-13**] 11:40PM BLOOD Neuts-86.4* Lymphs-10.4* Monos-2.7
Eos-0.2 Baso-0.2
[**2201-1-14**] 04:26AM BLOOD PT-15.6* PTT-146.0* INR(PT)-1.5*
[**2201-1-13**] 11:40PM BLOOD Glucose-140* UreaN-29* Creat-2.3* Na-145
K-4.7 Cl-103 HCO3-12* AnGap-35*
[**2201-1-14**] 04:26AM BLOOD ALT-62* AST-147* LD(LDH)-501*
CK(CPK)-1033* AlkPhos-80 TotBili-0.6
[**2201-1-14**] 04:26AM BLOOD CK-MB-182* MB Indx-17.6* cTropnT-2.31*
[**2201-1-13**] 11:40PM BLOOD Calcium-9.1 Phos-7.5* Mg-2.3
[**2201-1-13**] 11:43PM BLOOD Type-[**Last Name (un) **] pO2-49* pCO2-36 pH-7.14*
calTCO2-13* Base XS--16 Comment-GREEN TOP
[**2201-1-13**] 11:43PM BLOOD Lactate-11.6* Na-145 K-4.4 Cl-108
.
CARDIAC ENZYMES:
[**2201-1-13**] 11:40PM BLOOD cTropnT-1.90*
[**2201-1-14**] 04:26AM BLOOD CK-MB-182* MB Indx-17.6* cTropnT-2.31*
[**2201-1-14**] 10:00AM BLOOD CK-MB-250* MB Indx-17.2* cTropnT-3.35*
.
ARTERIAL BLOOD GASES:
[**2201-1-13**] 11:43PM BLOOD Type-[**Last Name (un) **] pO2-49* pCO2-36 pH-7.14*
calTCO2-13* Base XS--16 Comment-GREEN TOP
[**2201-1-14**] 01:38AM BLOOD Type-ART Rates-14/ Tidal V-450 FiO2-100
pO2-440* pCO2-27* pH-7.18* calTCO2-11* Base XS--16 AADO2-247 REQ
O2-49 -ASSIST/CON Intubat-INTUBATED
[**2201-1-14**] 04:47AM BLOOD Type-ART pO2-228* pCO2-32* pH-7.23*
calTCO2-14* Base XS--13
[**2201-1-14**] 05:45AM BLOOD Type-ART Temp-35.0 Rates-14/ Tidal V-400
PEEP-5 FiO2-50 pO2-207* pCO2-27* pH-7.33* calTCO2-15* Base XS--9
-ASSIST/CON Intubat-INTUBATED
[**2201-1-14**] 10:14AM BLOOD Type-ART pO2-222* pCO2-30* pH-7.35
calTCO2-17* Base XS--7
[**2201-1-14**] 01:10PM BLOOD Type-ART pO2-178* pCO2-29* pH-7.19*
calTCO2-12* Base XS--15
.
CT HEAD WITHOUT INTRAVENOUS CONTRAST ([**2201-1-13**]): The study is
somewhat limited by motion artifact. There is no acute
intracranial hemorrhage, edema, mass effect or major vascular
territorial infarct. Prominent ventricles and sulci are
compatible with age-related atrophy. There is no shift of the
normally midline structures. Basal cisterns are patent. The
visualized paranasal sinuses, middle ear cavities and mastoid
air cells
are clear. No acute osseous abnormality is identified.
Incidentally noted is bony excrescence emanating from the hard
palate, represent torus palatinus. Patient is status post
bilateral ocular lens surgery.
IMPRESSION: No acute intracranial process.
.
ECHO ([**2201-1-14**]): The left atrium is mildly dilated. The left
atrium is elongated. The estimated right atrial pressure is at
least 15 mmHg. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity is unusually small.
Left ventricular systolic function is hyperdynamic (EF>75%).
There is a mild resting left ventricular outflow tract
obstruction. The right ventricular cavity is mildly dilated with
mild global free wall hypokinesis. The ascending aorta is mildly
dilated. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8-1.0cm2). Moderate (2+) aortic regurgitation is seen.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. [In the
setting of at least moderate to severe tricuspid regurgitation,
the estimated pulmonary artery systolic pressure may be
underestimated due to a very high right atrial pressure.] There
is no pericardial effusion.
IMPRESSION: Mild-moderate symmetric left ventricular hypertrophy
with hyperdynamic systolic function and mild LVOT gradient.
Severe aortic stenosis with moderate aortic regurgitation. At
least moderate pulmonary artery systolic hypertension.
Brief Hospital Course:
[**Age over 90 **]F with inferior STEMI, now s/p cardiac catherization found to
have LMCA ostial lesion, LAD lesion and proximal RCA occlusion,
now s/p intra-aortic balloon pump placement.
.
# HYPOTENSION. Patient became hypotensive to systolic 50s while
in the [**Hospital1 18**] ED. She had maintained good SBPs prior to that
time. DDx included cardiogenic vs. septic shock. Elevated
filling pressures on right heart cath were consistent with
cardiogenic shock, and patient had high systemic vascular
resistance and cold peripheries were most consistent with
cardiogenic shock. Given severe lactic acidosis also considered
septic shock, possibly of GI origin given severe [**Last Name (un) 103**] pain on
admission so started vanc/zosyn. Mesenteric ischemic less likely
given guaiac negative. In cath lab, patient found to have LMCA
90% ostial lesion, LAD 80% lesion, and proximal RCA occlusion,
with EKG showing inferior STEMI in RCA distribution. No coronary
intervention performed given level of risk, but IABP was placed
to augment coronary perfusion and heparin gtt started. For
hypotension, patient initially started on dopamine drip to keep
SBP above 100. She remained intubated and sedated and was
admitted to CCU. Patient initially maintained MAPs, but over the
course of several hours in ICU she became progressively
hypotensive, requiring increasing pressors and ultimately
maximum doses of levophed and dopamine. After discussion with
patient's son (her healthcare proxy), family decided to
transition patient to DNR and ultimately CMO. Patient's IABP and
pressors were discontinued, and she expired peacefully shortly
afterward with family at bedside.
Medications on Admission:
diltiazem
lisinopril
buspirone
simvastatin (recently stopped)
aspirin (recently stopped)
Discharge Medications:
N/A (expired)
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"276.2",
"584.9",
"427.89",
"414.01",
"294.8",
"412",
"785.51",
"293.0",
"401.9",
"424.1",
"410.41",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.61",
"88.53",
"96.71",
"96.04",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
9464, 9473
|
7618, 9286
|
248, 273
|
9524, 9533
|
3910, 3910
|
9589, 9599
|
3094, 3154
|
9426, 9441
|
9494, 9503
|
9312, 9403
|
9557, 9566
|
3194, 3891
|
2844, 2869
|
4719, 7595
|
194, 210
|
301, 2750
|
3926, 4702
|
2900, 2975
|
2772, 2824
|
2991, 3078
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,567
| 130,733
|
3872
|
Discharge summary
|
report
|
Admission Date: [**2206-1-8**] Discharge Date: [**2206-1-11**]
Date of Birth: [**2143-6-19**] Sex: F
Service: MEDICINE
Allergies:
Tetracyclines
Attending:[**First Name3 (LF) 15519**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
62 y/o F with PMHx of CAD s/p MI, COPD on 2L home O2 and IgA
deficiency who presents with progressive SOB over last 4-5 days
with cough and increased sputum production. Pt recently finished
prednisone taper on [**12-30**]. Pt with multiple sick contacts
recently, including "strep throat." She denied CP, abd pain,
nausea, vomiting, diarrhea, fever and chills.
.
In the ED, initial vs were: T 98.1 P 110 BP 121/79 R 38 sats
100% on NRB. Patient was given Solumedrol 125mg IV, Levofloxacin
750mg, and stacked nebs. BP was noted to trend down to 90/50s
and pt received NS 500cc bolus, repeat bp 104/62. Pt was
mentating okay on CPAP.
Past Medical History:
- COPD, last PFTs [**8-4**] with FVC 1.72, FEV1 0.82, FEV1/FVC 66%
(61% and 40% predicted respectively); intubated several times in
the past. on 2L home O2.
- IgA deficiency, was on IV gamma globulin with Dr. [**Last Name (STitle) 2148**].
- CAD s/p MIs in [**2186**] (flu symptoms), [**2192**] (jaw pain), NSTEMI in
[**2197**] (chest pain with left arm discomfort). Cath in [**2197**] with
PTCA/stent to LCx. Cath in [**4-/2202**] with stent placement to RCA
and LCx.
- Hypertension
- Hyperlipidemia
- Gastritis, on PPI
- Osteoporosis, with history of multiple compression and rib
fractures from coughing
- History of thrush/[**Female First Name (un) **] esophagitis [**12-30**] steroid therapy
- Depression
- Tremor
Social History:
She lives with her daughter, [**Name (NI) 6177**], son-in-law and 3
grand-children. She is a widow. She is an ex-smoker, with
about a 30-pack-year smoking history, quit in [**2200**]. No EtOH.
Uses a cane and walker to ambulate.
Family History:
Mother with DM, father with pancreatic cancer.
Physical Exam:
Physical Exam:
VS: 65/[118/49]/18/98% 3L N/C
General: Alert, oriented, breathing comfortably
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD, no accessory muscle use.
Lungs: Severely kyphotic, pectus excuvatum, diffuse wheezes,
decreased BS at lung bases, short breaths at end of respiration.
CV: Sinus tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, cachetic, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no cyanosis or edema
Pertinent Results:
[**2206-1-8**] 10:20PM TYPE-ART RATES-/26 PO2-68* PCO2-42 PH-7.34*
TOTAL CO2-24 BASE XS--2 INTUBATED-NOT INTUBA
[**2206-1-8**] 10:20PM NA+-133* K+-4.0 CL--93* TCO2-22
[**2206-1-8**] 09:50PM URINE HOURS-RANDOM
[**2206-1-8**] 09:50PM URINE GR HOLD-HOLD
[**2206-1-8**] 09:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2206-1-8**] 09:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-150 BILIRUBIN-SM UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2206-1-8**] 09:50PM URINE RBC-[**1-30**]* WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-[**1-30**]
[**2206-1-8**] 09:50PM URINE HYALINE-[**1-30**]*
[**2206-1-8**] 09:50PM URINE MUCOUS-FEW
[**2206-1-8**] 08:09PM COMMENTS-GREEN TOP
[**2206-1-8**] 08:09PM LACTATE-1.5
[**2206-1-8**] 08:05PM GLUCOSE-80 UREA N-26* CREAT-0.8 SODIUM-138
POTASSIUM-5.3* CHLORIDE-90* TOTAL CO2-27 ANION GAP-26*
[**2206-1-8**] 08:05PM estGFR-Using this
[**2206-1-8**] 08:05PM WBC-12.4* RBC-5.10 HGB-14.5 HCT-45.8 MCV-90
MCH-28.4 MCHC-31.6 RDW-13.9
[**2206-1-8**] 08:05PM NEUTS-81.0* LYMPHS-13.1* MONOS-4.4 EOS-0.8
BASOS-0.7
[**2206-1-8**] 08:05PM PLT COUNT-563*
Brief Hospital Course:
Primary Care Physician: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
.
Chief Complaint: Shortness of breath
.
History of Present Illness:
62 y/o F with PMHx of CAD s/p MI, COPD on 2L home O2 and IgA
deficiency who presents with progressive SOB over last 4-5 days
with cough and increased sputum production. Pt recently finished
prednisone taper on [**12-30**]. Pt with multiple sick contacts
recently, including "strep throat." She denied CP, abd pain,
nausea, vomiting, diarrhea, fever and chills.
.
In the ED, initial vs were: T 98.1 P 110 BP 121/79 R 38 sats
100% on NRB. Patient was given Solumedrol 125mg IV, Levofloxacin
750mg, and stacked nebs. BP was noted to trend down to 90/50s
and pt received NS 500cc bolus, repeat bp 104/62. Pt was
mentating okay on CPAP.
.
On arrival to the ICU pt was breathing more comfortably on CPAP.
Pt felt symptomatically improved although still appeared
tachypneic.
.
Upon transfer to the floor, the patient's VS:
65/[118/49]/18/98%3LN/C. The patient is comfortable and reports
that she is breathing much better and is in no pain.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied chest, palpitations. Denied nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
- COPD, last PFTs [**8-4**] with FVC 1.72, FEV1 0.82, FEV1/FVC 66%
(61% and 40% predicted respectively); intubated several times in
the past. on 2L home O2.
- IgA deficiency, was on IV gamma globulin with Dr. [**Last Name (STitle) 2148**].
- CAD s/p MIs in [**2186**] (flu symptoms), [**2192**] (jaw pain), NSTEMI in
[**2197**] (chest pain with left arm discomfort). Cath in [**2197**] with
PTCA/stent to LCx. Cath in [**4-/2202**] with stent placement to RCA
and LCx.
- Hypertension
- Hyperlipidemia
- Gastritis, on PPI
- Osteoporosis, with history of multiple compression and rib
fractures from coughing
- History of thrush/[**Female First Name (un) **] esophagitis [**12-30**] steroid therapy
- Depression
- Tremor
.
Medications:
Albuterol nebs
Alendronate 70mg
Clopidogrel 75mg daily
Vitamin D 50,000 unit M/W
Fentanyl 25mcg/72hr
Fluticasone [**Hospital1 **]
Ipratropium nebs
Lisinopril 10mg daily
Singular 10mg daily
Nortriptyline 25mg daily
Omeprazole 20mg daily
Percocet 10mg/325mg QID prn
Paroxetine 10mg daily
Pravastatin 40mg daily
Advair [**Hospital1 **]
Colace [**Hospital1 **]
Multivitamin
.
Allergies: Tetracyclines
.
Social History:
She lives with her daughter, [**Name (NI) 6177**], son-in-law and 3
grand-children. She is a widow. She is an ex-smoker, with
about a 30-pack-year smoking history, quit in [**2200**]. No EtOH.
Uses a cane and walker to ambulate.
.
Family History:
Mother with DM, father with pancreatic cancer.
.
Physical Exam:
VS: 65/[118/49]/18/98% 3L N/C
General: Alert, oriented, breathing comfortably
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD, no accessory muscle use.
Lungs: Severely kyphotic, pectus excuvatum, diffuse wheezes,
decreased BS at lung bases, short breaths at end of respiration.
CV: Sinus tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, cachetic, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no cyanosis or edema
.
Micro: see omr
.
PFTs [**8-4**]: Mechanics: The FVC is mildly to moderately reduced,
the FEV1 is moderately to severly reduced, and the FEV1/FVC
ratio is severely reduced. Flow-Volume Loop: Marked expiratory
coving and abrupt termination of exhalation with reduced volume
excursion.
Impression: The reduced FEV1/FVC ratio indicates an obstructive
ventilatory defect. The reduced FVC may reflect gas trapping
although a concurrent restrictive process cannot be ruled out.
Since [**2204-5-21**], FVC has decreased 330cc (24%) and FEV1 has
decreased 260cc (46%).
.
ECHO IMPRESSION:[**2205-5-27**] Mild focal left ventricular systolic
dysfunction. Mildly dilated right ventricle with preserved
systolic function. At least moderate mitral regurgitation.
Moderate pulmonary artery systolic hypertension. The left atrium
is mildly dilated. No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is 10-20mmHg.
There is mild regional left ventricular systolic dysfunction
with hypokinesis/akinesis of the basal to mid inferolateral
wall. [Intrinsic left ventricular systolic function is likely
more depressed given the severity of valvular regurgitation.]
The right ventricular cavity is mildly dilated with normal free
wall contractility. The number of aortic valve leaflets cannot
be determined. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion. There
is an anterior space which most likely represents a fat pad.
.
CXR [**2206-1-8**]
Hyperinflation, no focal infiltrates, no evidence of PTX
(prelim)
.
Assessment and Plan:
62 y/o F with PMHx of COPD and Pulm HTN who presents with SOB,
cough and increased sputum production likely consistent with
COPD exacerbation.
.
# COPD: Pt with h/o severe obstructive lung disease c/w COPD.
Has h/o multiple intubations and is at high risk now given
recent course of steroids. CXR does not appear to indicate
concurrent PNA. Initial ABG on CPAP 3L 7.34/42/68/24.
Predinisone 60mg started and continued until discharge, at which
point a taper was started. Patient placed on a course of
azithromycin and continued on outpatient COPD meds and
nebulizers.
.
# CAD: Stable, last EF 50-55%. Patient cont. on plavix,
lisinopril, statin
.
# Hypertension: Stable on home ACEI.
.
# Depression: Stable on home regimen of nortriptyline,
paroxetine
Medications on Admission:
.
Medications:
Albuterol nebs
Alendronate 70mg
Clopidogrel 75mg daily
Vitamin D 50,000 unit M/W
Fentanyl 25mcg/72hr
Fluticasone [**Hospital1 **]
Ipratropium nebs
Lisinopril 10mg daily
Singular 10mg daily
Nortriptyline 25mg daily
Omeprazole 20mg daily
Percocet 10mg/325mg QID prn
Paroxetine 10mg daily
Pravastatin 40mg daily
Advair [**Hospital1 **]
Colace [**Hospital1 **]
Multivitamin
Discharge Medications:
1. Lisinopril 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
2. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: Two (2)
Tablet PO DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: 2.5 Tablet,
Chewables PO twice a day.
4. Azithromycin 250 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
5. Prednisone 10 mg Tablet [**Hospital1 **]: 1-5 Tablets PO once a day for 11
days: Please take as directed:
- 5 days of 60mg/day
- Then 3 days of 40mg/day
- Then 3 days of 20mg/day.
Disp:*60 Tablet(s)* Refills:*0*
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) nebulizer Inhalation every 4-6 hours
as needed.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Fentanyl 25 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
9. Paroxetine HCl 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO QAM (once
a day (in the morning)).
10. Oxycodone-Acetaminophen 10-325 mg Tablet [**Hospital1 **]: One (1) Tablet
PO four times a day as needed for pain.
11. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed.
12. Salmeterol 50 mcg/Dose Disk with Device [**Hospital1 **]: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. Nortriptyline 25 mg Capsule [**Hospital1 **]: One (1) Capsule PO QHS.
15. Pravastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
16. Clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
17. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
18. Montelukast 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
19. Alendronate 70 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a week.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
COPD exacerbation
Pneumonia
Discharge Condition:
Good and improved.
Discharge Instructions:
Call your doctor or return to the Emergency Department right
away if any of the following problems develop:
* You are not getting better in 24 hours, or you are getting
worse in any way.
* You experience new chest pain, pressure, squeezing or
tightness.
* You have shaking chills, or a fever greater than 102 degrees
(F)
* New or worsening cough or wheezing.
* Abdominal (belly) pain, vomiting, severe headache.
* Dizziness, confusion or change in behavior.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
Please follow up with you PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**]
Your appointment has been made:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2206-1-29**] 11:10
Completed by:[**2206-3-31**]
|
[
"491.21",
"412",
"401.9",
"414.01",
"285.9",
"279.01",
"V45.82",
"737.30",
"733.00",
"276.2",
"272.4",
"518.83",
"428.0",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12398, 12456
|
3782, 3874
|
278, 285
|
12528, 12549
|
2636, 3759
|
13134, 13508
|
6639, 6688
|
10271, 12375
|
12477, 12507
|
9862, 10248
|
12573, 13111
|
6703, 9836
|
3891, 3913
|
4894, 5220
|
3941, 4876
|
5242, 6376
|
6392, 6623
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,370
| 128,238
|
37620
|
Discharge summary
|
report
|
Admission Date: [**2184-3-18**] Discharge Date: [**2184-3-19**]
Date of Birth: [**2106-5-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Latex / Sulfa (Sulfonamide Antibiotics) /
Shellfish Derived
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
s/p ERCP with metal stent placement [**2184-3-18**].
History of Present Illness:
Ms. [**Known lastname 84397**] is a 77 year old female with pancreatic cancer with
liver and lung metastases with recent failure to gemcitabine
treatment who presents with new onset jaundice two days ago. She
reports feeling fatigued and having a poor appetitie ovr the
last three days, and noted jaundice on the morning of [**2184-3-15**].
She denies fevers, but does report night sweats that have been
going on for weeks. She had one episode of nausea and vomiting
after taking a pain pill on the evening of the [**2184-3-16**]. She
reports [**Location (un) 2452**] colored stool but denies pruritis or dark colored
urine. She has chronic abdominal pain related to her cancer,
but does not report any change in her abdominal pain. She has
never had an episode like this before.
.
In the ED, initial vitals were T 99.8, HR 95, BP 180/106, RR 18,
99% on RA. Her labs were notable for leukocytosis, elevated
LFTs with an obstructive pattern. Her [**Location (un) 5283**] u/s showed a common
bile duct dilation with obstruction at the level of a large
pancreatic mass. She was given Cipro/Flagyl and morphine for
pain. ERCP was consulted in the ED and plans to peform ERCP on
[**2184-3-18**].
.
Upon arrival to the [**Hospital Unit Name 153**], she was in no acute distress.
.
Review of sytems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
1. Metastatic pancreatic cancer with liver mets, diagnosed
[**10-26**]. She failed gemcitabine. She is currently enrolled in
hospice but is also interested in considering treatment options.
2. Lupus - no current treatment
3. Hypertension.
4. Hypercholesterolemia.
5. GERD.
6. Hypothyroidism.
7. COPD.
8. History of prior TIAs.
Social History:
She works in Marshalls in the fitting room. She does not smoke
cigarettes although was exposed to second hand smoke in the
past. She does not drink alcohol. She has two daughters with
her today on her visit who are very involved in her care. One
of her daughters has [**Name2 (NI) 499**] cancer and is currently
undergoing therapy. She is interested in having her mother move
in with her in order for mutual support.
Family History:
She has a daughter with [**Name2 (NI) 499**] cancer. She has a mother,
grandmother, and great grandmother with breast cancer. She has a
cousin with breast cancer at the age of 45. The cousin who had
breast cancer did undergo genetic testing and no
abnormalities were found.
Physical Exam:
Vitals: T: 98.3 BP: 164/65 P: 89 R: 19 O2: 96%/RA
General: Alert, oriented, no acute distress, jaundiced
HEENT: Scleral icterus, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: BS+, soft, diffusely tender, worse in LLQ
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Labs on Admission:
136 | 100 | 14 /
--------------- 96
4.5 | 26 | 0.6 \
.
ALT 135
AST 123
AP 561
T. bili 6.2
.
.. \ 11.2 /
16.9 ---- 562
.. / 35.4 \
.
PT 15.4
PTT 23.0
INR 1.4
.
Lactate 1.5
.
Micro:
Blood cultures x 2- pending
.
Images:
.
[**2184-3-18**]. [**Name (NI) 5283**] sono. *** wet read ***
intrahepatic and extrahepatic ductal dilation CBD 1.6cm. panc
head mass, multiple liver masses. portal vein patent w/
antegrade flow, but shown to be occluded at level of mass on CT.
gallstones, negative son[**Name (NI) 493**] [**Name2 (NI) **] sign.
findings are better delineated on CT [**3-15**] - please refer to CT
report for additional findings
CT [**3-15**]
1. Large hypoenhancing pancreatic head and uncinate process mass
(5cm), which has progressed in size and degree of local
invasion. This mass has resulted in occlusion of the portal vein
from the confluence extending into the SMV and splenic vein.
Additionally, the mass encases the celiac axis and its branches,
as well as the SMA and its proximal branches.
2. Intrahepatic biliary ductal dilatation, increased in the
interval, and likely related to the large pancreatic head mass.
3. Diffuse metastatic disease to the liver, which has increased
in size and number in the interval. Additionally, numerous
pulmonary nodules which are stable are noted, likely related to
metastatic disease.
4. Trace free fluid within the pelvis.
5. Small to moderate pericaridal effusion.
Brief Hospital Course:
77 yo female with known pancreatic CA with 5cm pancreatic head
mass p/w new onset jaundice, and found to have leukocytosis and
hyperbilirubinemia.
# Cholangitis: Patient with cholangitis secondary to known
pancreatic head mass obstructing the CBD per CT scan. An
ultrasound demonstrated dilated biliary ducts, but a patent
portal vein. LFT's were also consistent with an obstructive
process. She underwent ERCP and a plastic stent was removed and
replaced with a more permanent metal stent. Afterwards, her diet
was advanced and her pain regimen was weaned to her home
regimen. She was discharged on a 10 day course of Ciprofloxacin
& Flagyl despite no positive blood cultures.
# Metastatic pancreatic cancer: Patient has had multiple cycles
of gencytabine as an outpatient, but her CA [**92**]-9 continues to
rise ([**1-28**]: [**Numeric Identifier **], [**3-11**]: [**Numeric Identifier 84398**]). She is currently enrolled in
hospice but is considering palliative chemotherapy. During her
hospital stay, she was maintained on her home Fentanyl TD and
given additional IV Morphine for breakthrough pain.
# Hypertension: Patient's home antihypertensives were held in
the context of lower blood pressures, but her blood pressure
improved after ERCP and she was restarted on her home Diovan.
# Hyperlipidemia: Patient's home Pravastatin was held throughout
this hospitalization in the setting of elevated LFT's and she
was instructed to restart this medication at home.
# Hypothyroidism: Patient continued on her home Levothyroxine 75
mcg daily
# COPD: Patient continued on her home Spiriva & Albuterol PRN
# GERD: Patient continued daily PPI
# Code: Patient remained DNR/DNI throughout this
hospitalization.
To Do:
- F/U final read of blood cultures pending at time of discharge
Medications on Admission:
Albuterol prn
Nexium 40 mg daily
Levothyroxine 75 mcg daily
Pravastatin 40 mg daily
Spiriva (not taking per patient)
Diovan 320 mg daily
Tylenol prn
fentanyl 50mcf q72
vicodin prn
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Pancreatic Cancer
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted for jaundice and abdominal pain. You had an
ultrasound which showed a blockage of your bile ducts. An ERCP
was perfored, and a metal stenet was placed that opened the bile
duct and improved flow. Your jaundice and abdominal pain have
improved.
Please note the following changes in your medications:
Please START flagyl (metronidazole) 500mg by mouth, twice daily
Please START ciprofloxacin 400mg by mouth, three times daily
Please continue all other medications as you have previously.
Followup Instructions:
Please make a follow up appointment with your primary care
physician.
|
[
"496",
"537.3",
"530.81",
"197.7",
"576.1",
"401.9",
"576.2",
"197.0",
"V12.54",
"157.0",
"710.0",
"244.9",
"272.0",
"345.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
7111, 7117
|
5091, 6881
|
349, 403
|
7191, 7191
|
3627, 3632
|
7872, 7945
|
2865, 3142
|
7138, 7170
|
6907, 7088
|
7339, 7849
|
3157, 3608
|
295, 311
|
1732, 2048
|
431, 1714
|
3646, 5068
|
7206, 7315
|
2070, 2409
|
2425, 2849
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,236
| 132,436
|
52423
|
Discharge summary
|
report
|
Admission Date: [**2194-8-31**] Discharge Date: [**2194-9-9**]
Date of Birth: [**2112-2-19**] Sex: F
Service: MEDICINE
Allergies:
Belladonna Alkaloids
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
altered mental status, dyspnea
Major Surgical or Invasive Procedure:
BIPAP
1U pRBC given
History of Present Illness:
Ms. [**Known lastname 108328**] is an 82 year old female with MDS, Crohn's disease,
CAD s/p NSTEMI, CRI, h/o DVT with saddle embolus on weekly
lovenox due to h/o GIBs, h/o breast cancer, LUE DVT on home O2
who presents with dyspnea, AMS. Of note, patient was discharged
2 days ago from hospitalization for AMS, dyspnea and
representing with same complaints. Somnolent since discharge
per daughter, sleep 2 days prior to admission at home on 0.5L -
2LNC per daughter. [**Name (NI) **] prior to admission, daughter noted thumb
twitching and picking at site of port-a-cath. VNA visited for
line check. Reports new incontinence. Daughter worried because
patient ate 4 yogurts.
.
In ED, 7.13/108/97 on bipap. EMS reported 60% pulse ox on
roomair. Patient has been taking cefepime. Vitals 97.7 73 152/67
rr 16 non-rebreather 15L 100%. edema. a*o *2. UA neg. HyperK+
6.9 (K+ 5 on d/c [**8-28**]). In ED, Ca gluc, D50, insulin, 1gm vanc.
CXR atelextasis vs infilatrate. Sent blood cultures. HR 77 BP
154/95 RR 14 on BiPAP 100% on bipap.
.
Upon arrival to MICU, somnolent with stable vitals on BiPAP.
Past Medical History:
-h/o hyperkalemia
-PICC assiated LUE DVT and hematoma [**5-8**]
-Multifactorial anemia ([**3-3**] CRI, chronic disease, MDS)
-MDS dx 3 yrs ago
-Crohn's disease
-CAD s/p NSTEMI '[**89**]
-Chronic diastolic CHF EF 60-70's
-CRI w baseline Cr 1.5-1.8
-BL DVTs and saddle embolus in [**2190**] and [**2193**], previously on
warfarin, now off Lovenox as well for GIB
-Chronic BL LE edema
-Breast cancer s/p lumpectomy & XRT
-GERD
-Intracranial bleed and fx after pedestrian vs car 20 yrs ago
-Cataracts
-Venous stasis dermatitis
-Tinea pedis
-?Arrhythmia unspecified which daughter says is tx with
metoprolol
-s/p CY 10 yrs ago
-s/p Lumpectomy 13 yrs ago
Social History:
[**Year (4 digits) 595**] speaking only. Married; lives with her daughter [**Name (NI) 108329**],
[**Name2 (NI) 108330**] husband and 6 [**Name2 (NI) **] granddaughter. [**Name (NI) 108329**] is the caretaker
for both of her parents. Has daily visiting nurse at home.
Family History:
Non-contributory
Physical Exam:
Physical Exam on discharge:
Vitals Tm 98.0 HR 70-85 BP 130-133/50-63 RR 20 Sats 94-97% on
1.5L NC
General: NAD, cooperative, [**Name (NI) 595**]-speaking
[**Name (NI) 4459**]: NCAT, OP clear
Lungs: poor air movement throughout, CTA on limited exam
CV: RRR, nl S1, S2, systolic murmur heard best at LUSB. No
appreciable JVD.
Abd: S, NT/ND
Ext: WWP, 2+ pulses
Access: POC with benign skin changes, no appreciable erythema or
wamrth. Mildly tender to palpation.
Pertinent Results:
[**2194-8-31**] 01:40AM BLOOD WBC-7.2 RBC-3.01* Hgb-10.3* Hct-33.1*
MCV-110* MCH-34.1* MCHC-31.0 RDW-21.7* Plt Ct-156
[**2194-8-31**] 01:40AM BLOOD Neuts-85.0* Lymphs-11.0* Monos-3.6
Eos-0.2 Baso-0.2
[**2194-9-2**] 03:02AM BLOOD PT-10.5 PTT-25.6 INR(PT)-0.9
[**2194-8-31**] 01:40AM BLOOD Glucose-146* UreaN-43* Creat-2.1* Na-141
K-6.9* Cl-107 HCO3-26 AnGap-15
[**2194-8-31**] 05:19AM BLOOD Type-ART pO2-97 pCO2-108* pH-7.13*
calTCO2-38* Base XS-2
[**2194-9-3**] 05:23AM BLOOD WBC-4.4 RBC-2.73* Hgb-8.9* Hct-29.3*
MCV-107* MCH-32.5* MCHC-30.3* RDW-22.1* Plt Ct-140*
[**2194-9-2**] 03:02AM BLOOD Neuts-77.7* Lymphs-15.1* Monos-6.6
Eos-0.4 Baso-0.2
[**2194-9-3**] 05:23AM BLOOD Glucose-110* UreaN-41* Creat-1.9* Na-140
K-5.6* Cl-99 HCO3-37* AnGap-10
[**2194-9-3**] 05:49AM BLOOD Type-[**Last Name (un) **] pO2-30* pCO2-67* pH-7.38
calTCO2-41* Base XS-10
[**2194-9-5**] 04:11AM BLOOD WBC-7.7 RBC-3.25* Hgb-10.6* Hct-33.1*
MCV-102* MCH-32.5* MCHC-31.9 RDW-25.2* Plt Ct-208
[**2194-9-4**] 05:46AM BLOOD WBC-5.2 RBC-2.67* Hgb-9.1* Hct-28.2*
MCV-106* MCH-34.0* MCHC-32.1 RDW-22.3* Plt Ct-181
[**2194-9-3**] 05:23AM BLOOD WBC-4.4 RBC-2.73* Hgb-8.9* Hct-29.3*
MCV-107* MCH-32.5* MCHC-30.3* RDW-22.1* Plt Ct-140*
[**2194-9-5**] 08:25AM BLOOD HCO3-37*
[**2194-9-5**] 04:11AM BLOOD Glucose-91 UreaN-40* Creat-2.1* Na-143
K-4.6 Cl-99 HCO3-37* AnGap-12
[**2194-9-4**] 05:46AM BLOOD Glucose-88 UreaN-41* Creat-1.9* Na-140
K-4.9 Cl-99 HCO3-35* AnGap-11
[**2194-9-3**] 06:11PM BLOOD Glucose-137* UreaN-44* Creat-2.0* Na-138
K-5.3* Cl-97 HCO3-38* AnGap-8
[**2194-9-5**] 04:11AM BLOOD Calcium-8.5 Phos-3.8# Mg-2.4
[**2194-9-4**] 05:46AM BLOOD Calcium-8.1* Phos-2.2* Mg-2.3
[**2194-9-4**] 05:46AM BLOOD Vanco-27.0*
[**2194-9-5**] 10:39AM BLOOD Type-ART pO2-43* pCO2-84* pH-7.31*
calTCO2-44* Base XS-11
Cardiology Report ECG Study Date of [**2194-8-31**] 4:53:28 AM
Sinus rhythm with premature atrial contractions. Left atrial
abnormality.
Right bundle-branch block. Compared to the previous tracing of
[**2194-8-25**] there is no significant change.
CXR ([**8-31**])
IMPRESSION:
1. Retrocardiac opacity likely combination of atelectasis and
effusion. A
superimposed pneumonia in this region cannot be excluded.
2. CHF with interstitial edema, more prominent than prior study.
CXR ([**9-9**])
FINDINGS: There is essentially unchanged presentation of the
left pleural
effusion and of a left retrocardiac consolidation, most likely
consistent with atelectasis. The right lung is clear without
evidence of pneumothorax, consolidation or pleural effusion.
There is a right Port-A-Catheter in place with its tip ending at
the superior vena cava
IMPRESSION: Compared to [**2194-9-6**], there is unchanged left
retrocardiac consolidation, consistent with atelectasis and
there is unchanged left pleural effusion.
Brief Hospital Course:
82F with MDS, Crohn's with multiple GI bleeds, CAD s/p NSTEMI,
CKD, breast CA, with worsening respiratory status over past
several months of unclear etiology, admitted for altered mental
status and dyspnea within 3 days of discharge for same
presentation.
#. AMS. The patient presented with somnolence likely secondary
to hypercarbia. The patient had a PCO2 of 108 on admission with
a stable CXR and no WBC or fever. The patient was on cefepime
from her last hospitalization. The patient was pan-cultured
including blood and urine cultures. She was started on BiPAP
overnight. Patient CO2 improved per VBG. Blood cultures drawn
from the line were positive for coagulase negative gram
positive. The patient was discontinued from cefepime and started
on a two week course of vancomycin (Day 1 [**2194-9-1**]) for a
susptected line infection. The line was not removed due to poor
access. The patient's mental status returned to baseline after
antibiotics and a decrease in her VBG CO2. The following
surviellance cultures were negative. The patient was then
transferred to the medical floor from [**Date range (1) 62751**], at which time
she improved until [**9-5**] when she triggered after her daughter
decided to place the pt on BIPAP late in the morning but did not
connect the BIPAP to the machine. This caused acute hypoxia,
which was treated with nasal canula oxygen and BIPAP on the
floor. A CXR was unchanged from prior, and ABG (thought to be
venous stick) showed labs c/w hypercarbia probably secondary to
over oxygenation after the trigger event. There were no signs of
acute pulm edema or CHF. Due to receiving BIPAP on the floor,
she was transferred back to the ICU.
.
During her ICU course, her hypercarbia generally resolved on
nightly BIPAP and NC throughout the day at 2-4L. With this came
an improvement in mental status to baseline per the patient's
daughter. Giving 2.5 mg Zyprexa was found to be beneficial in
improving pt compliance with BIPAP at night. On [**9-8**], the pt
was transferred back to the floor and remained stable on nightly
BIPAP and 1.5L NC during the day.
.
The patient was discharged with instructions to complete her
2-wk course of vancomycin (concluding [**2194-9-15**]), as well as
nightly BIPAP 13/5 and NC during the day as needed.
.
# Dyspnea. The patient was slightly dyspneic at baseline on
presentation. The daughter reported that the patient was wearing
continuous O2 at home with good oxygen sats. The CXR was
consistent with fluid overload. The patient was diuresed with
lasix. The diureses greatly improved the patient's symptoms. She
was sating in the low 90's on room air. She was placed on CPAP
at night (on the patient's home settings) and nasal canula
during the day. She was then transferred to the floor, where the
patient had an inpatient overnight sleep study. As described
above, she then triggered and was transferred back to the ICU.
.
As described above, the pt's hypercarbia resolved on nightly
BIPAP and NC during the day.
.
# Diastolic Heart Failure. The patient presented with fluid
overload, which likely contributed to her dyspnea. The CXR was
consistent with fluid overload. The patient had an elevated BNP
as well. The patient was diuresed with lasix and her home dose
of lopressor was started (although the patient was not taking
this medication). The lopressor was later stopped due to patient
and family refusal. On the floor, the patient was diuresed on
her home dose of 20 Lasix PO. She did not have any signs of
acute CHF.
.
# Hyperkalemia. The hyperkalemia was likely in the setting of
acidemia. The patient was given kayexelate in the emergency
department. An EKG was checked on presentation and is described
above. Throughout the pt's hospitalization, the pt had episodes
of hyperkalemia noted on AM labs that responded well to po Lasix
and po Kayexalate. As these repeated episodes are concerning,
the pt will have K+ checked twice weekly by her visiting nurses,
with the results forwarded to her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3357**]. He will
interpret these results and provide guidance as to usage of
Kayexalate, for which the patient was given a prescription on
discharge.
.
# Crohn's Disease: The patient was continued on her home
mesalamin. She was also continued on her steroid [**Last Name (STitle) 15123**]. The
patient was guaiac positive during her stay, however, her
hematocrit remained stable and was not further assessed. The
patient also had 4 episodes of diarrhea. On the floor, her
steroids were continued on a [**Last Name (STitle) 15123**] starting at 35 mg po qd.
This [**Last Name (STitle) 15123**] was not completed at the time of discharge, and the
patient was discharged with instructions to continue tapering
down to 20 mg po qd.
.
# CKD. The patient presented with a creatinine near baseline.
.
# Anemia. The patient presented with a hematocrit at her
baseline, which has been stable since her last admission. The
etiology is likely of chronic disease. We continued her epo and
folic acit. She got B12 on [**2194-8-25**]. She had a HCT of 28 on the
floor and she received 1U pRBC with repeat HCT 33.
.
# CAD. The patient has a history of an NSTEMI. She is not on ASA
due to a history of recent GI bleeds. The patient was restarted
on her low dose beta blocker, which was later discontinued due
to patient request.
.
# LUE DVT. The patient had an ultrasound on [**2194-8-25**] which
revealed a stable hematoma and upper extremity DVT. She was
continued on her home dose of lovenox.
.
# Chronic bilateral LE edema and venous stasis. The patient was
continued on her home trimacinolone cream.
.
# GERD. Continued on protonix
.
# Fungal groin rash. Continued on Miconazole powder.
Medications on Admission:
MVI w/ minerals
Ciprofloxacin * 1 sat due to concern for somnulence
Cefepime 1 gram daily
Heparin line flush
NaCl line flush
Enoxaparin 60 mg daily
Triamcinolone Acetonide 0.025 % PRN: lower extremitites
Mesalamine 400 mg Tablet 3 tabs daily
Miconazole Nitrate 2 % Powder QID:PRN
Epoetin Alfa 40,000 units weekly
Folic Acid 1 mg daily
Furosemide 20 mg daily
Artificial Tears TI:PRN
Omeprazole 20 mg daily
Timolol Maleate 0.5 % one drop daily
Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) MLs PO DAILY --
has not taken at home
Prednisone [**Date Range **] 10 mg Tablet Sig: Take 55mg for 2 days, 50mg
for
2 days, 45mg for 2 days, 40mg for 2 days, 35mg for 2 days, 30mg
for 2 days, 25mg for 2 days, then continue with 20mg daily
Tablet PO once a day.
Discharge Medications:
1. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
Q24H (every 24 hours).
2. Triamcinolone Acetonide 0.025 % Cream Sig: One (1) Appl
Topical DAILY (Daily) as needed for lower extremities.
3. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
5. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
6. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-31**]
Drops Ophthalmic [**Hospital1 **] (2 times a day) as needed for dry eye.
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
9. Atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO DAILY
(Daily).
Disp:*300 ml* Refills:*2*
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H
(every 4 hours) as needed for pain.
12. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily) as
needed for shortness of breath, leg swelling.
Disp:*15 Tablet(s)* Refills:*2*
13. Prednisone 10 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily):
Please [**Hospital1 15123**] to home dose of 20mg. Take 35mg for 1 day, then
30mg 2 days, 25mg 2 days, then 20 mg daily.
Disp:*60 Tablet(s)* Refills:*0*
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet, Chewable(s)* Refills:*0*
15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
16. Vancomycin 500 mg Recon Soln Sig: 1.5 Recon Solns
Intravenous Q48H (every 48 hours) for 6 days.
Disp:*6 Recon Soln(s)* Refills:*0*
17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Five (5) ML
Intravenous PRN (as needed) as needed for line flush: Indwelling
Port (e.g. Portacath), heparin dependent: Flush with 10 mL
Normal Saline followed by Heparin as above daily and PRN per
lumen.
Disp:*500 ML(s)* Refills:*1*
18. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Five
(5) ML Intravenous PRN (as needed) as needed for DE-ACCESSING
port: Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, instill Heparin as above per lumen.
Disp:*500 ML(s)* Refills:*1*
19. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)): Administer
before BiPap.
Disp:*15 Tablet, Rapid Dissolve(s)* Refills:*2*
20. Kayexalate Powder Sig: Thirty (30) grams PO once a day
as needed for elevated potassium levels.
Disp:*300 grams* Refills:*2*
21. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
22. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation. Capsule(s)
23. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Primary:
acute mental status change secondary to sepsis/bacteremia and
respiratory distress
.
Secondary:
-h/o hyperkalemia
-PICC associated left upper extremity DVT and hematoma [**5-8**]
-BL DVTs and saddle embolus in [**2190**] and [**2193**], previously on
warfarin, on weekly lovenox due to prior UGIB, recently [**8-18**]
increased to daily lovenox for upper extremity DVT.
-Multifactorial anemia ([**3-3**] CRI, chronic disease, MDS)
-MDS dx 3 yrs ago
-Crohn's disease
-CAD s/p NSTEMI '[**89**] AND chronic diastolic congestive heart
failure: EF 60-70%
-CRI w baseline Cr 1.8-2.0 for past month, prior 1.5-1.7
-Chronic BL LE edema
-Breast cancer s/p lumpectomy & XRT
-GERD
-Intracranial bleed and fx after pedestrian vs car 20 yrs ago
-Cataracts
-Venous stasis dermatitis
-Tinea pedis
-?Arrhythmia unspecified which daughter says is tx with
metoprolol
Discharge Condition:
afebrile, stable vitals, tolerating POs, AOx3, stable
respiratory status, saturations > 93% on nightly BIPAP 13/5 and
NC 1.5L/min during the day
Discharge Instructions:
You were admitted for changes to your mental status. You were
found to have some difficulty breathing as well as blood
infection for which you were treated with IV antibiotics. You
were also given blood for low hematocrit. Your body fluid
balance and electrolytes were also corrected. You were placed on
BIPAP which improved your breathing. You were also evaluated
with a sleep study to determine your optimum level of BIPAP. You
will be treated with IV vancomycin for 6 more days. Your
prednisone was also increased and you will be sent home with
35mg day, which you can then slowly [**Year (2 digits) 15123**] to your home dose of
20mg. You should continue taking 20mg daily of lasix.
.
Please take all medications as prescribed.
Use BiPap as ordered at night.
Please attend all appointments below.
Please do not hesitate to return to the hospital for any
concerning symptoms or changes in your mental status or
breathing.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Followup Instructions:
PULMONARY FUNCTION [**Name8 (MD) **] Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2194-9-11**]
1:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2194-9-10**]
|
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"112.3"
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icd9cm
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[
[
[]
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] |
[
"93.90"
] |
icd9pcs
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,459
| 161,500
|
22618
|
Discharge summary
|
report
|
Admission Date: [**2171-5-27**] Discharge Date: [**2171-5-30**]
Date of Birth: [**2100-4-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 71 y/o male with ESRD on HD (last HD Friday), HTN,
DM2, diastolic CHF, who presented to the ED today with dyspnea
since Saturday. Patient was last dialyzed on Friday on a M/W/F
[**First Name3 (LF) **], however over the course of the weekend, developed
progressive DOE and orthopnea. No PND. No chest pain, cough,
palpitations, f/c/s. Recently admitted from [**Date range (1) 58640**] with
similar symptoms which improved with dialysis. His exacerbations
are thought to be [**1-18**] to dietary indiscretions.
.
In the ED, initial VS were T 97.2, BP 167/66, HR 78, RR 26, SaO2
97%/2L NC. He was given 40 mg IV lasix (although makes little
urine at baseline), nebs, and solumedrol x 1 given h/o COPD. CXR
with evidence of CHF. He was initially going to be admitted to
the floor, however while in the ED, became more tachypneic with
increasing O2 requirement and was put on NIV to alleviate his
respiratory symptoms. Of note, renal is aware and plans to
dialyze the patient this AM (pt is due for HD today anyway).
.
ROS otherwise negative.
Past Medical History:
1. ESRD on HD, began dialysis [**2166**]. AV graft placed in LUE on
[**2171-1-10**]. Congenital absence of one kidney. Gets HD MWF in
[**Location (un) **]/[**Location (un) 4265**]--followed by Dr. [**First Name (STitle) 805**]. On [**2171-2-13**],
underwent attempted thrombectomy, left upper arm AV graft.
Ligation of left upper arm AV graft and placement of right
femoral Quinton catheter.
2. HTN
3. Hypercholesterolemia
4. DM, type 2
5. Diastolic CHF, EF >55%
6. COPD
7. h/o GI bleeding
8. unilateral kidney
9. s/p cataract surgery
[**73**] H/o gastric lipoma,
11. PVD, s/p angioplasty.
12. h/o VRE UTI
13. Restless legs syndrome
14. CMML - diagnosed 6 months ago, pt of Dr. [**Last Name (STitle) 6944**]. Diagnosed
by bone marrow biopsy, did not have any symptoms. Not being
treated.
Social History:
Pt is a retired medical record coder at the VA. He is widowed
with 4 children and 5 grandchildren. Lives with 1 daughter. 120
pack year hx, quit 20 years ago. Quit smoking 14 years ago, but
smoked [**2-17**] ppd for 40+ years. No EtOh. No drug use. Pt was in
the army from [**2118**]-[**2142**].
Family History:
M: Died at 64 of MI; DM
F: Died at 41 of MI
Aunts maternal and paternal with DM.
Physical Exam:
PHYSICAL EXAM -
VS: Tc 97.2, BP 159/74, HR 89, RR 27, SaO2 95%/4 L NC
General: Pleasant male, dyspneic, AO x 3
HEENT: NC/AT, PERRL, EOMI. MMM, OP clear
Neck: supple, JVP approx 7 cm
Chest: bibasilar crackles with diffuse exp wheezes in upper lung
fields
CV: RRR s1 s2 normal, no m/g/r
Abd: soft, NT/ND, NABS
Ext: no c/c/e; +LUE AV fistula with thrill and bruit
Pertinent Results:
[**2171-5-27**] 09:18AM TYPE-ART TEMP-36.7 PO2-73* PCO2-53* PH-7.37
TOTAL CO2-32* BASE XS-3 INTUBATED-NOT INTUBA
[**2171-5-27**] 01:48AM K+-4.3
[**2171-5-27**] 01:40AM GLUCOSE-138* UREA N-42* CREAT-7.8*#
SODIUM-140 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-24 ANION GAP-20
[**2171-5-27**] 01:40AM CK(CPK)-76
[**2171-5-27**] 01:40AM CK-MB-NotDone cTropnT-0.07* proBNP-GREATER TH
[**2171-5-27**] 01:40AM WBC-14.5* RBC-3.47* HGB-9.6* HCT-30.1* MCV-87
MCH-27.7 MCHC-32.0 RDW-20.2*
[**2171-5-27**] 01:40AM PT-14.0* PTT-28.7 INR(PT)-1.2*
.
RADIOLOGY Preliminary Report
CHEST (PORTABLE AP) [**2171-5-28**] 12:45 AM
.
CHEST (PORTABLE AP)
.
Reason: Please compare to prior film for volume status/effusions
.
[**Hospital 93**] MEDICAL CONDITION:
71 year old man with sob in setting of vol overload
REASON FOR THIS EXAMINATION:
Please compare to prior film for volume status/effusions
AP CHEST, 4:18 A.M.
.
HISTORY: Shortness of breath. Volume overload.
.
IMPRESSION: AP chest compared to [**4-1**] through [**5-27**]:
.
Severe pulmonary and mediastinal vascular congestion and
mild-to-moderate enlargement of the cardiac silhouette have
worsened since [**4-28**]. Borderline interstitial edema is present.
A large bore right supraclavicular central venous line ends in
the low SVC. No pneumothorax. Pleural effusion, if any, is
minimal, on the left. Leftward deviation of the trachea at the
thoracic inlet due to a goiter is longstanding problem,
unchanged. Healed bilateral rib fractures with overlying pleural
thickening are also chronic.
.
Cardiology Report ECG Study Date of [**2171-5-27**] 1:23:30 AM
.
Sinus rhythm with baseline artifact. Compared to the previous
tracing
of [**2171-4-29**] the findings are similar.
.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
77 186 90 [**Telephone/Fax (2) 58641**] 78 67
.
Brief Hospital Course:
This is a 71 y/o male with ESRD, COPD, CML who presented with
dyspnea, relieved with hemodialysis secondary to volume
overload.
Dyspnea - Given that there was a rapid improvement after large
volume dialysis as well as no signs of COPD exacerbation, his
dyspnea was likely caused only by fluid overload. He rapidly
Improved significantly with hemodialysis in which 5 kilos were
removed on [**2171-5-27**]. He was continued on his outpatient COPD
medication: tiotropium, advair, albuterol nebs prn. No IV
steroids were given.
Leukocytosis - appears to be at patient's baseline and likely
seconary to CMML as documented previously. In the absence of
fever or any other localizing symptoms, did not culture. CIS.
ESRD - HD MWF s/p HD yesterday. He was dialyzed two consecutive
days and had an excess of [**4-21**] L removed. He was again
counselled on the necessity of adherance to a low salt diet.
Addtionally, a nutrition consultant spoke with the patient and
daughter (caretaker).
COPD - continue spiriva, adavir, and albuterol; no need for
systemic steroids
CMML - Diagnosed 6 months ago, and the patient is not being
treated at this time. Persistently elevated WBC count likely due
to CMML. Already being followed by oncology ([**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6944**])
DM - He was treated with NPH, Regular insulin sliding scale QID
HTN - toprol XL, lisinopril, diltiazem
Medications on Admission:
1. Aspirin 81 mg qd
2. Fosinopril 10 mg qd
3. Requip 0.25 mg [**Hospital1 **]
4. Diltiazem 30 mg tid Tu/Th/Sa/[**Doctor First Name **]
5. Toprol XL 25 mg qhs
6. Calcium Acetate 1334 mg tid
7. Tiotropium qd
8. Sevelamer 1600 tid
9. Colace 100 mg [**Hospital1 **]
10. Nephrocaps qd
11. Advair 250/50 [**Hospital1 **]
12. Omeprazole 20 mg qd
13. Vitmain E 400 units qd
14. Lovastatin 10 mg qhs
15. Insulin NPH 15 units qhs, RISS
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for on Tu/Th/Sa/[**Doctor First Name **].
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO HS (at bedtime).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Lovastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Fosinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. Ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifteen
(15) Subcutaneous at bedtime: and continue regular insulin
sliding sclae.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Fluid overload, end stage renal disease
Secondary: Chronic obstructive pulmonary disease, congestive
heart failure, hypertension, hypercholesterolemia, diabetes,
peripheral vascular disease, Chronic Myelomonocytic leukemia
Discharge Condition:
improved breathing
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
FLUID restriction: no more than 1250 mL daily. ([**3-21**] cups)
.
You were admitted after you had trouble breating because of too
much fluid. It is very important that you do not eat foods with
high sodium (salt) and that you do not drink too much fluids.
Please adhere to a low salt, kidney diet.
.
Please return to the ED if you have any shortness of breath,
vomiting, chest pain, fever, chills or any other concerning
symptoms
Followup Instructions:
Please continue with your regularly scheduled dialysis. Please
follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**6-13**]
at 8:45 AM. If you have difficulty making this appointment
please call [**Telephone/Fax (1) 12411**]
Also you have follow up with oncology:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6952**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2171-7-24**] 3:00
|
[
"496",
"428.0",
"403.91",
"428.30",
"V45.1",
"250.00",
"205.10",
"443.9",
"585.6",
"272.0",
"753.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8314, 8320
|
4941, 6354
|
323, 330
|
8586, 8606
|
3032, 3745
|
9187, 9660
|
2553, 2635
|
6831, 8291
|
3782, 3834
|
8341, 8565
|
6380, 6808
|
8630, 9164
|
2650, 3013
|
276, 285
|
3863, 4918
|
358, 1408
|
1430, 2220
|
2237, 2537
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,981
| 197,448
|
16331
|
Discharge summary
|
report
|
Admission Date: [**2140-10-10**] Discharge Date: [**2140-10-13**]
Date of Birth: [**2075-6-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Fevers, diarrhea, rash
Major Surgical or Invasive Procedure:
Right internal jugular central line insertion
Arterial line insertion
History of Present Illness:
Mr. [**Known lastname **] is a 65 year old man with a PMH s/f CLL, s/p cycle 1
of pentostatin and cytoxan on [**9-20**], who was in his usual state
of health until this morning when he began to experience chills,
diarrhea, and a rash. The onset was sudden for all of the
latter symptoms. The diarrhea is described as watery and
non-bloody. The rash is described as "prickly heat" initially,
and evolved into a warm erythematous diffuse patch over his
head, arms, and trunk. The patient recently traveled this past
weekend to [**Location (un) **] where he attended a bar mitzvah, he ate sushi
and soft cheeses, and other foods that were low risk, including
pizza. He notes that he experienced an episode of dizziness
upon standing while at the celebration (which is two days prior
to admission), which lasted 15-20 minutes and resolved
spontaneously. He traveled via plane. He has not recently had
any antibiotics. He has no known sick contacts.
.
REVIEW OF SYSTEMS: Is as per the HPI, and also positive for
conjunctival erythema. ROS is otherwise negative for headaches,
blurred vision, sinus congestion, rhinorrhea, pharyngitis, or
cough.
Past Medical History:
1. Chronic lymphocytic leukemia
-s/p cycle 1 of pentostatin and cytoxan on [**2140-9-20**], to begin
rituxan in addition to pentostatin and cytoxan on cycle #2 in
about 1 week.
2. Hypertension
3. Hypercholesterolemia
4. History of shingles three years ago
5. Heart murmur
Social History:
Lives at home in [**Hospital1 8**], MA with his wife. [**Name (NI) **] has grown
children. He is employed as an attorney. He recently traveled
to [**Location (un) **] as noted above where he had no unusual exposures to
animals, foods, or soil.
Family History:
Brother who had colon cancer. No other FH of cancer.
Physical Exam:
T:103.5 BP:111/53 HR:60 RR:tachypnic
.
.
PHYSICAL EXAM
GENERAL: Toxic appearing male, tachypnic, warm to touch,
diffusely erythematous. Able to give a clear history and
answers questions appropriately.
HEENT: Normocephalic, atraumatic. Erythematous conjunctiva
bilaterally, no discharge or edema. No scleral icterus.
PERRLA/EOMI. Oropharynx is dry. OP clear. Neck Supple, Positive
nontender cervical LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Positive pansystolic
murmur heard best at the sternal border. No JVD
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: Trace pitting edema to the ankles. No calf pain,
2+ dorsalis pedis/ posterior tibial pulses.
SKIN: Diffuse erythematous, blanching rash on head, face, arms,
and trunk. Spares the legs. No petechiae or papules.
NEURO: CN2-12 in tact. Normal gait and strength.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2140-10-10**] 01:15PM WBC-92.8* RBC-3.62* HGB-11.6* HCT-33.0*
MCV-91 MCH-32.0 MCHC-35.1* RDW-15.0
[**2140-10-10**] 01:15PM NEUTS-2* BANDS-0 LYMPHS-98* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
.
[**2140-10-10**] 03:41PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2140-10-10**] 03:41PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
.
Urine Culture: Negative, and also negative for urine legionella
antigen
.
Blood Culture: No growth for 4 days
.
Stool Culture: Negative, viral culture still pending
.
CXR: No evidence of pneumonia
Brief Hospital Course:
The patient was admitted with sudden onset of high fevers, rash
and diarrhea, in the setting of immunocompromise. Although a
viral etiology is likely, given the systemic nature of these
symptoms, a bacterial illness was ruled out given his
immunocompromised state. The patient's blood, urine, and stool
were cultured, and a chest X ray was obtained on admission.
After cultures were drawn, the patient was started on cefepime
and flagyl for broad empiric coverage of gastro-intestinal
organisms. On the evening of admission, the patient became
acutely hypotensive on the floor and was transferred to the
intensive care unit. Due to his recent hx of diarrhea and fever
in the setting of hypotension, sepsis was the leading concern.
Subsequently he received aggressive fluid resusciation with 4L
overnight, a central line was placed and he was briefly on
levophed to maintain MAP >65. He was continued on cefepime and
flagyl as well as vancomycin for empiric antibiotic coverage. He
has a normal [**Last Name (un) 104**] stim, so corticosteroids were not continued.
Upon transfer to the floor, the patient's antibiotics were
withdrawn and he tolerated this well, remaining afebrile and
normotensive for 36 hours. All of his cultures were
unrevealing, and his chest X ray was negative. There was some
concern for a possible allergy to bactrim, as the patient
reports onset of these symptoms after taking this medication.
We held it on discharge, and will have the patient follow-up
with Dr. [**First Name (STitle) 1557**] to restart it.
Medications on Admission:
1. Bactrim DS: one tab three times per week
2. Acyclovir 400mg TID
3. Amlodipine 5mg QD
4. Lisinopril-HCTZ 20/25mg QD
5. Simvastatin 20mg QD
Discharge Medications:
1. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
4. Lisinopril-Hydrochlorothiazide 20-25 mg Tablet Sig: One (1)
Tablet PO once a day.
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Fevers
CLL
Discharge Condition:
Stable, afebrile, normotensive
Discharge Instructions:
You were admitted because of your sudden fevers, rash and
diarrhea. While you were here, your blood pressure became very
low, which required us to transfer you to the intensive care
unit for management. You did very well and your blood pressure
normalized quickly. We gave you three days of intavenous
antibiotics, and cultured your blood, urine and stool. None of
your body fluids grew any pathogenic organisms, so we weaned off
your antibiotics. You tolerated this well when we observed you
overnight.
.
We are holding one of your medications- bactrim, as there is
concern for a possible drug allergy. When you follow up with
Dr. [**First Name (STitle) 1557**], you can re-address this.
.
Please take all of your medications as directed, and follow-up
as indicated. Return to the emergency department or call you
doctor if your symptoms recur.
.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 1557**] as you had discussed. Call
their office tomorrow to schedule your appointment and cancel
the appointment made for you on monday.
|
[
"458.9",
"401.9",
"782.1",
"787.91",
"780.6",
"785.2",
"204.10",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
5980, 5986
|
3873, 5416
|
340, 412
|
6060, 6093
|
3219, 3850
|
6997, 7187
|
2168, 2224
|
5608, 5957
|
6007, 6007
|
5442, 5585
|
6117, 6974
|
2239, 3200
|
1414, 1591
|
278, 302
|
440, 1395
|
6026, 6039
|
1613, 1887
|
1903, 2152
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,119
| 161,146
|
37475
|
Discharge summary
|
report
|
Admission Date: [**2108-1-2**] Discharge Date: [**2108-1-10**]
Date of Birth: [**2039-6-26**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Suicidal ingestion.
Major Surgical or Invasive Procedure:
Intubation
Nasogastric lavage
Esophagoduodonoscopy
History of Present Illness:
This is a 68 year old male with a history of depression who was
admitted on [**1-2**] after an apparent intentional overdose of
Seroquel, Paxil, and aspirin and found down with dried blood
along his lips. Due to somnolence and poor gag reflex, he was
intubated and admitted to the ICU. NG lavage was performed and
revealed coffee grounds. GI was consulted and he received IV
PPI, and one unit of pRBCs. They perfomed upper endoscopy which
showed gastritis, no evidence of active bleeding, and pill
fragments (some of which could be collected). Per toxicology,
serial aspirin levels were checked with a max of 38. He was
given IVFs with bicarb, and actived charcoal on [**1-3**]. There was
some concern re: serotonin syndrome but with no symptoms of this
and nl QT intervals on serial EKGs. He was treated for a likely
aspiratin pneumonia with Unasyn, transitioned to Augmentin, was
extubated and is now satting well on room air. He has been
treated for renal failure which is resolving. CKs elevated but
are now downtrending. Psychiatry has been following and
recommended continuing to hold Paxil and inpatient psych
admission. Section 12 was signed.
Past Medical History:
- Depression
- HTN
- History of colonic polyps
- Hematuria
Social History:
Lives with daughter who recently returned from living abroad.
She has pain disorder - this and her resulting behavior in the
setting of financial issues have caused distress at home within
the family. Non-smoker with occasional glass of wine per family
and prior records. The patient was born in [**State 531**]. Both of his
parents are deceased. He has one brother who lives in [**Name (NI) **].
The patient has a PhD in psychology and has been teaching
religion and [**Hospital1 100**] Studies for the last 30 years. He recently
decided to take the next semester off from teaching because of
decreased ability to concentrate and his worries about his
financial situation. He is married and has two sons and one
daughter.
Family History:
Family history of depression and suicide.
Physical Exam:
On admission:
Vitals: T: 98.6 P: 85 BP: 99/57 R: 18 O2: 98% ventilator
General: Sedated, intubated
HEENT: Pupils noreactive bilaterally, 3mm
Neck: JVP not elevated
Lungs: Coarse lung sounds, equal bilaterally
CV: RRR no murmurs
Abdomen: Soft, NT, non-distended, no rebound, no guarding, BS+
GU: Foley in place with yellow, clear urine drainage
Ext: Warm, well perfused, 1+ pedal pulses, no edema
Pertinent Results:
Complete Blood Count:
[**2108-1-2**] 03:00PM BLOOD WBC-13.6* RBC-3.87* Hgb-12.2* Hct-36.2*
MCV-94 MCH-31.6 MCHC-33.8 RDW-12.4 Plt Ct-193
[**2108-1-3**] 01:45AM BLOOD WBC-12.8* RBC-3.30* Hgb-10.6* Hct-30.8*
MCV-93 MCH-32.1* MCHC-34.5 RDW-13.7 Plt Ct-134*
[**2108-1-3**] 10:44AM BLOOD WBC-13.4* RBC-3.49* Hgb-11.4* Hct-32.7*
MCV-94 MCH-32.5* MCHC-34.7 RDW-14.0 Plt Ct-141*
[**2108-1-3**] 08:05PM BLOOD WBC-11.2* RBC-3.31* Hgb-10.7* Hct-30.3*
MCV-92 MCH-32.4* MCHC-35.4* RDW-13.9 Plt Ct-140*
[**2108-1-4**] 05:11AM BLOOD WBC-9.4 RBC-3.21* Hgb-9.9* Hct-29.7*
MCV-93 MCH-30.9 MCHC-33.4 RDW-13.9 Plt Ct-131*
[**2108-1-5**] 08:40AM BLOOD WBC-8.3 RBC-3.36* Hgb-10.4* Hct-32.0*
MCV-95 MCH-31.0 MCHC-32.6 RDW-13.5 Plt Ct-138*
[**2108-1-6**] 07:25AM BLOOD WBC-6.7 RBC-3.03* Hgb-9.6* Hct-28.5*
MCV-94 MCH-31.6 MCHC-33.7 RDW-13.3 Plt Ct-140*
[**2108-1-7**] 08:45AM BLOOD WBC-6.2 RBC-3.30* Hgb-10.5* Hct-31.1*
MCV-94 MCH-31.8 MCHC-33.8 RDW-13.0 Plt Ct-189
[**2108-1-8**] 08:05AM BLOOD WBC-6.0 RBC-3.54* Hgb-11.0* Hct-33.3*
MCV-94 MCH-31.2 MCHC-33.2 RDW-12.9 Plt Ct-233
[**2108-1-9**] 08:00AM BLOOD WBC-6.4 RBC-3.33* Hgb-10.8* Hct-31.8*
MCV-95 MCH-32.4* MCHC-34.0 RDW-12.7 Plt Ct-278
[**2108-1-10**] 06:55AM BLOOD WBC-5.5 RBC-3.50* Hgb-10.9* Hct-33.1*
MCV-95 MCH-31.1 MCHC-32.9 RDW-13.0 Plt Ct-316
.
Coagulation Profile:
[**2108-1-2**] 03:00PM BLOOD PT-13.4 PTT-20.8* INR(PT)-1.1
[**2108-1-3**] 01:45AM BLOOD PT-14.7* PTT-26.8 INR(PT)-1.3*
[**2108-1-3**] 10:44AM BLOOD PT-15.6* PTT-27.9 INR(PT)-1.4*
[**2108-1-4**] 05:11AM BLOOD PT-16.3* PTT-29.6 INR(PT)-1.4*
[**2108-1-4**] 01:48PM BLOOD PT-12.8 PTT-22.0 INR(PT)-1.1
[**2108-1-5**] 08:40AM BLOOD PT-13.1 PTT-26.6 INR(PT)-1.1
[**2108-1-6**] 07:25AM BLOOD PT-13.3 PTT-26.2 INR(PT)-1.1
[**2108-1-7**] 08:45AM BLOOD PT-14.3* PTT-24.2 INR(PT)-1.2*
[**2108-1-8**] 08:05AM BLOOD PT-14.9* PTT-24.4 INR(PT)-1.3*
[**2108-1-9**] 08:00AM BLOOD PT-15.0* PTT-23.5 INR(PT)-1.3*
.
Basic Metabolic Profile:
[**2108-1-2**] 07:59PM BLOOD Glucose-112* UreaN-31* Na-140 K-4.6
Cl-111* HCO3-18* AnGap-16
[**2108-1-3**] 01:45AM BLOOD Glucose-109* UreaN-29* Creat-1.4* Na-143
K-3.9 Cl-112* HCO3-22 AnGap-13
[**2108-1-4**] 05:11AM BLOOD Glucose-104* UreaN-16 Creat-1.2 Na-143
K-3.3 Cl-107 HCO3-28 AnGap-11
[**2108-1-5**] 08:40AM BLOOD Glucose-102* UreaN-19 Creat-1.2 Na-141
K-3.4 Cl-106 HCO3-27 AnGap-11
[**2108-1-6**] 07:25AM BLOOD Glucose-96 UreaN-16 Creat-1.1 Na-142
K-3.5 Cl-108 HCO3-26 AnGap-12
[**2108-1-7**] 08:45AM BLOOD Glucose-112* UreaN-15 Creat-1.0 Na-139
K-3.6 Cl-104 HCO3-25 AnGap-14
[**2108-1-8**] 08:05AM BLOOD Glucose-115* UreaN-15 Creat-1.0 Na-140
K-3.8 Cl-105 HCO3-26 AnGap-13
[**2108-1-9**] 08:00AM BLOOD Glucose-123* UreaN-23* Creat-1.1 Na-141
K-4.1 Cl-105 HCO3-28 AnGap-12
[**2108-1-10**] 06:55AM BLOOD Glucose-98 UreaN-29* Creat-1.1 Na-143
K-4.0 Cl-106 HCO3-30 AnGap-11
[**2108-1-3**] 01:45AM BLOOD Albumin-2.9* Calcium-7.2* Phos-3.4 Mg-1.8
[**2108-1-10**] 06:55AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.2
.
[**2108-1-2**] 03:00PM BLOOD ALT-16 AST-23 AlkPhos-101 TotBili-0.5
[**2108-1-3**] 01:45AM BLOOD ALT-25 AST-63* AlkPhos-74 TotBili-0.8
[**2108-1-4**] 05:11AM BLOOD ALT-25 AST-57* LD(LDH)-215 CK(CPK)-1635*
AlkPhos-74 TotBili-0.3
.
[**2108-1-4**] 01:48PM BLOOD CK(CPK)-[**2003**]*
[**2108-1-5**] 08:40AM BLOOD CK(CPK)-1341*
[**2108-1-6**] 07:25AM BLOOD LD(LDH)-212 CK(CPK)-657*
[**2108-1-7**] 08:45AM BLOOD CK(CPK)-360*
[**2108-1-8**] 08:05AM BLOOD CK(CPK)-171
[**2108-1-10**] 06:55AM BLOOD CK(CPK)-75
.
[**2108-1-5**] 08:40AM BLOOD TSH-1.7
.
[**2108-1-2**] 03:00PM BLOOD ASA-26* Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2108-1-3**] 10:44AM BLOOD ASA-38*
[**2108-1-3**] 02:59PM BLOOD ASA-36*
[**2108-1-3**] 06:06PM BLOOD ASA-31*
[**2108-1-3**] 08:05PM BLOOD ASA-31*
[**2108-1-3**] 11:00PM BLOOD ASA-30*
[**2108-1-4**] 05:11AM BLOOD ASA-19
[**2108-1-4**] 01:48PM BLOOD ASA-11
.
Urine:
[**2108-1-3**] 10:16AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2108-1-2**] 06:40PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2108-1-3**] 10:16AM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2108-1-2**] 06:40PM URINE Blood-LG Nitrite-NEG Protein-75
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2108-1-3**] 10:16AM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
[**2108-1-2**] 06:40PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2 TransE-0-2
[**2108-1-2**] 06:40PM URINE CastHy-[**2-24**]*
[**2108-1-3**] 10:16AM URINE Hours-RANDOM UreaN-268 Creat-23 Na-34
.
[**2108-1-2**] 06:40PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-POS
.
Microbiology:
- Urine culture [**2108-1-3**]: No growth
- Blood culture [**2108-1-3**]: No growth to date
- Sputum culture [**2108-1-3**]:
GRAM STAIN (Final [**2108-1-3**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH OROPHARYNGEAL FLORA.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
- Blood culture [**2108-1-6**]: No growth to date
- Urine culture [**2108-1-7**]: No growth
.
ECG [**2108-1-2**]: Sinus tachycardia. Prominent inferior lead Q waves
raise the consideration of prior inferior myocardial infarction
although are non-diagnostic. Diffuse ST-T wave abnormalities are
non-specific. Clinical correlation is suggested. No previous
tracing available for comparison.
.
ECG [**2108-1-3**]: Sinus rhythm. Early precordial QRS transition.
Modest inferolateral ST-T wave changes. Findings are
non-specific. Since the previous tracing of same date there is
probably no significant change.
.
Chest radiograph [**2108-1-2**]: FINDINGS: The tip of the endotracheal
tube is 4.4 cm from the carina. A nasogastric tube courses
through the esophagus, enters into the stomach, but extends off
the field of view of this image. Lung volumes are low. No focal
consolidations are present. The left costophrenic angle was
excluded from view of this image. The cardiac silhouette, hilar
and mediastinal contours appear normal. The aorta is slightly
tortuous.
IMPRESSION: ET tube in satisfactory position. Lung volumes are
low without
evidence for focal consolidation.
.
CT head without contrast [**2108-1-3**]: FINDINGS: There is no
hemorrhage, Edema, mass effect, or evidence for acute vascular
territorial infarction. [**Doctor Last Name **]-white matter differentiation
appears well preserved. In the region of the left basal ganglia
is a prominent CSF space (2:11). There is moderate mucosal
thickening with air-fluid level within the right maxillary sinus
and bilateral ethmoid air cells. The frontal sinuses, sphenoid
sinuses, and mastoid air cells are clear. Middle ear cavity is
clear. The globes and orbits are intact. There are no fractures.
Rounded hyperdensity along the posterior medial region of the
inferior bony orbit (2:5) on axial images is not substantiated
on coronal reformatted images and likely represents volume
averaging with the orbital bone and inferior rectus.
IMPRESSION:
1. No acute intracranial pathology.
2. Moderate right maxillary and ethmoid sinus opacification.
.
Chest radiography [**2108-1-4**]: FINDINGS: In comparison with the
study of [**1-3**], the endotracheal and nasogastric tubes have been
removed. The right base is now essentially clear, and there is
no convincing evidence of aspiration.
.
Chest radiography [**2108-1-6**]:
IMPRESSION: PA and lateral chest compared to [**1-3**] and 13.
Mild relative congestion in the right lung could be due to early
edema in the site of previous aspiration, but does not suggest
pneumonia. Left lung is clear. Heart size is normal. Tiny left
pleural effusion is seen only on the lateral view. Heart size
normal. No pneumothorax.
Brief Hospital Course:
This is a 68 year old male with a past medical history of
depression who was admitted status post suicide attempt with
overdose ingestion of Seroquel, Paxil, and aspirin. Status post
3 day course in the MICU. Now doing well on the floor and as of
[**2108-1-7**], medically stable for transfer to psychiatric unit for
further management of acute on chronic depression.
.
Suicidal Ingestion: Mr. [**Known lastname 84199**] was admitted after ingesting a
large number of aspirin tablets, Seroquel and Paxil. This was
confirmed by toxicology and EGD. NGT was placed, activated
charcoal administered, and bicarb gtt was started. EKG and ABGs
were followed serially. Made NPO and started on IV pantoprazole.
EGD revealed a large number of intact aspirin tablets in the
antrum of his stomach, which were removed. ASA known to cause
spasm of the pylorus, so gastric emptying may have been slowed.
Erosions had appeared - a likely cause of hematemesis at
presetation. ASA continued to rise early in the admission with a
peak of 38, which fell to 11 prior to transfer to the general
medicine floor. Bicarbonate was given for resulting acidosis. A
marked anion gap was never present. In regards to paxil and
seroquel, patient was monitored closely for extrapyramidal
symptoms and for serotonin syndrome but none were found.
Medically stable for transfer to psychiatric floor.
.
Acute Blood Loss Anemia: Secondary to gastritis from pill
ingestion, as evidenced by EGD. Required 1 unit PRBC
transfusion but hematocrits were measured serially and have been
stable upon reaching the general medicine floor. IV PPI was
initially administered and was transitioned to PO. Lisinopril
and nifedipine was restarted and uptitrated to home dose with
stable blood pressures.
.
Depression and Suicidality: Patient is status post suicide
attempt with overdose of seroquel, paxil, and aspirin. Familial
predisposition may have played some role. He will likely
benefit more from combined therapy and medication.
Anti-depressive/anxiety medications were held in the context of
having received an enormous dose. Was placed on 1:1 sitter.
Consulted by social work and psychiatry teams. Will likely
reinitiate antidepressant treatment upon transfer to psychiatric
unit. Patient is medically stable as of [**2108-1-7**] and will
require transfer to psychiatric inpatient facility for further
management of psychiatric issues.
.
Aspiration Pneumonia: Chemical lung injury suspected on basis of
clear aspiration of blood and stomach contents. Due to question
of pneumonia on chest radiograph, was started on Unasyn and
transitioned to Augmentin in the MICU. Was found to develop low
grade fevers upon reaching the general medicine floor, with
negative culture data. Due to question of drug fever (and
documented allergy to amoxicillin), patient was transitioned to
levaquin. Intermittent low grade fevers are likely secondary to
resolving URI. Medically stable for transfer to psychiatry.
.
Acute Renal Failure: Peaked to high of 1.9. [**Month (only) 116**] be
multifactorial, with urine lytes nondiagnostic. Brief period of
hypotension, aspirin ingestion, and elevation of CK associated
with rhabdomyolysis may have all contributed to kidney damage.
Was given IV hydration with normalization of creatinine.
.
Rhabdomyolysis: Patient found on the floor for unclear duration.
Likely muscle breakdown with CK rising to [**2003**]. CK values at
the time of discharge were within normal limits.
Medications on Admission:
- Paroxetine 40mg QD 30 [**12-14**]
- Seroquel 100mg 2 QHS 60 [**12-14**]
- Citalopram 30mg PO daily
- Ativan 1mg [**Hospital1 **] PRN
- Lisinopril 40mg PO daily
- nifedipine sr 30mg PO daily
- asa 81mg daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain: Do not exceed more than 4grams
daily.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule 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. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Depression
Suicidal Ingestion/ideation
Aspiration pneumonia
Acute renal failure
Hypertension
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 at [**Hospital1 827**]. You were admitted to the hospital after
ingesting paxil, seroquel, and aspirin. You were sent to the
ICU and a tube was placed in your mouth to protect your
breathing. You also were found to have some signs of bleeding,
and required scoping procedures from the gastroenterology
(stomach) doctors which showed [**Name5 (PTitle) 84200**] of your stomach but
no active sources of bleeding. You were given medications to
help clear your ingested pills from your body. You now have a
possible pneumonia in your lungs, but are doing well with
antibiotics. Due to your depression, you are being transferred
to a psychiatric inpatient unit to further monitor your
progress.
.
We have made the following changes to your medications:
- STARTED Protonix 40mg twice a day
- STARTED Senna
- STARTED Colace
- STARTED Acetaminophen 325-650 mg every 6 hours as needed for
pain/fever
- STOP paroxetine
- STOP seroquel
- STOP citalopram
- HOLD aspirin until you see your primary care physician
.
Please seek medical attention should you develop worsening
depression, anxiety, chest pain, shortness of breath, dizziness,
lightheadedness, blood in your stool, or coughing up blood.
Followup Instructions:
Please follow up with the following appointments:
.
Please see your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 3788**] [**Last Name (NamePattern1) **], [**12-24**]
weeks after you are discharged from your psychiatric inpatient
admission. Phone: [**Telephone/Fax (1) 2261**].
.
Please also see your outpatient psychiatrist, Dr. [**First Name (STitle) 24529**] [**Name (STitle) 6051**],
1-2 weeks after you are discharged from your psychiatric
inpatient admission. Phone: [**Telephone/Fax (1) 84201**].
|
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"276.2",
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"E950.3",
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"E950.0",
"518.81",
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icd9cm
|
[
[
[]
]
] |
[
"96.04",
"98.03",
"96.71",
"96.34",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
15108, 15123
|
10656, 14132
|
291, 344
|
15260, 15260
|
2841, 7796
|
16658, 17208
|
2367, 2410
|
14392, 15085
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15144, 15239
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14158, 14369
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15405, 16167
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2425, 2425
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7833, 10633
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16196, 16635
|
232, 253
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372, 1524
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2439, 2822
|
15274, 15381
|
1546, 1606
|
1622, 2351
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,987
| 101,344
|
2821+55414
|
Discharge summary
|
report+addendum
|
Admission Date: [**2146-4-20**] Discharge Date: [**2146-4-27**]
Date of Birth: [**2111-2-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2146-4-20**] redo sternotomy/AVR ( [**Street Address(2) 6158**]. [**Male First Name (un) 923**] mechanical)/repl.
asc. aorta ( 24 mm Gelweave)/ aortic root enlargement
(pericardial patch)/right fem. art. repair
[**2146-4-21**] RLE fasciotomy
History of Present Illness:
35 yo male with prior homograft Bentall procedure done [**5-11**] for
bicuspid AV and ascending aortic aneurysm. This was complicated
by a sternal wound infection. Presented in [**2-18**] with CHF/ DOE.
First evaluated in [**3-21**], and a prior echo revealed prosthetic
AS/ AI. Referred for surgery.
Past Medical History:
prosthetic aortic stenosis/insufficiency s/p redo operation (
see below)
s/p Homograft Bentall procedure [**5-11**]
sternal wound infection [**5-11**]
gastroesophageal reflux disease
hypertension
hemorrhoids
Social History:
He is a civil engineer, having a desk job. He is a never-smoker.
He drank alcohol socially. He denies street drug use.
Family History:
There is no family history of premature coronary artery disease
or sudden death. His aunt had [**Name2 (NI) 499**] cancer and grandmother had
uterine
cancer.
Physical Exam:
5' 10" 160#
HR 105 RR 14 right 106/58 left 102/60
NAD
skin warm, dry
NCAT, PERRL, sclera anicteric, OP benign, teeth in good repair
neck supple, full ROM, no JVD
CTAB, healed sternotomy scar, stable sternum
RRR , [**Last Name (un) 13778**], [**5-16**] blowing holosystolic murmur, [**3-18**] diastolic
murmur, +PVCs
warm, well-perfused, trace edema
alert and oriented x3, nonfocal exam
2+ bil. fem/DP/PT/radials
murmur transmits to bil. carotids
Pertinent Results:
Conclusions
PREBYPASS
1. The left atrium is moderately dilated.
2. Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is borderline normal
(LVEF 45-50%).
3. Right ventricular chamber size and free wall motion are
normal.
4. The ascending aorta tube graft appears abnormal with a
supravalvular obstruction which may represent a kinking of the
aortic root (homograft root) and ascending aortic tube graft
connection. A bioprosthetic aortic valve prosthesis is present.
Motion of the aortic valve prosthesis leaflets/discs is abnormal
with one leaflet prolapsing into the LVOT and the other two
leaflets are calcified and fairly immobile. The prosthetic
aortic valve leaflets are thickened. There is moderate aortic
valve stenosis ?supravalvular(area 1.0-1.2cm2). Moderate to
severe (3+) aortic regurgitation is seen.
5. Mild (1+) mitral regurgitation is seen.
6. There is no pericardial effusion.
7. Dr. [**Last Name (STitle) **] was notified in person of the results
during the surgery on [**2146-4-20**] at 1156
POST-BYPASS:
The patient is in sinus rhythm and on infusions of
phenylephrine, epinephrine 0.03 mcg/kg/min, and vasopressin
3units/hour
1. Biventricular is mildly depressed in the immediate post
bypass period. The function normalized by the end of the surgery
(on vasoactive infusions). Overall LVEF 50 to 55%
2. A new mechanical aortic valve is present is good position
with good leaflet motion and appropriate washing jets. The peak
velocity through the valve is approximately 3 m/s with a peak
gradient of 37 mmHg (C.O 6 l/min]
3. A new aortic tube graft has replaced the previous one and
relieved the supravalvular obstrucion.
4. Mild MR and trivial TR.
5. Intact thoracic aorta.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician
[**2146-4-25**] 07:05AM BLOOD WBC-5.7 RBC-3.39* Hgb-10.2* Hct-29.1*
MCV-86 MCH-30.1 MCHC-35.0 RDW-15.6* Plt Ct-159#
[**2146-4-26**] 06:55AM BLOOD PT-27.2* INR(PT)-2.7*
[**2146-4-25**] 07:05AM BLOOD PT-25.7* INR(PT)-2.5*
[**2146-4-24**] 12:34AM BLOOD PT-19.0* PTT-34.6 INR(PT)-1.8*
[**2146-4-25**] 07:05AM BLOOD Glucose-90 UreaN-11 Creat-0.7 Na-139
K-4.3 Cl-108 HCO3-27 AnGap-8
Brief Hospital Course:
Admitted [**4-20**] and underwent surgery with Dr. [**Last Name (STitle) **]. Please
refer to separate operative note. Extubated the following
morning and suffered a single seizure. Neurology was consulted.
CT of the head revealed no bleed, and multiple old granulomas.
EEG did not reveal evidence for seizure. The patient developed
compartment syndrome of right lower extremity. He was
reintubated for surgical fasciotomy by Dr. [**Last Name (STitle) **] after
right calf swelling noted on POD #1. Extubated again on POD #2.
He awoke neurologically intact without further seizure or
neurological complication. Wound vac was placed to fasciotomy
sites. Chest tubes and pacing wires were discontinued in the
usual fashion without complication. Coumadin was started. He
was gently diuresed toward his preoperative weight. The
physical therapy service was consulted for assistance with
post-operative strength and mobility. The patient noted
difficulty with [**Location (un) 1131**] comprehension, so neurology was
re-consulted. MRI/MRA of the head and neck were performed and
results are pending at the time of discharge. Postop course was
otherwise uneventful and the patient was discharged home with
appropriate follow up instructions as well as VNA services on
POD 5.
Medications on Admission:
ASA 81 mg daily
lisinopril 5 mg daily
lasix 40 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. 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*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
Disp:*7 Tab Sust.Rel. Particle/Crystal(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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: dose
will change daily- to be managed by Dr. [**Last Name (STitle) 13779**] goal INR [**3-15**].
Disp:*30 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
Serial PT/INR
Dx: mechanical aortic valve
Goal INR [**3-15**]
Results to Dr. [**Last Name (STitle) 2204**], fax: [**Telephone/Fax (1) 13780**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
prosthetic aortic stenosis/insufficiency s/p redo operation (
see below)
right lower extremity compartment syndrome
s/p right lower extremity fasciotomies this admission
s/p Homograft Bentall procedure [**5-11**]
sternal wound infection [**5-11**]
gastroesophageal reflux disease
hypertension
hemorrhoids
Discharge Condition:
good
Discharge Instructions:
shower daily and pat incisions dry
no lotions, creams or powders on any incision
call for fever greater than 100, redness, drainage, weight gain
of 2 pounds in 2 days or 5 pounds in a week
no driving for one month
no lifting greater than 10 pounds in 10 weeks
Followup Instructions:
see Dr. [**Last Name (STitle) 2204**] in [**2-11**] weeks
Dr. [**Last Name (STitle) 2204**] will follow coumadin/INR, fax: [**Telephone/Fax (1) 13780**]
(confirmed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **])
see Dr. [**Last Name (STitle) 120**] in [**3-15**] weeks
see Dr. [**Last Name (STitle) **] in 4 weeks
see Dr. [**Last Name (STitle) **] in 2 weeks
please call for all appts.
Completed by:[**2146-4-26**] Name: [**Known lastname 2100**],[**Known firstname **] Unit No: [**Numeric Identifier 2101**]
Admission Date: [**2146-4-20**] Discharge Date: [**2146-4-27**]
Date of Birth: [**2111-2-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 741**]
Addendum:
Neurology recommended obtaining a brain MRI/A to follow-up Mr.
[**Known lastname 2117**] complaint of difficulty [**Location (un) **]. This study demonstrated
multiple regions of cortical DWI lesions suggestive of embolic
disease. ON post-operative day seven he was discharged to home
after his wound VAC was placed.
Major Surgical or Invasive Procedure:
[**2146-4-20**] redo sternotomy/AVR ( [**Street Address(2) 743**]. [**Male First Name (un) 744**] mechanical)/repl.
asc. aorta ( 24 mm Gelweave)/ aortic root enlargement
(pericardial patch)/right fem. art. repair
[**2146-4-21**] RLE calf fasciotomies, medial and lateral
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
Followup Instructions:
see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2118**] in [**2-11**] weeks
Dr. [**Last Name (STitle) 2118**] will follow coumadin/INR for a mechanical aortic
vavle replacement, fax: [**Telephone/Fax (1) 2119**], phone ([**Telephone/Fax (1) 2120**]
(confirmed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **])
f/u with Dr. [**First Name4 (NamePattern1) 2121**] [**Last Name (NamePattern1) 2122**] (neuro) next week [**Telephone/Fax (1) 2123**]
see Dr. [**Last Name (STitle) 2124**] (cardiology) in [**3-15**] weeks
see Dr. [**Last Name (STitle) **] (cardiac surgery) in 4 weeks ([**Telephone/Fax (1) 2125**]
see Dr. [**Last Name (STitle) **] (vascular) in 2 weeks
please call for all appts.
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2146-4-27**]
|
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icd9cm
|
[
[
[]
]
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[
"00.40",
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icd9pcs
|
[
[
[]
]
] |
9086, 9144
|
4258, 5539
|
8789, 9063
|
7325, 7332
|
1907, 4235
|
9167, 10027
|
1261, 1421
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5645, 6895
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6997, 7304
|
5565, 5622
|
7356, 7617
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1436, 1888
|
238, 259
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573, 875
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897, 1107
|
1123, 1245
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,124
| 127,431
|
49811
|
Discharge summary
|
report
|
Admission Date: [**2195-7-15**] Discharge Date: [**2195-7-24**]
Date of Birth: [**2133-2-8**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
Nausea, diarrhea, and abdominal pain.
Major Surgical or Invasive Procedure:
Intubation.
Central venous line placement.
History of Present Illness:
62 yo male with history of ESRD [**2-5**] anti-GBM disease on
peritoneal dialysis, CAD, OA, COPD on chronic steroids and
dementia, who presents with N/V, diarrhea, abdominal pain and
chest pain. His wife reports that at 5pm on [**7-14**], he had the
chills with a temp of 99.1. She reports chronic nonbloody
diarrhea, but today had NBNB emesis and lower abdominal pain.
She drained his abdomen at home. Of note, at baseline, he is
incontinent of urine and stool, and is only able to answer some
questions given his baseline dementia. EMS brought the patient
to ED, on arrival to [**Name (NI) **] pt began experiencing chest pain but
denied SOB. He reportedly has a chronic nonproductive smoker's
cough which was at its baseline.
In the ED, initial vitals were 5 97.8 98 112/59 18 96% ra. The
peritoneal fluid drained and sent off was cloudy. Pressures were
initially in the low 100's and he was given fluids. He then
dropped his pressures to the 80's. Given his bandemia, he was
given empiric vanc/zosyn. He was also noted to be hypoglycemic
with a rising lactate from 4 to 7. He had trouble lying flat and
became tachypneic with persistent cough. CXR with questionable
evidence of pneumonia, so he was intubated without issue with a
glide scope and succinylcholine/etomidate. He has been
intermittently on and off neosynephrine which was chosen as he
was tachycardic. EKG revealed a RBBB which was thought secondary
to demand given elevated trop and neg CKMB. ABG was notable for
a mixed acidosis. Central venous access was attempted at the
right IJ which was complicated by arterial puncture. A CVL was
placed in the left IJ. He was given 50 hydrocort for stress dose
given home steroids. Renal was contact[**Name (NI) **] re: likely peritonitis
from PD catheter, and commented to consider intraperitoneal but
hold for now. Transplant [**Doctor First Name **] recs: Not on transplant list,
removed for non-compliance issues, NPO, IVF, treat bacterial
peritonitis with IV abx, trend lactates to make sure trending
down, ?colitis is mild, should send stool cultures and C.diff.
Most recent vitals prior to transfer: 99.8 113 32 103/52 100% on
AC.
On arrival to the MICU, he is not responsive or following
commands
Past Medical History:
1. ESRD: [**2-5**] anti-GBM disease, on HD since [**3-8**], then PD since
[**9-10**]
-s/p L AV graft: [**7-8**]
2. HTN
3. Chronic low back pain [**2-5**] herniated discs
4. Diastiolic CHF- TTE [**12-10**] EF 75%, LVH
5. Peripheral neuropathy
6. Anemia
7. Depression
8. Type 2 Diabetes
9. Pulmonary HTN
10. TR
11. Rheumatoid arthritis
12. h/o nephrolithiasis
13. s/p cervical laminectomy; ?osteo in past
14. Depression
15. MSSA/E. coli bacteremia ([**3-10**]-infected HD catheter)
16. L4-5 diskitis, osteo, epidural abscess [**12-8**]
17. MRSA cath tip infection
18. MSSA peritonitis [**6-11**]
19. Thyroid nodule on u/s [**6-11**], recommended f/u 1 yr
20. Wheelchair bound due to knee/muscle contraction since had a
PNA and ICU admission in [**2187**]
21. h/o IJ clot
22. Right third digit abscess through the entire finger
including flexor sheath s/p amputation 9/[**2193**].
Social History:
Lives in [**Location 2268**] with wife, who takes care of him at home, she
also takes care of his peritoneal dialysis. He uses a wheel
chair to move around at home which has been more difficult for
him and wife has had difficulties with transfers. Has two sons.
One of his sons lives in [**Name (NI) 3908**] and the other lives in [**Location 86**].
Smokes 1-2 packs per day for the past 40 years. Last drinking 8
years ago. Denies illicits.
Family History:
No family history of high blood pressure or heart attack. Two of
his grandparents, his aunt, and his father had diabetes, but he
is not sure which type. Both his father and mother passed away
from lung cancer. No fam hx of renal disease.
Physical Exam:
Admission:
Vitals: 98.1 104 118/63 29 100% on 440x 28, 5/50%
General: Intubated and sedated
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, pupils not
reactive
Neck: supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB anterolaterally
Abdomen: +BS, soft, tender in LLQ, non-distended, no
organomegaly
GU: +foley
Ext: warm, well perfused, no clubbing, cyanosis or edema,
chronic contractures
Neuro: unresponsive
Discharge: expired.
Pertinent Results:
[**2195-7-14**] 08:30PM BLOOD WBC-4.2 RBC-3.99* Hgb-12.0* Hct-37.9*
MCV-95 MCH-29.9 MCHC-31.6 RDW-14.7 Plt Ct-450*#
[**2195-7-14**] 08:30PM BLOOD Neuts-78* Bands-12* Lymphs-9* Monos-0
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2195-7-14**] 08:30PM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2195-7-14**] 08:30PM BLOOD PT-10.8 PTT-25.4 INR(PT)-1.0
[**2195-7-18**] 12:55AM BLOOD Fibrino-783*
[**2195-7-17**] 10:56PM BLOOD Ret Aut-0.6*
[**2195-7-14**] 08:30PM BLOOD Glucose-63* UreaN-36* Creat-8.0* Na-135
K-3.8 Cl-94* HCO3-21* AnGap-24*
[**2195-7-15**] 08:32AM BLOOD ALT-30 AST-35 CK(CPK)-579* AlkPhos-93
TotBili-0.1
[**2195-7-14**] 08:30PM BLOOD Lipase-14
[**2195-7-14**] 08:30PM BLOOD CK-MB-3
[**2195-7-14**] 08:30PM BLOOD cTropnT-0.32*
[**2195-7-15**] 08:32AM BLOOD CK-MB-13* MB Indx-2.2 cTropnT-0.35*
[**2195-7-15**] 05:52PM BLOOD CK-MB-25* MB Indx-1.7 cTropnT-0.38*
[**2195-7-16**] 03:32AM BLOOD CK-MB-16* MB Indx-1.1 cTropnT-0.40*
[**2195-7-17**] 04:00AM BLOOD CK-MB-10 MB Indx-1.0 cTropnT-0.39*
[**2195-7-14**] 08:30PM BLOOD Calcium-8.3* Phos-3.7 Mg-1.4*
[**2195-7-17**] 10:56PM BLOOD Hapto-234*
[**2195-7-15**] 08:32AM BLOOD Vanco-9.3*
[**2195-7-15**] 12:06AM BLOOD Type-ART Rates-16/ PEEP-5 FiO2-100
pO2-355* pCO2-51* pH-7.18* calTCO2-20* Base XS--9 AADO2-309 REQ
O2-57 -ASSIST/CON Intubat-INTUBATED
[**2195-7-14**] 08:38PM BLOOD Lactate-4.0*
[**2195-7-21**] 03:50AM BLOOD HEPARIN DEPENDENT ANTIBODIES-
[**2195-7-23**] 03:27AM BLOOD WBC-17.7* RBC-2.57* Hgb-7.6* Hct-23.8*
MCV-93 MCH-29.6 MCHC-31.9 RDW-15.5 Plt Ct-127*#
[**2195-7-23**] 03:27AM BLOOD PT-15.1* PTT-76.6* INR(PT)-1.4*
[**2195-7-23**] 03:27AM BLOOD Glucose-215* UreaN-44* Creat-4.5* Na-132*
K-3.1* Cl-97 HCO3-16* AnGap-22*
[**2195-7-23**] 03:27AM BLOOD cTropnT-0.18*
[**2195-7-23**] 03:27AM BLOOD Calcium-7.7* Phos-2.6* Mg-2.1
[**2195-7-23**] 03:27AM BLOOD Vanco-22.3*
[**2195-7-23**] 03:43AM BLOOD Type-ART Temp-36.8 Rates-20/9 Tidal V-500
PEEP-5 FiO2-35 pO2-143* pCO2-32* pH-7.39 calTCO2-20* Base XS--4
-ASSIST/CON Intubat-INTUBATED
[**2195-7-23**] 03:43AM BLOOD Lactate-2.9*
[**2195-7-18**] 10:14AM OTHER BODY FLUID WBC-745* RBC-3* Polys-96*
Lymphs-0 Monos-4*
[**2195-7-14**] 02:13AM ASCITES WBC-101* RBC-94* Polys-0 Lymphs-0
Monos-0
[**2195-7-20**] 01:48PM ASCITES WBC-2111* RBC-278* Polys-98* Lymphs-1*
Monos-1*
Micro:
[**2195-7-14**] 8:40 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT [**2195-7-20**]**
Blood Culture, Routine (Final [**2195-7-20**]):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
[**2195-7-14**] 9:25 pm PERITONEAL FLUID
GRAM STAIN (Final [**2195-7-15**]):
Reported to and read back by [**Female First Name (un) **] [**Doctor Last Name **] @ 00:35A
[**2195-7-15**].
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
FLUID CULTURE (Final [**2195-7-18**]):
STAPH AUREUS COAG +. HEAVY GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
[**2195-7-18**] 10:20 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2195-7-20**]**
C. difficile DNA amplification assay (Final [**2195-7-19**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final [**2195-7-20**]):
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final [**2195-7-20**]): NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final [**2195-7-20**]): NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final [**2195-7-20**]): NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2195-7-19**]):
NO E.COLI 0157:H7 FOUND.
Cryptosporidium/Giardia (DFA) (Final [**2195-7-20**]):
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
[**7-14**] CT Abdomen:
1. Mild wall thickening of the sigmoid colon and rectum could
be related to colitis.
2. Small volume ascites.
3. Chronic fibrotic changes are noted in both lung bases.
4. Gallbladder sludge or small gallstones.
[**7-15**] TTE: The left atrium is mildly dilated. The right atrium is
moderately dilated. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). The
estimated cardiac index is normal (>=2.5L/min/m2). The right
ventricular cavity is dilated with mild global hypokinesis. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
preserved left ventricular systolic function. Dilated right
ventricle. Right ventricular function is mildly depressed.
Moderate tricuspid regurgitation
CTA CHEST:
1. No evidence of pulmonary embolism or acute aortic syndrome.
2. Nearly total collapse of the left lower lobe and parts of
the lingula are increased compared with imaged lung portions on
abdomen CT from one day prior to this exam.
3. Acute dilatation of the heart [**Doctor Last Name 1754**] with an increase of
approximately 3 cm of transverse diameter cmpared with exam
performed one day prior to this exam.
4. Chronic pulmonary fibrotic changes and cavitary lesions are
stable since [**2191**], when it were characterized as changes from
prior MAC infection, although no history of this infection was
found in OMR.
NCHCT: There is no evidence of hemorrhage, edema, mass effect,
or
infarction. If there is significant concern for acute
infarction, MRI is
recommended, if there is no contraindication to MRI.
MRI brain: 1. 3-mm focus of slow diffusion in the white matter
of the right frontal centrum semiovale, without definite
FLAIR-correlate, represents acute infarction, most likely of
embolic origin given the reported history of paroxysmal atrial
fibrillation.
2. Prominent sulci and ventricles, likely age-related global
atrophy.
3. Chronic small vessel ischemic disease, some of which may
represent
previous embolic infarction.
Brief Hospital Course:
62 yo male with history of ESRD [**2-5**] anti-GBM disease on
peritoneal dialysis, CAD, OA, COPD on chronic steroids and
dementia who presented with vomiting and diarrhea found to have
septic shock and respiratory failure likely from bacterial
peritonitis.
# Septic shock: Low grade fevers in the setting of prednisone,
bandemia, hypotension, and tachycardia with a known source -
peritoneal cultures with MSSA. He was started on broad spectrum
antibiotics and ID was consulted. Based on goals of care, PD
catheter not removed and attempted to treat through it with IP
cefazolin. Pressor requirement and lactate trended down, but
then developed increasing pressor requirement and lactate again
later in ICU course. He was also treated for VAP/HCAP with
broad spectrum antibiotics. C. diff and UA negative, was
empirically treated for C. diff with PO Vanco briefly.
Hydrocortisone 100mg Q8H also started and tapered off. Family
meeting was held with wife/HCP after he developed increasing
hemodynamic instability despite maximal treatment and he was
transitioned to a focus on comfort. HD not pursued in accordance
with goals of care and previous difficulty with vascular access.
# Respiratory failure: Most likely a result of volume overload
vs HCAP. Barrier to extubation later in course mostly altered
mental status (see below). He was terminally extubated after
goals of care discussion.
# Altered mental status: Patient non-responsive despite
lightening and stopping sedation while on vent. EEG c/w global
toxic/metabolic encephalopathy. MRI head showed new R frontal
infarct, likely in setting of new AF, though unlikely to explain
AMS entirely. Most likely related to uremia in setting of
inadequate PD vs ICU delirium.
# Tachycardia: Most likely secondary to febrile illness and
sepsis. CTA negative for PE. AF seen on tele with RVR during
this admission, which was new.
# New RBBB: Trops lower than baseline, with flat MB's, trended
up but no further EKG changes, TTE without new WMAs.
# ESRD on PD: Started on PD and renal consult service followed
along, no HD pursued in lines with goals of care, continued
sevelamer, calcitriol, cinacalet. Outpatient nephrologist very
involved and helpful in guiding goals of care discussions.
# CAD: continued aspirin, nifedipine, simvastatin.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from last d/c summ.
1. sevelamer CARBONATE 800 mg PO TID W/MEALS
2. Aspirin 325 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Cinacalcet 30 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Ferrous Sulfate 325 mg PO DAILY
7. Gabapentin 300 mg PO QAM
8. Gabapentin 600 mg PO QHS
9. Hydroxychloroquine Sulfate 200 mg PO BID
10. Ibuprofen 200 mg PO Q8H:PRN pain
11. Methadone 10 mg PO Q6H:PRN pain
Please hold for sedation and RR<12
12. Mirtazapine 30 mg PO HS
13. NIFEdipine CR 90 mg PO DAILY
hold for SBP<100 or HR<60
14. Omeprazole 20 mg PO DAILY
15. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
16. Paroxetine 20 mg PO DAILY
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. PredniSONE 7.5 mg PO DAILY
19. Simvastatin 20 mg PO DAILY
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Sepsis
2. Peritonitis
3. Shock
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
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icd9cm
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[
[
[]
]
] |
[
"96.04",
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icd9pcs
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[
[
[]
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12835, 14240
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16134, 16143
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3554, 3999
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,397
| 167,553
|
10030
|
Discharge summary
|
report
|
Admission Date: [**2177-4-6**] Discharge Date: [**2177-4-26**]
Service: SURGERY
Allergies:
Penicillins / Aspirin / Codeine
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
1. Abdominal pain
2. Constipation
Major Surgical or Invasive Procedure:
[**2177-4-8**]: Exploratory laparotomy and sigmoid colectomy with
colocolostomy.
.
[**2177-4-21**]: Botox injection to anal sphincter.
History of Present Illness:
Patient is a 89 years-old female with history of chronic
constipation present with new [**7-29**] colicky LLQ pain. It woke her
from sleep two nights ago. Her last BM was 2 days ago and was
normal per patient report. She feels like she needs to defecate
or pass flatus but can't. She has had no emesis.
Past Medical History:
1. Hypertension
2. Urge incontinence
3. Osteoporosis
4. Chronic constipation
Social History:
Married. Denies tobacco, EtOH, illicit drugs.
Family History:
Non-contributory
Physical Exam:
On Admission:
VS: T 98.3, HR 93, BP 136/76, RR 16, O2 Sat 99% RA
A&Ox4, NAD
RRR
CTAB
Abd - distended, firm, R subcostal scar, no hernias
Rectal - tight sphincter, no blood
Ext - 1+ edema
On Discharge:
Abdomen: soft, nondistended, low midabdominal incision open to
air and clean/dry and intact
Pertinent Results:
On Admission:
[**2177-4-6**] 04:15PM GLUCOSE-104* UREA N-27* CREAT-0.8 SODIUM-139
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15
[**2177-4-6**] 04:15PM estGFR-Using this
[**2177-4-6**] 04:15PM ALT(SGPT)-12 AST(SGOT)-28 ALK PHOS-54 TOT
BILI-0.2
[**2177-4-6**] 04:15PM CALCIUM-9.8 PHOSPHATE-4.1 MAGNESIUM-2.1
[**2177-4-6**] 04:15PM WBC-10.7 RBC-4.38 HGB-11.9* HCT-36.3 MCV-83
MCH-27.1 MCHC-32.7 RDW-14.1
[**2177-4-6**] 04:15PM NEUTS-81.3* LYMPHS-13.0* MONOS-3.6 EOS-1.4
BASOS-0.7
[**2177-4-6**] 04:15PM PLT COUNT-274
[**2177-4-6**] 04:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2177-4-6**] 04:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2177-4-9**] 07:50AM BLOOD WBC-12.8*# RBC-4.04* Hgb-11.3* Hct-33.4*
MCV-83 MCH-27.9 MCHC-33.8 RDW-14.1 Plt Ct-219
[**2177-4-9**] 07:50AM BLOOD Plt Ct-219
[**2177-4-9**] 07:50AM BLOOD Glucose-87 UreaN-12 Creat-0.5 Na-141
K-4.2 Cl-105 HCO3-26 AnGap-14
.
[**2177-4-6**] CT ABDOMEN W/CONTRAST:
IMPRESSION:
1. Sigmoid volvulus.
2. Intra-hepatic and extra-hepatic biliary ductal dilatation
with an apparent intraluminal lesion within the distal common
bile duct, possibly a stone or mass. Clinical correlation with
LFTs are recommended, and consider ERCP or MRCP for further
evaluation once the patient is clinically stable.
3. Fibroid uterus.
4. Two adjacent 4-mm nodules in the right middle lobe, which are
slightly
larger than on the prior study. One year follow up CT chest is
recommended for further evaluation.
.
[**2177-4-7**] CHEST X-RAY:
IMPRESSION: No acute cardiopulmonary process.
.
[**2177-4-10**] 09:07AM BLOOD WBC-10.8 RBC-3.69* Hgb-10.3* Hct-30.4*
MCV-82 MCH-27.8 MCHC-33.8 RDW-14.2 Plt Ct-206
.
[**2177-4-12**] CHEST XRAY:
No pulmonary edema, no evidence of infection. The extensive
intestinal
distention, seen on the pre-operative radiograph, has not
decreased
.
[**2177-4-8**] Pathology Examination:
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 33550**],[**Known firstname **] [**2087-10-30**] 89 Female [**Numeric Identifier 33551**]
[**Numeric Identifier 33552**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) 2093**] Description by: DR. [**Last Name (STitle) **]. WENSON/dif
SPECIMEN SUBMITTED: sigmoid.
Procedure date Tissue received Report Date Diagnosed
by
[**2177-4-8**] [**2177-4-8**] [**2177-4-14**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7001**]/ttl
Previous biopsies: [**-7/3354**] GI BIOPSIES. (2 JARS)
DIAGNOSIS: Sigmoid colon, segmental resection:
1. Colonic segment with focal, mild submucosal fibrosis,
suggestive of prior injury; no active diverticular disease
identified.
2. No intrinsic mucosal abnormalities otherwise recognized.
3. Regional lymph nodes with no diagnostic abnormalities
recognized.
.
[**2177-4-15**] ABDOMEN X-RAY:
IMPRESSION: 1. Markedly dilated loops of large bowel consistent
with obstruction or ileus.
2. NG tube with side port at the level of GE junction and should
be advanced to ensure side port positioning within the stomach.
.
[**2177-4-15**] CXR:
IMPRESSION:
1. No definite evidence of pneumonia or aspiration pneumonitis.
2. Left PIC catheter with tip now at distal left brachiocephalic
vein.
Advancent by 3-4 cm is recommended.
3. Feeding tube with side port projecting above GE junction,
unchanged.
[**2177-4-18**] EKG:
Sinus tachycardia. Leftward axis. Left bundle-branch block.
Possible biatrial enlargment. Non-specific ST-T wave
abnormalities. Compared to the previous tracing of [**2177-4-14**]
evidence for left atrial abnormality is more suggestive.
Otherwise, there is no diagnostic change.
.
[**2177-4-18**] ABD CT:
IMPRESSION:
1. Multiple dilated loops of small and large bowel consistent
with ileus,
though the degree of distention of large bowel is not
significantly different from multiple prior examinations dating
back to [**2169**]. No evidence of ischemia.
2. New small bilateral pleural effusions.
.
MICROBIOLOGY:
[**2177-4-14**] BLOOD CULTURE-FINAL: No GROWTH.
[**2177-4-14**] SEROLOGY/BLOOD RAPID PLASMA REAGIN
TEST-FINAL: NON-REACTIVE.
[**2177-4-14**] BLOOD CULTURE-FINAL: NO GROWTH.
[**2177-4-14**] URINE URINE CULTURE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE, STAPHYLOCOCCUS, COAGULASE NEGATIVE}:
**FINAL REPORT [**2177-4-18**]**
URINE CULTURE (Final [**2177-4-18**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000
ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000
ORGANISMS/ML..
SECOND MORPHOLOGY.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance Oxacillin RESISTANT Staphylococci MUST be
reported as
also RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- 4 R 4 R
NITROFURANTOIN-------- <=16 S <=16 S
OXACILLIN------------- =>4 R 1 R
TETRACYCLINE---------- <=1 S <=1 S
VANCOMYCIN------------ <=0.5 S <=0.5 S
.
[**2177-4-7**] MRSA SCREEN-FINAL: NEGATIVE.
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation of the aforementioned problem. On [**2177-4-8**], the
patient underwent exploratory laparotomy and sigmoid colectomy
with colocolostomy, 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, on IV fluids, with a foley catheter and Dilaudid PCA for
pain control. The patient was hemodynamically stable.
.
Post-operative pain was initially well controlled with Dilaudid
PCA, which was converted to oral pain medication (Tylenol and
Oxycodone) when tolerating clear liquids. The patient was
started on sips of clears on POD# 1. The foley catheter was
discontinued at midnight of POD# 2. The patient subsequently
voided without problem. [**Name (NI) **] was advanced to clear liquids on
POD# 2, and tolerated well. She did not have bowel movement
since operation, her abdomen became more distended on POD #4.
Patient's diet was changed to NPO except meds. On [**2177-4-13**] she
triggered for decreased urine output as well as nausea/vomiting
and abdominal distention. This was managed with NG tube and IVF
as well as metoclopramide. Foley catheter was placed. Urine
output improved on [**4-14**], patient was given several fluid
boluses and started on continues IVF @ 175 cc/hr. Same day,
patient was evaluated by dietitian, and was started on TPN. Her
IVF was adjusted to 125 cc/hr total (TPN + IVF). Urinalysis and
urine cultures were sent, urinalysis showed elevated WBC. CBC
test also revealed elevated WBC. Patient was started on
Ciprofloxacin IV, Foley catheter was removed, urine culture
revealed infection with staphylococcus organism, patient was
continue on Cipro IV for 3 days total. Starting on [**2177-4-13**] the
patient was noted to have alteration in mental status. Geriatric
consult was called, their recommendations were followed. On
[**4-15**] patient became more agitated, she tried to pull NGT and
IV, became severely delirious. Patient received dose of Haldol
with minimal effect, then physical restraints were utilized,
When patient's condition improved, 1:1 sitter was used for
observation. Same day, patient had several episodes of
asymptomatic SVT, her Lopressor doses were increased to 10 mg
q6h, patient returned to regular rate. NG tube was removed on
POD#7, patient started to pass small amounts of liquid stool.
Neurologically improving, Haldol dose was decreased to 0.25 mg
qhs prn and she no longer rquired a sitter. On POD#8, she had
negative cardiac enzymes from the SVT yesterday. On POD#9, she
became more incontinent of urine, but her mental status improved
markedly. On POD #10, she was comfortable, not in any pain and
had one large and one small loose bowel movements. Had rectal
tube placed with drainage of stool on POD#11. She continued to
have small liqud to no stooling and was given a botox injection
into the rectum via anoscopy. There was 300 mL of liquid stool
drained. She was given a soap suds enema and had brown stool.
She had no abdominal discomfort or any nausea, she was advanced
to a clear liquid diet, which she tolerated well. She was given
a regular, mechanical soft diet for dinner and tolerated a small
amount of it on POD 17.
.
During this hospitalization, the patient was evaluated by
Physical Therapy, they recommended discharge patient in Rehab to
continue PT. Patient 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 regular
diet, ambulating with assistance, voiding without assistance,
and pain was well controlled. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
1. Motrin 200 mg PO prn pain
2. VESIcare 10 mg PO bid
3. Fosamax 70 mg weekly
4. GlycoLax PRN constipation
5. Lisinopril 10 mg PO qday
6. Tolterodone 1 mg PO BID
Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain.
3. Vesicare 10 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
8. 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.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: [**5-8**] mL
Intravenous twice a day: Please flush with 5-10 cc prior to TPN
start and flush with 10-20 cc after TPN is finished, NaCl must
be sterile.
Disp:*500 mL* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Sigmoid volvulus.
2. Dilirium.
3. UTI.
4. Chronic anal fissure and hypertonic internal anal sphincter.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
General 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 [**4-28**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
1. Please call [**Telephone/Fax (1) 133**] to arrange a follow up appointment
with Dr. [**Last Name (STitle) 2472**] (PCP) in [**1-22**] weeks after discharge.
.
2. Please call [**Telephone/Fax (1) 2998**] to arrange a follow up appointment
with Dr. [**First Name (STitle) 2819**] (General Surgery) in [**1-22**] weeks after surgery.
Completed by:[**2177-4-26**]
|
[
"293.0",
"427.89",
"569.49",
"530.81",
"560.39",
"569.2",
"560.1",
"560.2",
"564.09",
"997.4",
"518.0",
"401.9",
"263.0",
"788.31",
"565.0",
"276.50",
"733.00",
"041.11",
"599.0",
"E878.2",
"997.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.76",
"38.93",
"46.85",
"99.15",
"99.57"
] |
icd9pcs
|
[
[
[]
]
] |
12537, 12607
|
7034, 11220
|
271, 408
|
12757, 12757
|
1270, 1270
|
14002, 14367
|
922, 940
|
11433, 12514
|
12628, 12736
|
11246, 11410
|
12940, 12940
|
13565, 13979
|
955, 955
|
1157, 1251
|
12972, 13550
|
198, 233
|
436, 743
|
1284, 7011
|
12772, 12916
|
765, 843
|
859, 906
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,036
| 126,526
|
14505
|
Discharge summary
|
report
|
Admission Date: [**2114-1-12**] Discharge Date: [**2114-2-6**]
Date of Birth: [**2073-12-15**] Sex: M
Service: [**Hospital1 **]/Internal Medicine
This 40-year-old male was transferred from Surgical service
to the Medicine service on [**2114-2-1**]. The care of his
hospitalization prior to this starting on [**2114-1-24**] is
described under Dr.[**Name (NI) 2056**] dictation from the Surgery
service.
Briefly, this is a 40-year-old male with ulcerative colitis,
who is status post proctocolectomy in [**Month (only) 359**] of this past
year and end pouch formation with diverting ileostomy, who is
seen in the Emergency Department earlier last month for
increasing abdominal pain and vomiting. He was found to have
pouchitis, and was ultimately determined to have a small
bowel obstruction, which resolved with lysis of adhesions.
However, the patient became septic and ended up developing
what was felt to be an aspiration pneumonia multilobar. He
was intubated and sedated in the SICU, eventually was
improved and his remaining pulmonary issues, he was
transferred to the Medical service for further management.
Pulmonary consult was obtained as the patient had
parapneumonic effusions bilaterally right greater than left.
A pigtail catheter was placed and drained. The cultures
returned negative on the pleural fluid, and did not appear to
be exudative. He was treated with Levaquin and Flagyl for
his aspiration pneumonia as well as p.o. vancomycin for his
Clostridium difficile enteritis. He also received TPN until
he was able to take adequate p.o. per consult with nutrition.
His strength improved and his oxygenation requirements
lessoned. His pain medication regimen was returned to its
regimen prior to admission for his chronic pain issues.
Patient was encouraged to attend rehab for a few days in
order to ensure that his oxygenation and strengthening were
completely up to par, however, he demanded to be discharged.
He was confident, he was felt safe to do so given the fact
that his wife will also be home with him at the same time.
Today on [**2114-2-6**], the patient will be discharged after
receiving the last of his dose of his IV vancomycin, which
had been added empirically during the acute phase of his
sepsis workup, although no organism was ever isolated for his
pneumonia. His triple lumen catheter, right subclavian line,
as well as staples were taken out prior to his discharge.
CONDITION ON DISCHARGE: He is discharged in stable
condition.
FOLLOW-UP INSTRUCTIONS: He will be followed up by Dr.
[**Last Name (STitle) **] for his surgical issues as well as with Dr.
[**Last Name (STitle) 575**] in Pulmonology Clinic regarding is pigtail drainage
catheter and pneumonia, and also with his primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], who is the primary coordinator of his
pain medication issues.
Specific problems include discharge diagnosis:
1. Aspiration pneumonia, presumed. Patient will finish a
course of p.o. Levaquin and Flagyl at home. He is also
treated with vancomycin intravenously, although no source was
ever identified. He was given incentive spirometry, and
discharged home on nasal cannula oxygen to be continued until
he is followed up by Dr. [**Last Name (STitle) **] within two weeks.
2. Small bowel obstruction. The patient's bowel function
returned to [**Location 213**] and he is taking adequate p.o. intakes by
calorie counts as well as plenty of nutrition. He will
follow up with his surgeon.
3. Sepsis. Combination of an aspiration pneumonia as well as
small bowel obstruction. This has now resolved.
4. Anemia: Patient's hematocrit upon discharge is 25, and
has remained stable for some time. He was given iron and
multivitamins while admitted, and will be discharged as well
on a multivitamin. His abdominal examination has remained
benign and his stools have been without any blood.
5. Clostridium difficile enteritis: Given another seven days
of p.o. vancomycin treatment for this as an outpatient and
also received some Phenergan prophylactically for nausea.
6. Right-sided apical pneumothorax now resolved on most
recent chest x-ray. Likely complication of pigtail catheter.
Patient was given instructions of recurrent pneumothorax and
instructions to return should he experience any of those
symptoms.
7. Seizure disorder: Patient had been well controlled on
Keppra and Trileptal prior to admission and was discharged as
same. He has had no seizures while he has been admitted.
8. Anxiety: He has been on a healthy amount of Xanax prior
to admission as well as Klonopin at night. Patient has other
issues with narcotics regarding chronic pain issues. We did
not address those here, but would rather that they were
addressed in a non-acute setting with other medical problems
complicating this issue.
9. Pain control: Chronic/chronic pain. The patient has a
prior spinal injury from motorcycle/vehicle accident, for
which he is on 80 mg OxyContin t.i.d. with breakthrough
Percocet 10 mg/650 mg of Percocet. He has been on this
regimen for quite some time. Dr. [**Last Name (STitle) **] has tried to
negotiate with the patient in the past regarding his narcotic
use, which may at this time involve dependence. He certainly
exhibited a significant amount of tolerance to medications,
and had frequent requests for pain medication despite being
near sedated at times.
The Acute Pain service has tried to work with him in the
past, but the patient has refused to [**Doctor First Name 8266**] the pharmacy
permission to speak with the Pain service regarding what
medications he is taking and when he is having them refilled
further raising the suspicion of opiate dependence.
10. Nutrition: Patient is discharged on a high-protein diet,
as well as taking 5 Boost Plus a day in order to maintain
adequate nutrition to promote surgical wound healing.
11. Please see Dr.[**Name (NI) 2056**] earlier note regarding other
issues and diagnoses that arose during the prior phase of his
hospitalization.
DISCHARGE MEDICATIONS:
1. Levetiracetam 750 mg b.i.d.
2. Oxcarbazepine 300 mg b.i.d.
3. Clonazepam 2 mg p.o. h.s. prn.
4. Xanax 2 mg p.o. q.i.d. prn.
5. OxyContin 80 mg SR one tablet p.o. t.i.d.
6. Docusate.
7. Levofloxacin 500 mg p.o. q.d. x4 days.
8. Metronidazole 500 mg p.o. t.i.d. for seven days.
9. Percocet 10/650 mg p.o. q.6h. prn breakthrough pain.
10. Phenergan 25 mg p.o. q.6h. prn for vancomycin-associated
nausea.
11. Vancomycin 250 mg tablet p.o. q.i.d. for seven days for
Clostridium difficile enteritis.
12. Multivitamin.
13. Boost Plus five cans t.i.d. for three weeks.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Last Name (NamePattern1) 4791**]
MEDQUIST36
D: [**2114-2-6**] 14:06
T: [**2114-2-6**] 14:03
JOB#: [**Job Number 42853**]
(cclist)
|
[
"008.45",
"512.1",
"E878.2",
"038.9",
"507.0",
"780.39",
"560.81",
"276.8",
"997.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.51",
"45.24",
"34.04",
"34.91",
"99.15",
"54.59",
"54.4"
] |
icd9pcs
|
[
[
[]
]
] |
6081, 6926
|
2944, 6058
|
2527, 2923
|
2463, 2502
|
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