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20,105
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25138
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Discharge summary
|
report
|
Admission Date: [**2136-8-2**] Discharge Date: [**2136-8-23**]
Date of Birth: [**2098-4-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
nausea/vomiting/diarrhea/rash
Major Surgical or Invasive Procedure:
1. Colonoscopy
2. EGD
3. Bone Marrow Biopsy
4. Bronchoalveolar Lavage
5. 2 skin biopsies
History of Present Illness:
HPI: 38 y/o M w/ no PMH who presents with 2 day h/o N/V/D and
rash. He reports the first symptom he noticed was development of
rash on Tuesday, 2 days prior to admission. Rash was initially
pruritic and started in lower legs. Rash then spread up legs to
arm and trunk. No longer pruritis. He then developed nausea,
vomiting and diarrhea over last 48 hours. Denies abdominal pain,
chest pain, palpitations or SOB. No dysuria, hematuria, BRBPR.
He reports that 2 weeks ago he was outdoors in [**State 5887**] when
he was bitten by mosquitos. No known tick bites. No other
environmental exposure. No sick contacts. [**Name (NI) **] exotic food intake.
.
Febrile to 103 on arrival, tachy. Given IVF, CXR w/no clear
evidence of pna. U/A w/ moderate bacteria but no leuks/nitr.
Given Levo 500mg x1, Flagyl 500mg x1 and Doxy 100mg x 1. Blood
cx drawn x 2.
Past Medical History:
h/o syphilis tx w/ pcn per pt
Social History:
Works as financial advisor; lives at home w/ roomate; originally
from [**Country **]- moved to US in [**2116**]; reports being up to date on
vaccinations. sexually active- reports using protection, but
does have h/o syphilis. no h/o other stds; never tested for HIV
"i'm scared to check"
Family History:
NC
Physical Exam:
Physical Exam On Admission:
vitals: T 100.9, HR 118, BP 96/60, 100% RA
gen: warm, non-toxic, anxious but NAD
heent: EOMI. sclera injected, non-icteric, MMM, whitish caking
on tongue- scrapes off; no tonsilar or posterior pharyngeal
exudate; no erythema
neck: supple. full ROM. able to flex neck to chest; large ~2cm
soft, non-tender lymph node in R posterior auricular area; no
ant cervical or supraclavicular lad.
pulm: CTA b/l. no r/r/w
CV: RRR. no m/r/g
ABD: soft, NT/ND. NABS
EXT: no joint tenderness or swelling, no echymoses
SKIN: diffuse erythematous maculopapular rash extending from
feet up legs, sparing groin; involves b/l UE's and coalesced on
trunk as well; back, face and palms spared. no nodules or
pustules. there is a 1 cm rounded excoriative lesion on R ant
shin w/ no active bleeding or pus drainage
Neuro: no meningismus. CN intact. motor fn [**4-5**] b/l
.
Physical Exam On Discharge:
T: 98.7 BP: 98/72 HR: 90s-100s RR: 18 O2: 96% on RA
Gen: Coughing, otherwise in NAD
Skin, warm, dry
HEENT: : painful tongue ulcer remains
Heart: +s1+s2 RRR No murmurs
Lungs: B/L crackles [**12-5**] way up lung fields
Abd: Soft NTND
Extremities: 1+ pretibial edema (down from 3+)
Pertinent Results:
MICRO:
[**Date range (1) 63036**]: Blood, Urine and Stool Cultures Negative
[**2137-8-3**]: TOXOPLASMA IgG ANTIBODY (Final [**2136-8-7**]):
POSITIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA.
27 IU/ML.
Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml.
TOXOPLASMA IgM ANTIBODY (Final [**2136-8-7**]):
NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
A positive IgG result generally indicates past exposure.
Infection with Toxoplasma once contracted remains latent
and may
reactivate when immunity is compromised.
If current infection is suspected, submit follow-up serum
in [**1-5**]
weeks.
.
[**2137-8-3**]: RPR:
RAPID PLASMA REAGIN TEST (Final [**2136-8-6**]):
REACTIVE.
Reference Range: Non-Reactive.
QUANTITATIVE RPR (Final [**2136-8-22**]):
TEST PERFORMED BY STATE LAB.
REACTIVE AT A TITER OF 1:4.
TREPONEMAL ANTIBODY TEST (Final [**2136-8-22**]):
TEST PERFORMED BY STATE LAB.
TP-PA REACTIVE.
ASO Screen (Final [**2136-8-17**]):
< 200 IU/ml PERFORMED BY LATEX AGGLUTINATION.
Reference Range: < 200 IU/ml (Adults and children > 6
years old
.
[**2137-8-3**]:
HIV-1 Viral Load/Ultrasensitive (Final [**2136-8-8**]):
84,400 copies/ml.
.
[**2137-8-4**]: Blood and Urine Cultures: Negative
.
[**2136-8-7**]:
EBV:
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2136-8-9**]): POSITIVE BY
EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2136-8-9**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2136-8-9**]):
NEGATIVE <1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION
.
[**2136-8-7**]:
RUBEOLA ANTIBODY, IgG (Final [**2136-8-8**]):
POSITIVE BY EIA.
A positive IgG result generally indicates past exposure
and/or
immunity.
CRYPTOCOCCAL ANTIGEN (Final [**2136-8-8**]):
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
.
[**Date range (1) 29638**]: Blood and sputum cultures negative. Neg for PCP
.
[**2136-8-10**]: Broncheoalveolar LAvage:
GRAM STAIN (Final [**2136-8-10**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2136-8-12**]): NO GROWTH.
LEGIONELLA CULTURE (Final [**2136-8-20**]):
NO LEGIONELLA ISOLATED.
PAECILOMYCES SPECIES.
POTASSIUM HYDROXIDE PREPARATION (Final [**2136-8-10**]):
NO FUNGAL ELEMENTS SEEN.
IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final
[**2136-8-10**]):
PNEUMOCYSTIS CARINII NOT SEEN.
FUNGAL CULTURE (Final [**2136-8-22**]):
ASPERGILLUS SP. NOT FUMIGATUS, FLAVUS OR [**Country **].
PENICILLIUM SPECIES.
ACID FAST SMEAR (Final [**2136-8-13**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Final [**2136-10-15**]): NO MYCOBACTERIA
ISOLATED.
OVA + PARASITES (Final [**2136-8-10**]):
NO OVA AND PARASITES SEEN.
NO STRONGYLOIDES SEEN.
.
[**2136-8-9**]: HSV anal swab:
[**2136-8-9**] 2:32 pm SWAB Source: Anorectal.
**FINAL REPORT [**2136-8-16**]**
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final [**2136-8-16**]):
HERPES SIMPLEX VIRUS TYPE 2.
CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY.
.
[**2136-8-10**]:
Rapid Respiratory Viral Antigen Test (Final [**2136-8-10**]):
Respiratory viral antigens not detected.
CULTURE CONFIRMATION PENDING.
SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA
A,B AND
RSV.
This kit is not FDA approved for direct detection of
parainfluenza
virus in specimens; interpret parainfluenza results with
caution.
VIRAL CULTURE (Final [**2136-9-7**]): NO VIRUS ISOLATED.
.
[**2136-8-11**]:
CMV Viral Load (Final [**2136-8-14**]):
CMV DNA not detected.
Performed by PCR.
.
[**Date range (1) 63037**]: SPutum, blood cultures negative
.
[**2136-8-15**]: Bone MArrow Biopsy:
FLUID CULTURE (Final [**2136-8-19**]): NO GROWTH.
FUNGAL CULTURE (Final [**2136-9-17**]): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Final [**2136-10-15**]): NO MYCOBACTERIA
ISOLATED.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [**2136-9-14**]):
NO VIRUS ISOLATED.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
[**2136-8-20**]):
NEGATIVE FOR CYTOMEGALOVIRUS EARLY ANTIGEN.
REFER TO CULTURE RESULTS
.
[**8-16**]: Sputum culture: Negative for nocardia
.
[**2136-8-16**]: HBV Viral load:
IMMUNOLOGY
QUANTITATE TO ENDPOINT THE HBV VIRAL LOAD.
**FINAL REPORT [**2136-8-23**]**
HBV Viral Load (Final [**2136-8-23**]):
Greater than 38,000,000 IU/ml.
HBV end-point determination.
Performed by PCR.
.
[**Date range (1) 63038**]: Blood and Stool cultures: NEgative
.
[**8-23**]: Cecal tissue: negative for CMV and AFB
.
IMAGING:
[**2136-8-2**]: CXR:
FINDINGS: The heart size is at the upper limits of normal. The
mediastinal and hilar contours are within normal limits. The
lungs demonstrate no confluent areas of consolidation or
effusion. The osseous structures are within normal limits.
IMPRESSION: No evidence of CHF or pneumonia.
.
[**2136-8-3**]: ECHO:
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses and
cavity size are normal. Regional left ventricular wall motion is
normal.
Overall left ventricular systolic function is low normal (LVEF
50-55%). 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. No
masses or vegetations are seen on the aortic valve. There is no
aortic valve stenosis. The mitral valve appears structurally
normal with trivial mitral regurgitation. No mass or vegetation
is seen on the mitral valve. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
[**2136-8-6**]: CXR
CHEST, PA AND LATERAL: Patchy infiltrates are present in the
left lower lobe and the right lower lobe consistent with
bilateral basal pneumonia. Blunting of both costophrenic angles
is seen on the lateral film.
IMPRESSION: Pneumonia in the right and left lower lobe.
.
[**2136-8-7**]:CT OF THE CHEST WITH CONTRAST: There are small bilateral
pleural effusions, right greater than left. There is a small
amount of pericardial fluid. There are enlarged lymph nodes
within the axillae bilaterally. Some have fatty centers, but at
least one left axillary lymph node measures 13 mm in short axis
dimension. There are numerous small lymph nodes within the
mediastinum and hila as well. There are several nodular
opacities particularly within the left upper lobe posteriorly.
These can be seen on series 2, image 18, 19 and 21. The finding
is concerning for infection, especially given the patient's very
low CD4 count. There is dependent atelectasis at the lung bases,
related to bilateral pleural effusions. The central airways are
patent.
CT OF THE ABDOMEN WITH CONTRAST: The liver, pancreas, and
adrenal glands are normal. There may be some edema of the
gallbladder, and there are several dependent areas of free fluid
within the abdomen, which may be related to third spacing.
Within the spleen, there is a 23-mm hypodense lesion that is
incompletely characterized on this exam. A splenule is also
noted. The kidneys enhance symmetrically. The aorta is of normal
caliber. This stomach is unremarkable. The small bowel loops are
not dilated. There is mesenteric lymphadenopathy, to the left of
the superior mesenteric artery. There is free fluid in the
paracolic gutters.
CT OF THE PELVIS WITH CONTRAST: There is a Foley catheter within
the bladder. There is air within the bladder, which may be
related to instrumentation, but correlation with urinalysis is
requested. The prostate and seminal vesicles are unremarkable,
as is the rectum. There is a small amount of free fluid in the
pelvis. There are enlarged inguinal nodes bilaterally.
BONE WINDOWS: There are no suspicious osteolytic or sclerotic
lesions.
IMPRESSION:
1. Several nodular opacities in the posterior portion of the
left upper lobe, which may be infectious in the etiology. A CT
follow-up after treatment is recommended to ensure resolution.
2. Approximately 2-cm rounded hypodense lesion within the
spleen, of undetermined etiology. There are no prior studies for
comparison. The finding may represent an infectious focus or an
abscess, but a benign process such as hemangioma is also in the
differential diagnosis.
3. Axillary, mediastinal, hilar, mesenteric and inguinal
lymphadenopathy.
4. Small bilateral pleural effusions, pericardial fluid, and
small amount of free fluid in the abdomen and pelvis
.
[**2136-8-10**]: CXR
PORTABLE AP CHEST AT 8:20: Comparison is made to [**2136-11-8**]. Cardiac size is top normal given the technique. There is
improvement in pulmonary vascular engorgement. There is
continued left lower lobe collapse/consolidation and small
bilateral effusions.
.
[**2136-8-14**]:
CT OF THE CHEST WITHOUT CONTRAST: Multiple small adjacent
nodules in the left upper lobe are slightly decreased in size in
the interval. Two less than 5 mm non-calcified nodules in the
right upper lobe are unchanged. In addition, a single nodule in
the left lower lobe, non-calcified and approximately 5 mm is
unchanged as well. There is probable minor fluid in the right
minor fissure. There are bilateral small pleural effusions,
slightly smaller on the right and unchanged on the left. There
is slight interval increase in size to a small pericardial
effusion.
Multiple small axillary lymph nodes are again noted and
unchanged. Several small but non-enlarged mediastinal lymph
nodes, and several right hilar lymph nodes, some of which are
coarsely calcified are again appreciated and unchanged. The
heart and great vessels are unremarkable. Dependent opacities
are noted at the lung bases posteriorly, likely secondary to
compressive effect from effusions and dependent positioning.
Bone windows show no suspicious lesions. A focal area of
irregular hypodensity in the spleen is unchanged.
IMPRESSION:
Slight interval improvement in clustered left upper lobe nodules
and stable appearance to other nodules, likely indicative of an
infectious etiology responding to interval treatment. Additional
possibilities in the abscence of antibiotic therapy would
include vasculitis, nonbacterial infection (fungal or
mycobacteria), or, less likely, a lymphoproliferative process
.
[**2136-8-19**]:
IMPRESSION: AP chest compared to [**8-9**] and [**8-10**]:
Pulmonary edema improved substantially between [**8-9**] and
9th. Bibasilar opacification concerning for bilateral pneumonia
has not cleared subsequently and there is still small volume of
pleural effusion bilaterally. Heart size is top normal
.
SKIN BIOPSY:
[**2136-8-3**]:
SPECIMEN SUBMITTED: SKIN BX, LEFT ARM.
Procedure date Tissue received Report Date Diagnosed
by
[**2136-8-3**] [**2136-8-3**] [**2136-8-8**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 12033**]/jip
DIAGNOSIS:
Skin, left arm, punch biopsy:
Superficial perivascular mixed lympho-histiocytic, eosinophilic,
and neutrophilic infiltrate with rare plasma cells, upper dermal
edema and spongiosis
.
[**2136-8-7**]:
Skin, left medial thigh, punch biopsy:
Superficial and deep dermal perivascular eosinophil-[**Doctor First Name **]
infiltrate with admixed neutrophils and occasional lymphocytes,
upper dermal edema and spongiosis
.
Bone MArrow Biopsy:
Hypercellular panhyperplastic bone marrow with features
characteristic of HIV myelopathy, see note
.
LABS:
CBCs:
[**2136-8-29**] 10:30AM 7.1 3.16* 8.5* 26.7* 85 26.9* 31.8 14.0
490*
[**2136-8-23**] 07:30AM 8.5 3.14* 8.8* 26.3* 84 28.1 33.4 14.0
387
[**2136-8-22**] 08:50AM 10.1 3.14* 8.8* 27.0* 86 28.1 32.7 14.4
384
[**2136-8-21**] 06:25AM 12.8* 3.42* 9.6* 29.7* 87 28.0 32.3 14.5
423
[**2136-8-20**] 06:35AM 11.2* 3.25* 9.1* 28.3* 87 28.0 32.3 14.3
305
[**2136-8-19**] 06:10AM 15.9* 3.40* 9.6* 29.5* 87 28.2 32.4 14.0
315
[**2136-8-18**] 06:20AM 10.8 3.12* 8.9* 26.4* 85 28.4 33.6 14.3
267
[**2136-8-17**] 06:50AM 13.4* 3.28* 9.4* 28.4* 87 28.6 33.0 14.6
233
[**2136-8-16**] 09:50AM 14.6* 3.26* 9.3* 27.8* 85 28.5 33.4 14.7
200
QUANTITATE TO ENDPOINT THE HBV VIRAL LOAD
[**2136-8-15**] 08:00AM 19.0* 3.38* 9.7* 28.8* 85 28.6 33.6 14.6
135*
[**2136-8-14**] 06:50AM 25.8* 3.36* 9.4* 28.5* 85 28.1 33.2 14.3
100*#
[**2136-8-13**] 06:40AM 25.3* 3.27* 9.2* 27.8* 85 28.2 33.1 14.9
62*#
[**2136-8-12**] 06:00AM 27.6* 3.67* 10.5* 31.4* 85 28.5 33.3 14.6
39*
[**2136-8-11**] 06:22AM 26.5* 3.36* 9.6* 28.9* 86 28.7 33.3 14.9
33*
[**2136-8-10**] 06:12AM 28.7* 3.59* 10.3* 31.1* 87 28.8 33.3 14.9
24*
[**2136-8-9**] 04:15AM 24.1* 3.43* 9.7* 28.4* 83 28.3 34.2 14.4
24*
[**2136-8-8**] 02:44PM 27.0* 3.43* 9.8* 28.9* 84 28.7 34.0 14.8
28*
[**2136-8-8**] 05:46AM 28.4* 3.77* 10.5* 32.5* 86 27.9 32.3 14.7
33*
[**2136-8-7**] 06:45AM 19.7* 4.08* 11.8* 34.3* 84 29.0 34.5 14.0
45*
[**2136-8-6**] 06:35AM 13.5* 3.96* 11.4* 32.9* 83 28.7 34.6 13.6
71*1
1 PLT VERIFIED
[**2136-8-5**] 06:45AM 14.0* 4.09* 11.5* 33.6* 82 28.2 34.4 13.1
119*
[**2136-8-4**] 07:20AM 12.5* 4.33* 12.5* 36.7* 85 28.9 34.1 13.4
137*
[**2136-8-3**] 07:10AM 13.7* 4.38* 12.6* 37.4* 85 28.7 33.6 13.0
137*
[**2136-8-2**] 08:45PM 15.3* 4.27* 12.5* 34.6* 81* 29.2 36.1*
12.8 128*
.
[**2136-8-15**] 08:00AM 82* 2 1* 2 9* 0 0 4* 0
[**2136-8-14**] 06:50AM 661 1 4* 1* 22* 0 0 4* 2*
1 TOXIC GRANULATIONS
[**2136-8-12**] 06:00AM 74* 1 1* 2 22* 0 0 0 0
[**2136-8-11**] 06:22AM 68 6* 3* 1* 21* 0 0 0 1*
[**2136-8-10**] 06:12AM 71* 4 2* 3 20* 0 0 0 0
[**2136-8-9**] 04:15AM 59 2 2* 3 32* 0 0 2* 0
[**2136-8-8**] 05:46AM 68 19* 0 0 11* 0 0 2* 0
[**2136-8-6**] 06:35AM 611 21* 0 3 11* 0 0 3* 1*
.
SMA 7:
T LYMPHOCYTE SUBSET WBC [**Last Name (un) **] AbsLym CD3% Abs CD3 CD4% Abs CD4
CD8%
Absolute CD 4: : [**2136-8-7**]: 6
.
Brief Hospital Course:
cc:[**CC Contact Info 63039**]*
HPI: Pt is a 38 yo man w/ recent treatment of syphilis and no
other sig PMH who presented on [**2136-8-2**] to general medical service
w/ fevers to 103, malaise, BUE, BLE, buttock rash with no
palmar/sole involvement. Also compained of copious diarrhea but
no weight loss and "food not passing through his stomach" for
several months with occasional emesis. For full H+P, please see
admit note.
*
Since admission, patient was thought to likely have HIV w/
possible acute seroconversion, given multiple, unprotected
sexual contacts. Superinfection w/ syphilis, viral exanthem, and
ricketsial disease were also entertained. ID service has been
following him as well as the derm service for work up of his
rash/fevers. He has multiple serologies pending, cultures w/o
growth, and his rash was biopsied but did not show evidence for
syphilis. He has been clincally stable, with ongoing mild
hypotension (unsure what his baseline bp's are) and sinus
tachycardia. He has been covered with doxy and ceftriaxone for
empiric ricketsial infections and ?syphilis.
*
Floor team called [**Hospital Unit Name 153**] team with concern for sespis, given
persistent low grade temp, ongoing tachy/low bp as well as
rising wbc to 19.7 w/ 21% bands and concern for sepsis. Patient
had been getting maintenance fluids only since admit up until
this point. He appeared well despite all of above, was given
bolus of 500 cc NS with appropriate BP bump to 100/60. He
remained hemodynamically stable until this evening when he
became hypotensive to 78/50, HR 120's-130's. He rec'd total of
6L of NS today and 2L in last hour with vitals as above. Night
float intern/resident called [**Hospital Unit Name 153**] again for evaluation -
however, patient remained stable. Also of note, DIC panel was
also sent and heme service called today, given droppping
platelets over last days (today = 45). Also of note, echo was
normal during this admission w/o vegetations; normal EF.
*
ID:
Patient was treated with IVFs and was placed on broad spectrum
antibiotic coverage.
His ID course during this hospitalization was intense given
persistently elevated temperatures despite multiple antibiotics,
night sweats, rash, diarrhea, an eosinophilia and BPs in the
90s-100s. An EXTENSIVE workup was done during this admission. In
brief, the main findings in this patient were a CD4 count of 6
and a VL of [**Numeric Identifier 18318**]. He was also found to have an HBV VL of [**Numeric Identifier **]
in his blood stream and thrush via an EGD. These were both new
diagnoses. Multiple other blood, urine and stool cultures were
negative. A large array of viral serologies were also negative.
He had a bone marrow biopsy, skin biopsies and cecal biopsies
which were all negative as well as an EGD (which showed the
thrush). The cecal biopsy and the multiple stool cultures were
sent because of the patient's copious diarrhea during this
admission. He was hydrated vigorously to keep up with his losses
and given immodium with benefit (after C Diff was excluded). By
the time of his discharge, his diarrhea had decreased in
quantity and frequency and his fevers decreased to low grade and
he was afebrile [**Company 5249**] of 98.7 upon discharge. In the end, a
unifying diagnosis was that this was putatively HIV
seroconversion. For the full panel of tests sent, please see the
TESTS section.
.
Follow up for him was arranged with ID for treatment of his HIV
and continued treatment of his HBV.
He was discharged on fluc for his thrush, atovaquone for PCP
[**Name Initial (PRE) 1102**] (did not want bactrim for fear of rash), acyclovir
for HSV. His HBV will be treated along with HIV when he starts
HAART regimen as outpatient.
.
#. rash: The differential for this was large, including viral
exanthems, ricketsial infections, HIV seroconversion, etc.
Biopsy x 2 did not reveal any pathogens. Has h/o syphilis and
treatment. RPR reactive. Felt to be due to HIV seroconversion.
*
#. thrombocytopenia: [**1-4**] sepsis? [**1-4**] HIV? Had not rec'd heparin
here. Had no splenomegaly on exam. DIC w/u with normal
fibrinogen, haptoglobin. Bone marrow biopsy indicated that HIV
myelopathy. HOwever, no other reasons for thrombocytopenia were
found. COuld be explained by his HIV.
*
#. ARF: patient had bump in CR during this admission. Resolves
to 0.5 by time of discharge.
*
#. full code
Follow up with:
- ID - as above
- GI - for diarrhea
Medications on Admission:
None
Discharge Medications:
1. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*10 Tablet(s)* Refills:*1*
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
3. Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) mL PO DAILY
(Daily).
Disp:*300 ml* Refills:*2*
4. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day).
Disp:*180 Capsule(s)* Refills:*2*
5. Fluconazole 100 mg Tablet Sig: Two (2) Tablet PO once a day:
Please take 2 tablets per day until Monday the 26th; then switch
to one tablet per day.
Disp:*40 Tablet(s)* Refills:*2*
6. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea: You can start to decrease the
frequency of this once your stools start to become formed.
Disp:*100 Capsule(s)* Refills:*0*
7. Benadryl 25 mg Capsule Sig: One (1) Capsule PO three times a
day as needed for rash.
8. Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL
Mouthwash Sig: Five (5) mL Mucous membrane three times a day as
needed: Take before meals and as needed.
Disp:*200 ml* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Newly diagnosed HIV
2. Newly diagnosed HBV
3. rash of unknown etiology
4. diarrhea of unknown etiology
5. fevers from unknown source
Discharge Condition:
1. Patient ambulating; edema markedly improved; rash has
resolved. Still intermittently spiking fevers
Discharge Instructions:
1. For your fevers, please alternate between taking tylenol and
ibuprofen(Advil or Motrin). Do not take both at once.
-You can take 1000mg of tylenol every 6 hours.
-You can take 400mg of ibuprofen every 6 hours
.
2. Continue to take the loperamide for your diarrhea.
.
3. Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) 63040**] in the event
that your rash returns.
.
Followup Instructions:
1. Please keep the following appointments:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2136-8-28**] 3:00pm
- For this appointment, please call the clinic on Friday the
23rd or MOnday the 26th to be registered with them.
.
2. Please keep this appointment with the Infectious Diseases
Doctor:
- though it states [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] below, you will also be seen by
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] - whom you known from this hospitalization.
Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2136-8-29**] 9:00
Completed by:[**2137-4-20**]
|
[
"070.30",
"287.5",
"584.9",
"780.6",
"211.3",
"112.84",
"782.1",
"787.91",
"528.2",
"042",
"782.3",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16",
"45.25",
"33.24",
"41.31",
"86.11"
] |
icd9pcs
|
[
[
[]
]
] |
22768, 22774
|
17131, 21558
|
343, 434
|
22954, 23059
|
2919, 17108
|
23541, 24437
|
1688, 1692
|
21613, 22745
|
22795, 22933
|
21584, 21590
|
23083, 23518
|
1707, 1721
|
2613, 2900
|
274, 305
|
462, 1314
|
1735, 2585
|
1336, 1367
|
1383, 1672
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,056
| 138,591
|
50527+59266
|
Discharge summary
|
report+addendum
|
Admission Date: [**2180-2-14**] Discharge Date: [**2180-2-23**]
Date of Birth: [**2113-2-2**] Sex: M
Service: MEDICINE
Allergies:
Hmg-Coa Reductase Inhibitors (Statins)
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
shortness of breath, chest pain
Major Surgical or Invasive Procedure:
Cardiac catherization
History of Present Illness:
Most of history obtained via notes from OSH and cardiology, who
was able to speak with family, as family no longer at bedside
and pt. intubated/sedated. In brief, he is a 67 yo with h/o CAD
s/p CABG, with gradually worsening DOE in last 1-2 months, who
was initially seen at [**Hospital3 1443**] for dyspnea on exertion
with concern for unstable angina and was started on heparin gtt.
While being admitted, he had acute left-sided chest pain,
tachypnea, concurrent with systolic to 200s while getting his
blood drawn, with apparent desaturations, not recorded. At this
point, pt. was intubated, given 140mg IV lasix, nitro gtt with
concern for flash pulmonary edema [**12-18**] acute MI, and transferred
to [**Hospital1 18**] for cath. ABG prior to transfer showed 7.14/58/323
with trop 0.12 in setting of Cr 2.7
.
On arrival to [**Hospital1 18**] ED, SBPs fell to 72/50, so nitro gtt
stopped, with return of SBPs to 140s/150s. ABG on arrival
7.27/45/264, settings unclear. EKG showed TWI in inferior
leads, V6. Initial ABG
7.27/45/264 on unclear settings. CXR here showed good ETT and
OG tube placement, with no acute cardiopulmonary process.
Repeat enzymes here showed trop 0.18 with negative CKs.
.
Of note, pt. had renal artery stent about 4 weeks ago. In
addition, had been off plavix for 3d as he had had some rectal
bleeding from chronic hemmorhoids.
.
On review of symptoms per cards notes and OSH, he denies any
prior history of stroke, TIA, deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, cough, hemoptysis, black stools. + hemmorhoidal bleeding
in last week. He denies recent fevers, chills or rigors. Mild
exertional cramping in legs and throughout body. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for chest pain, dyspnea on
exertion, without paroxysmal nocturnal dyspnea, orthopnea, ankle
edema, palpitations, syncope or presyncope.
.
Past Medical History:
- CAD with 5vCABG in [**2172**]
- MI with PCI [**2172**], PCI in [**5-/2179**] (DES to RCA)
- left renal artery stenosis on [**2180-1-10**], nuclear scan showed 82%
function on R and 16% function on L. 99% stenosis on renal
angiogram with BMS X 1
- CRI ([**2180-1-18**] Cr 2.2)
- HTN
- hemmorhoids
- hypercholesterolemia (LDL 98)
- PVD
- h/o liver lesions
- s/p rectal prolapse repair
- known carotid disease 16-49% stenosis on R, 50-79% on left
- s/p herniorrhaphy
.
Cardiac Risk Factors: Dyslipidemia, Hypertension
.
Cardiac History: CABG, in [**2172**] anatomy as follows: LIMA->LAD,
SVG to PDA, OM1, OM2, and diag.
.
Percutaneous coronary intervention, in [**2177**] anatomy as follows:
total occlusion of native vessels and LIMA, with patent SVG to
diag which backfilled LAD. 40% stenosis in SVG to OM.
.
Social History:
Social history is significant for current tobacco use (52 pack
year smoking history). There is no history of alcohol abuse.
Family history was not elicited
Physical Exam:
VS: T 98.0, BP 149/67, HR 68, RR 18, O2 100% on
Gen: middle aged male intubated, sedated
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with no JVD.
CV: PMI wnl RRR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. mild
upper airway sounds, No crackles, wheezes, rhonchi.
Abd: soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Neuro: PERRL, EOMI, + gag, + corneal, moves all 4 ext.
spontaneously, as well as with stimulation.
Pertinent Results:
CXR here: Lungs Clear, satisfactory positioning of lines and
tubes.
.
CTA Chest:
1. No PE.
2. No overt CHF.
3. Dependent atelectasis and pleural effusions bilaterally.
4. Emphysema.
5. Evidence of old granulomatous disease.
6. Coronary artery disease.
.
EKG demonstrated sinus brady at 53 with peaked Ts in v2-v4, TWI
in inferior leads, V6, with sl. deeper TWIs in inferior leads
compared with prior dated [**12-24**].
.
Cardiac Catheterization [**2180-2-18**]
1. The native coronary circulation was not engaged due to known
proximal
occlusion and need to conserve contrast use in light of severe
renal
insufficiency.
2. The arterial conduit (LIMA) was not engaged as it is known to
be
atretic per recent cath.
3. Selective coronary angiography of the 4 vein grafts revealed
occlude
RSVG-dRCA and RSVG-OM1. The RSVG-D1 and the RSVG-OM2 were
patent. The
RSVG-OM2 had moderate disease throughout similar to the findings
of the
cardiac catheterization from 7/[**2178**].
4. Limited resting hemodynamic assessment revealed normal
systemic
arterial pressure (127/65 mmHg) and borderline elevated
pulmonary
arterial pressure (27/12 mmHg). The left- and right-sided
filling
pressures were normal (mean PCWP 9 mmHg and RVEDP 8 mmHg). The
cardiac
output and cardiac index were normal at 5.7 l/min and 3.5
l/min/m2
respectively.
5. Left ventriculography was deferred due to renal
insufficiency.
FINAL DIAGNOSIS:
1. Known severe obstructive three vessel coronary artery
disease. The
native coronary arteries were not engaged.
2. Ocluded RSVG-OM1 and RSVG-RCA.
3. Patent RSVG-OM2 and RSVG-D1.
4. The LIMA was not engaged as it is known to be atretic.
5. Normal left and right ventricular filling pressures.
6. Left ventriculography was deferred.
.
RENAL U.S. [**2180-2-21**] 2:45 PM
FINDINGS: The right kidney measures 9.5 cm. Normal color
vascularity is seen throughout the right kidney. The left kidney
measures 7.9 cm. A simple cyst measuring 1.6 x 0.8 cm is seen in
the interpolar region of the left kidney. Normal color
vascularity is seen throughout the left kidney. In the main
renal artery, peak systolic velocity is 40 cm/sec with sharp
systolic upstroke. Normal waveforms are visualized in the left
renal vein.
IMPRESSION:
1. Normal waveform in the left renal artery. In comparison with
the examination of [**2180-2-15**], the left renal artery is
better visualized but probably not significantly changed.
2. Left renal cyst.
.
CHEST (PRE-OP PA & LAT) [**2180-2-22**] 6:14 PM
FINDINGS: PA and lateral views of the chest. The patient is
status post median sternotomy, sternotomy wires are unchanged.
Mediastinal surgical clips are again noted. The
cardiomediastinal silhouette is unchanged. There is no
pneumothorax, consolidation, or pleural effusion. The pulmonary
vasculature is normal. The osseous structures are unchanged.
IMPRESSION: No acute cardiopulmonary process.
.
Carotid U/S [**2180-2-23**]: pending as of this discharge summary.
.
Labs:
[**2180-2-14**] 10:21PM TYPE-ART PO2-264* PCO2-45 PH-7.27* TOTAL
CO2-22 BASE XS--5 INTUBATED-INTUBATED
[**2180-2-14**] 09:20PM GLUCOSE-167* UREA N-38* CREAT-2.8* SODIUM-142
POTASSIUM-5.9* CHLORIDE-113* TOTAL CO2-19* ANION GAP-16
[**2180-2-14**] 09:20PM ALT(SGPT)-15 AST(SGOT)-21 CK(CPK)-55 ALK
PHOS-95 AMYLASE-67 TOT BILI-0.1
[**2180-2-14**] 09:20PM LIPASE-22
[**2180-2-14**] 09:20PM CK-MB-NotDone
[**2180-2-14**] 09:20PM cTropnT-0.18*
[**2180-2-14**] 09:20PM ALBUMIN-3.7 CALCIUM-8.4 PHOSPHATE-4.8*
MAGNESIUM-2.1
[**2180-2-14**] 09:20PM WBC-14.8* RBC-3.56* HGB-10.7* HCT-32.7*
MCV-92 MCH-30.1 MCHC-32.7 RDW-14.9
[**2180-2-14**] 09:20PM NEUTS-92.2* BANDS-0 LYMPHS-4.5* MONOS-2.4
EOS-0.8 BASOS-0.1
[**2180-2-14**] 09:20PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL
POLYCHROM-OCCASIONAL
[**2180-2-14**] 09:20PM PLT COUNT-239
[**2180-2-14**] 09:20PM PT-14.0* PTT-93.9* INR(PT)-1.2*
Brief Hospital Course:
67yo man with CAD s/p CABG and stent to graft in [**5-22**], renal
artery stenosis and atrophic left kidney s/p stenting, HTN, CRI
who presented with chronic dyspnea with acute decompensation
likely secondary to decompensated acute pulmonary edema. Had
cardiac cath showing complete occlution of two of his grafts
(OM2, RCA) and tight lesion in OM1.
.
#. Dyspnea - Unclear etiology, but possible etiologies include
decreased function from ischemia with finding of 2 occluded
prior grafts and only patient graft in SVG to diag with known
occlusion of all native vessels. Also could be [**12-18**] to HTN from
renal artery stenosis in this patient with stent to atrophic
left kidney. Patient with finding of new MR [**First Name (Titles) **] [**Last Name (Titles) **] without
compromise of right heart pressures on cath.
CT surgery was consulted and plans to see him as an outpatient
for possible CABG and valve replacement. He has an appointment
on [**2180-3-2**] for continued pre-op workup.
.
# acute on chronic systolic and diastolic CHF.
[**Date Range **] showed new MR as well as impaired relaxation. EF was more
impaired than would be expected with MR [**First Name (Titles) 13225**] [**Last Name (Titles) 5660**]
poor systolic dysfunction.
See above regarding dyspnea and MR. [**Name13 (STitle) **] is not on an
ACE-inhibitor currently given element of acute renal failure.
He should discuss initiating ACE-inhibitor with nephrologist
once acute element of renal failure has resolved.
.
# Rhythm: continued in NSR.
.
# CAD: Patient with 2 patent grafts on cardiac cath but one at
significant risk for graft failure. History is notable for
short patency of patient's CABG (7 years). Patient is a current
smoker which may have contributed, and has not tolerated
statins. His lipids were fairly well-controlled when checked
here even without statin. Tricor was started for elevated
triglycerides. Patient was counseled on importance of smoking
cessation and expressed a strong interest in quitting.
continued aspirin, plavix, and metoprolol. It is unclear if
muscle pain is truly statin myopathy however LDL is fairly
well-controlled and patient absolutely refuses to be on statin
medications.
.
#Anxiety
patient intermittently diaphoretic, anxious. He feels anxiety
contributes to his dyspnea as he gets diaphoretic before he has
an event. He finds that benzodiazepines help calm him down. He
was therefore given klonopin. EKG during diaphoretic spell did
not show any changes.
.
# acute on chronic renal insufficiency: Cr 2.6. BL 2.0-2.2 based
on older [**Hospital1 336**] records, now elevated above baseline but starting
to trend down (2.9 on admission). Once extubated patient
reported baseline may be closer to 2.6. Patient with known L
atrophic kidney with stenting for renal artery stenosis. Some
consideration was given to whether stent thrombosis could
explain atrophic kidney and hypertension. On review of old
records it seems that kidney was atrophic even prior to stenting
so this may not be a change. Also, renal artery stenosis cannot
fully explain elevated creatinine as he should still have normal
creatinine with a single kidney. Given CKD, cardiac
catheterization was performed with only a minimal amount of
intravenous contrast. Renal ultrasound showed left kidney 7.9
cm as above. His creatinine on discharge was 2.8 after peaking
at 3 post cath dye load. He had instructions and a prescription
to get BUN, Cr, and potassium checked on [**2180-2-29**].
.
# HTN: BP well controlled on home toprol and nifedipine CR.
.
#. h/o myalgias - Patient with history of myalgias, even
unrelated to statin intolerance. ESR elevated at 80.
Rheumatology saw him and believed the presentation to be
consistent with PVD, the he also has upper extremity
pain/weakness. ESR was considered of uncertain significance.
.
# chronic anemia - Patient with low Fe and ferritin on Fe
studies. No evidence of bleeding/bruising. This may be in part
due to his kidney disease +/- iron deficiency. He was on FeSO4
as an outpatient and was discharged on his home regimen.
.
# FEN: Cardiac diet
.
# Prophylaxis: heparin SC initially ordered but patient refused.
He was encouraged to ambulate to prevent DVT.
.
# Code: FULL CODE
.
# Communication: wife [**Name (NI) **] (?[**Telephone/Fax (1) 105220**]
Medications on Admission:
- ASA 325
- plavix 75 (not taking X 3d [**12-18**] bloody stool)
- toprol 100 qdaily
- nifedical 30 qdaily
- FeSo4 325 qdaily
- alprazolam
Discharge Medications:
1. Outpatient Lab Work
You will need your BUN, Creatinine, and potassium checked on
Tuesday, [**2-29**]. Please fax results to Dr. [**Last Name (STitle) **] at
[**Hospital1 18**]. Fax: ([**Telephone/Fax (1) 15187**]. Phone: ([**Telephone/Fax (1) 1504**], and Dr.
[**First Name (STitle) 3236**] Office Fax: ([**Telephone/Fax (1) 105221**], phone: ([**Telephone/Fax (1) 5687**]
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
6. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
7. Alprazolam Oral
8. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO QD
().
Disp:*30 Tablet(s)* Refills:*2*
9. 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*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute decompensated systolic congestive heart failure
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with worsening of your shortness of breath and
developed chest pain, low blood pressure, and difficulty
breathing requiring intubation. You had a cardiac
catheterization and two of your previous heart vessel grafts
were found to be blocked. You were optimized on your medical
therapy. CT surgery saw you and is planning to see you as an
outpatient as below. It is imperative that you follow-up with
them.
.
You will need to stop your plavix before your surgery. The CT
surgeons will tell you when to do so.
.
Please take your medications as prescribed.
.
Please follow-up as below.
.
You will need to have your BUN and Creatinine checked on Tuesday
[**2-29**]. These results should be reported to Dr.[**Name (NI) 5572**]
office by fax. You will have a prescription that you can take
to your usual lab.
.
You should call your primary care provider/cardiologist or
return to the emergency department if you experience shortness
of breath, chest pain, loss of consciousness, weakness, or any
other symptoms that concern you.
Followup Instructions:
Please call your cardiologist and primary care physician to make
an appointment within 1-2 weeks of discharge from the hospital.
([**Last Name (LF) 3236**], [**First Name3 (LF) 5987**] ([**Telephone/Fax (1) 68758**] in [**Location (un) 29789**])
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD (Cardiac Surgery)
Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2180-3-2**] 3:30
Name: [**Known lastname 17132**],[**Known firstname 33**] Unit No: [**Numeric Identifier 17133**]
Admission Date: [**2180-2-14**] Discharge Date: [**2180-2-23**]
Date of Birth: [**2113-2-2**] Sex: M
Service: MEDICINE
Allergies:
Hmg-Coa Reductase Inhibitors (Statins)
Attending:[**First Name3 (LF) 6568**]
Addendum:
Per Rheum note (see OMR note for full details):
?????? ABI testing would likely help determine the severity of PVD if
this has not already been done.
?????? Would suggest out patient Rheum follow up if he develops any
new symptoms that would suggest PMR or GCA.
.
Suggest primary team look for other causes of elevated ESR if
warranted (although he does have significant cardiac disease).
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3518**] MD [**MD Number(1) 3519**]
Completed by:[**2180-2-23**]
|
[
"300.00",
"414.02",
"414.01",
"305.1",
"584.9",
"492.8",
"424.0",
"272.0",
"518.81",
"403.90",
"285.21",
"428.43",
"585.9",
"440.1",
"443.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"88.57",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
16251, 16414
|
8086, 12407
|
329, 353
|
13973, 13982
|
4159, 5544
|
15074, 16228
|
12596, 13846
|
13896, 13952
|
12433, 12573
|
5561, 8063
|
14006, 15051
|
3365, 4140
|
258, 291
|
381, 2339
|
2361, 3177
|
3193, 3350
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,892
| 156,142
|
17389
|
Discharge summary
|
report
|
Admission Date: [**2154-5-9**] Discharge Date: [**2154-5-13**]
Date of Birth: [**2124-8-1**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 48638**]
Chief Complaint:
spontaneous rupture of membranes at 41w2d gestation
Major Surgical or Invasive Procedure:
s/p NVD, s/p D&C, s/p TAH
History of Present Illness:
29yo G3P1011 @ 41w2d presents to labor and delivery with SROM
3hours ago with clear fluid. No painful ctx, no vag bleed, good
FM.
Past Medical History:
PMH: alpha thalassemia trait
PSH: Denies
POBH:
- [**2150**] FT SVD 7#7oz, c/b PPH secondary to atony s/p cytotec,
PIT, 2u PRBC transfusion
PGYNH: no abnl pap, no STIs
Social History:
No T/E/D
Physical Exam:
97.6 75 118/69
NAD
RRR/CTAB
soft, gravid, NT
lower ext NT/NE b/l
FHT: 130s/mod variability/+accels/some early decel
Toco: q3min
SVE: [**4-/2127**]/-1
Pertinent Results:
[**2154-5-9**] 05:47AM BLOOD WBC-8.4 RBC-4.54 Hgb-10.7* Hct-31.1*
MCV-69* MCH-23.5*# MCHC-34.3# RDW-15.9* Plt Ct-258
[**2154-5-9**] 04:01PM BLOOD WBC-16.1*# RBC-3.25*# Hgb-7.4*#
Hct-23.2*# MCV-72* MCH-22.8* MCHC-31.9 RDW-16.3* Plt Ct-198
[**2154-5-9**] 04:01PM BLOOD WBC-20.0*# RBC-3.61* Hgb-8.8* Hct-26.8*
MCV-74* MCH-24.4* MCHC-32.8 RDW-16.8* Plt Ct-181
[**2154-5-9**] 07:22PM BLOOD WBC-10.8 RBC-3.21* Hgb-9.1* Hct-24.7*
MCV-77* MCH-28.3# MCHC-36.7*# RDW-17.0* Plt Ct-155
[**2154-5-9**] 11:25PM BLOOD WBC-7.9 RBC-2.25*# Hgb-6.3*# Hct-17.1*#
MCV-76* MCH-27.9 MCHC-36.8* RDW-17.1* Plt Ct-123*
[**2154-5-10**] 05:16AM BLOOD WBC-8.9 RBC-3.02*# Hgb-8.9*# Hct-24.4*#
MCV-81* MCH-29.6 MCHC-36.6* RDW-17.4* Plt Ct-132*
[**2154-5-10**] 09:37AM BLOOD WBC-8.2 RBC-2.94* Hgb-8.7* Hct-23.7*
MCV-80* MCH-29.6 MCHC-36.8* RDW-17.4* Plt Ct-123*
[**2154-5-10**] 01:42PM BLOOD WBC-9.4 RBC-2.96* Hgb-8.7* Hct-24.1*
MCV-82 MCH-29.6 MCHC-36.2* RDW-17.6* Plt Ct-132*
[**2154-5-10**] 05:33PM BLOOD Hct-25.2*
[**2154-5-11**] 05:45AM BLOOD WBC-10.8 RBC-3.01* Hgb-8.9* Hct-24.6*
MCV-82 MCH-29.7 MCHC-36.4* RDW-17.7* Plt Ct-163
[**2154-5-9**] 03:40PM BLOOD PT-10.5 PTT-25.5 INR(PT)-0.9
[**2154-5-9**] 07:22PM BLOOD PT-12.8 PTT-30.7 INR(PT)-1.1
[**2154-5-9**] 11:25PM BLOOD PT-12.6 PTT-30.0 INR(PT)-1.1
[**2154-5-10**] 05:16AM BLOOD PT-11.7 PTT-30.5 INR(PT)-1.0
[**2154-5-10**] 09:37AM BLOOD PT-11.8 PTT-30.1 INR(PT)-1.0
[**2154-5-10**] 01:42PM BLOOD PT-11.5 PTT-29.1 INR(PT)-1.0
[**2154-5-9**] 03:40PM BLOOD Fibrino-288
[**2154-5-9**] 07:22PM BLOOD Fibrino-185
[**2154-5-9**] 11:25PM BLOOD Fibrino-183
[**2154-5-10**] 05:16AM BLOOD Fibrino-321#
[**2154-5-10**] 09:37AM BLOOD Fibrino-353
[**2154-5-10**] 01:42PM BLOOD Fibrino-403*
[**2154-5-9**] 07:22PM BLOOD Glucose-112* UreaN-6 Creat-0.4 Na-134
K-3.7 Cl-102 HCO3-24 AnGap-12
[**2154-5-10**] 05:16AM BLOOD Glucose-77 UreaN-4* Creat-0.4 Na-137
K-3.8 Cl-103 HCO3-28 AnGap-10
[**2154-5-10**] 05:16AM BLOOD ALT-12 AST-30 LD(LDH)-138 AlkPhos-63
TotBili-1.1
[**2154-5-9**] 07:22PM BLOOD Calcium-9.7 Phos-4.0 Mg-1.4*
[**2154-5-10**] 05:16AM BLOOD Calcium-8.1* Phos-4.2 Mg-2.2
[**2154-5-10**] 05:16AM BLOOD Hapto-63
[**2154-5-9**] 03:56PM BLOOD Type-ART pO2-101 pCO2-42 pH-7.35
calTCO2-24 Base XS--2 Intubat-NOT INTUBA
[**2154-5-9**] 04:19PM BLOOD Type-ART pO2-201* pCO2-32* pH-7.39
calTCO2-20* Base XS--4
[**2154-5-9**] 04:41PM BLOOD Type-ART pO2-158* pCO2-32* pH-7.38
calTCO2-20* Base XS--4 Intubat-INTUBATED
[**2154-5-9**] 05:22PM BLOOD Type-ART pO2-161* pCO2-41 pH-7.35
calTCO2-24 Base XS--2
[**2154-5-9**] 05:54PM BLOOD Type-ART pO2-162* pCO2-40 pH-7.37
calTCO2-24 Base XS--1
[**2154-5-9**] 03:56PM BLOOD Lactate-3.8*
[**2154-5-9**] 04:19PM BLOOD Glucose-94 Lactate-5.1* Na-132* K-4.1
Cl-109
[**2154-5-9**] 04:41PM BLOOD Glucose-78 Lactate-4.1* Na-133* K-4.1
Cl-111
[**2154-5-9**] 05:22PM BLOOD Glucose-84 Lactate-4.7* Na-133* K-3.7
Cl-113*
[**2154-5-9**] 05:54PM BLOOD Glucose-110* Lactate-4.3* Na-134* K-3.9
Cl-108 calHCO3-22
Brief Hospital Course:
Pt was admitted to the labor and delivery [**Hospital1 **] for ruptured
membranes and in active labor. Pt was initially managed per
expectant managment, but was started on oxytocin per protocol as
her contractions started to space out and was making only
minimal cervical change. Upon active management of labor, pt
delivered by normal vaginal delivery a live viable male infant.
Following spontaneous vaginal delivery, patient continued to
have vaginal bleeding. Pt was noted to have postpartum
hemorrhage of approximately 1 liter in the delivery room. Pt
received multiple uterotonics serially, including methergine
0.2mg IM x2, hemabate x2, cytotec 1000mcg x1 PR. Patient was
then brought back to the OR for exam under anesthesia. Steady
bleeding was noted. U/S guided sharp and suction endometrial
curettage were performed with small fragments of possible tissue
and large amounts of clot retrieved. Labs were sent on arrival
to the OR, including coagulation studies. Hct returned at 23;
transfusion was begun. No vaginal nor cervical laceration
noted. Pt remained hemodynamically stable throughout but had
lost approximately 2500cc. OB hemorrhage protocol was
initiated. Decision was made to proceed with laparotomy with
likely hysterectomy, given lower uterine segment with
considerable atony despite efforts thus far.
The details of the procedure are available elsewhere in a
separate operative report. Briefly, total abdominal
hysterectomy was performed under GETA for significantly atonic
lower uterine segment and postpartum hemorrhage without
complications. Total blood loss was approximately 4500cc. Pt
received 4units of PRBC, 4bags of FFP and 10units
cryoprecipitate. The uterus/cervix were sent as specimens. Pt
was transferred to the ICU for close hemodynamic observation.
While in ICU, there was no longer any evidence of bleeding. Pt
remained with 2 large borse IVs and q4h cbc, coags, and
fibrinogen were checked and noted to all be stable. Pt was
transferred to regular postpartum floor on POD#1.
The rest of her postpartum/postoperative course remained
uncomplicated. Pt was discharged on POD#4 in good condition:
afebrile, stable vitals, tolerating po, ambulant and with pain
controlled. Pt was advised to follow up later in the week at
her primary OB's office.
Medications on Admission:
Denies
Discharge Medications:
1. Breast Pump Device Sig: One (1) Miscellaneous every four
(4) hours.
Disp:*1 pump* Refills:*0*
2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*50 Tablet(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q3-4H (Every 3 to 4 Hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*60 Capsule(s)* Refills:*2*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
three times a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p svd, complicated by postpartum hemorrhage/uterine atony
requiring D&C and total abdominal hysterectomy as well as
multiple blood products
blood loss anemia
Discharge Condition:
stable
Discharge Instructions:
see nursing sheets
Followup Instructions:
follow up at [**Hospital3 **] on Thursday [**5-16**] for staple removal
Completed by:[**2154-5-14**]
|
[
"285.1",
"V27.0",
"648.22",
"338.18",
"663.31",
"282.49",
"666.12",
"645.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"68.49",
"99.07",
"69.02",
"73.59",
"73.6",
"99.06"
] |
icd9pcs
|
[
[
[]
]
] |
6922, 6928
|
3944, 6255
|
379, 407
|
7132, 7141
|
970, 3921
|
7208, 7311
|
6312, 6899
|
6949, 7111
|
6281, 6289
|
7165, 7185
|
798, 951
|
288, 341
|
435, 567
|
589, 757
|
773, 783
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,228
| 181,455
|
53363
|
Discharge summary
|
report
|
Admission Date: [**2188-5-7**] Discharge Date: [**2188-5-14**]
Date of Birth: [**2143-9-20**] Sex: M
Service: MEDICINE
Allergies:
Levoxyl
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Low blood pressure
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
44 y/o male with PMH of ESRD, gastric bypass, hx of bilateral
DVTs and orthostatic hypotension presented to OSH with
chronically low albumin after his gastric bypass found on
routine labs at dialysis. At [**Hospital1 **] [**Location (un) 620**], patient was found to
have systolic blood pressure of 75. Patient was transferred to
[**Hospital1 18**] for further evaluation.
.
In the ED, VS: T98.6 HR 88 BP 79/50 RR 16 97%on NC ?L. Received
500cc NS bolus x 3, zofran for nausea, midodrine 10mg x 1.
Patient was mentating well despite hypotension. He denied any
symptoms with the exception of occasional nausea. A right
femoral line was placed and patient was started on dopamine.
Prior to transfer, he developed hypoxia, O2sat 70's per report
though no note in chart, and dropped his BP to sys 50s despite
pressors. ECG was notable for sinus tachycardia without other
changes. Patient said he could feel his heart "pounding" since
starting the dopamine. He was sent for CTA that was negative for
PE but did note large bilateral effusions. Patient was sent to
the floor for further BP monitoring and pressors as needed.
.
Of note patient has been hypotensive at dialysis limiting his
fluid removal. Per report, his weight is up 5kg. He does endorse
history of syncope secondary to low BP. Patient was recently
evaluated on [**4-30**] by neurology and was diagnosis with
orthostatic hypotension. He was started on midodrine and
directed to minimize period of time that he is supine along with
taking salt tabs. Patient does not believe he started salt tabs.
Has been eating only [**11-21**] bowls of wonton soup daily. Patient
spends most of his time lying in bed. Has had surgical
complications since gastric bypass in [**Month (only) 1096**]. At one point,
comatose for 3 weeks. Since then, minimal activity.
.
ROS: Denies fevers, chills, weakness, chest pain, shortness of
breath, abdominal pain
Past Medical History:
IDDM ?????? diagnosed at 27 years age; complicated by end-organ
failure
s/p Gastric bypass [**10/2187**]
Bilateral DVTs dx in [**1-/2188**]
Chronic renal insufficiency on HD
s/p parathyroidectomy [**2183**]
Diabetic retinopathy; legally blind
Bilateral ankle arthrosis (??????Charcot joints??????): sequential
fractures to ankles requiring ORIF.
Social History:
Separated from wife; father effective HCP; has high school
diploma and is unemployed. Nonsmoker, no ETOH, remote marijuana
use, otherwise no illicit drugs
Family History:
No known neurological disorder. Parents alive at 77, mother has
lung CA. Three healthy children, ages 14, 17, and 18.
Physical Exam:
VS: Afebrile BP 72.47 HR 117 96%RA
GEN: Obese male lying in bed awake, alert in NAD
HEENT: EOMI, PERRL, anicteric, OP clear
NECK: Supple
CHEST: CTA anteriorly, no wheezes, rales, rhonchi
CV: Tachycardic, S1S2, no m/r/g
ABD: Soft, NT, ND; Laparatomy scar C/D/I
EXT: nonpitting edema bilaterally; 2x3cm Stage 4 ulcer on left
heel, necrotic with granulation tissue; L AV fistula
SKIN: hyperpigmentation of B/L LEs
NEURO: AAOx3; CN ii-xii intact; strength 5/5 in UEs, [**2-23**]
bilateral lower extremities; toes downgoing; decreased sensation
in b/l lower extremities
Pertinent Results:
[**2188-5-7**] 07:01PM BLOOD WBC-5.3 RBC-4.61 Hgb-12.5* Hct-42.5
MCV-92 MCH-27.1 MCHC-29.5* RDW-18.6* Plt Ct-299
[**2188-5-8**] 05:25AM BLOOD WBC-10.0# RBC-3.81* Hgb-10.9* Hct-35.1*
MCV-92 MCH-28.7 MCHC-31.2 RDW-19.0* Plt Ct-404
[**2188-5-8**] 02:55PM BLOOD Hct-33.9*
[**2188-5-8**] 12:20AM BLOOD PT-26.4* PTT-32.1 INR(PT)-2.6*
[**2188-5-7**] 07:01PM BLOOD Glucose-121* UreaN-14 Creat-4.4* Na-142
K-3.9 Cl-99 HCO3-37* AnGap-10
[**2188-5-8**] 05:25AM BLOOD Glucose-89 UreaN-15 Creat-4.1* Na-142
K-3.0* Cl-101 HCO3-31 AnGap-13
[**2188-5-7**] 07:01PM BLOOD ALT-36 AST-48* CK(CPK)-17* AlkPhos-271*
TotBili-1.4
[**2188-5-8**] 05:25AM BLOOD ALT-29 AST-43* LD(LDH)-226 CK(CPK)-11*
AlkPhos-232* TotBili-1.6*
[**2188-5-7**] 07:01PM BLOOD CK-MB-NotDone cTropnT-0.13*
[**2188-5-8**] 05:25AM BLOOD CK-MB-3 cTropnT-0.14*
[**2188-5-8**] 05:25AM BLOOD Albumin-2.2* Calcium-7.2* Phos-2.5*
Mg-1.5*
[**2188-5-7**] 07:01PM BLOOD Albumin-1.8*
[**2188-5-7**] 07:01PM BLOOD TSH-2.0
[**2188-5-7**] 07:01PM BLOOD T4-6.3
[**2188-5-7**] 07:03PM BLOOD Lactate-1.6
.
Blood culture ([**2188-5-8**]): Pending.
C. Diff Toxin assay ([**2188-5-7**]): Pending.
.
CT Chest/Abd/Pelvis with contrast ([**2188-5-7**]): 1. No evidence of
pulmonary embolism with ______through the proximal segmental
pulmonary arteries. Distal segmental pulmonary arteries and
subsegmental arteries are not optimally evaluated on this study.
2. Pulmonary edema and bilateral large pleural effusions without
definite cardiomegaly. Extensive coronary artery disease. 3.
Moderate right proximal subclavian artery stenosis and calcified
plaque. 4. Diffuse fatty infiltration of the liver. 5.
Cholelithiasis, without evidence of cholecystitis. 6. Extensive
renal calcification from diabetes and chronic renal
insufficiency. 7. Large cystic lesion superior to the bladder
and inseparable from the sigmoid colon likely represents an
enteric duplication cyst; however, this is
uncertain without intravenous contrast. A pelvic MRI is
recommended to
characterize further if this has not been characterized on
outside studies.
8. Extensive arteriosclerosis from diabetes and chronic
insufficiency.
.
CXR ([**2188-5-7**]): Limited study with small right pleural effusion
and increased retrocardiac opacity, which may reflect
atelectasis versus early pneumonia. Dedicated PA and lateral
views may be obtained to further assess.
.
Echo Cardiogram [**2188-5-9**]
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets appear structurally normal
with good leaflet excursion. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Overall normal
biventricular cavity sizes and systolic function. No pericardial
effusion. .
.
MRI Pelvis:
PRELIMINARY FINDINGS AND IMPRESSION: MR images were obtained
without
intravenous contrast because of end-stage renal disease.
Non-contrast images
demonstrate a large cystic lesion with a mildly thickened and
irregular wall
immediately superior to the bladder, including a small amount of
debris. The
lesion closely approaches the sigmoid colon, but does not
definitely
communicate with it. Differential considerations include a giant
sigmoid
diverticulum, duplication cyst but an unusual appearance of a
cystic
gastrointestinal stromal tumor or paraganglioma is not entirely
excluded. In
order to assess further for the possibility of solid vascular
components,
ultrasound examination is recommended, as there is apparently a
good window
from the anterior abdominal wall. Depending on the results, CT
with contrast
could be considered.
Brief Hospital Course:
ICU Course: Mr. [**Known lastname 72009**] is a 44 yo M with a history of DM with
complications of ESRD who underwent recent gastric bypass with
significant weight loss and complications of very low albumin
and severe, asymptomatic hypotension. The patient reported that
his outpatient nephrologist thought he needed albumin with
dialysis. Due to profound hypotension to the range of sbp 60-70,
the patient underwent CTA to evaluate for PE and abd/pelvis CT.
Both studies was unrevealing unrevealing for source of
hypotension. The patient was completely asymptomatic with
apparently normal mentation. Renal was consulted for dialysis.
The renal fellow did find a case report of severe,
incapacitating autonomic dysfunction in a diabetic after large
sum weight loss, as occurred in this patient. The patient's
outpatient PCP/nephrologist was contact[**Name (NI) **] and she reported that
the patient had a history of poor compliance. She was concerned
about possible depression and was considering psychiatry consult
as well as feeding tube for supplementation due to poor oral
feeding. The patient's prior PCP noted that she recommended that
the patient not undergo gastric bypass surgery though he went
ahead anyway (with significant complications) and reported to
the ICU team that he underwent the surgery to improve his
chances of renal transplant.
.
Wards course:
44 yo M with PMH of DM, ESRD on HD, hx of bilateral DVT, s/p
gastric bypass with dx of orthostatic hypotension here with low
BP and hypoalbuminemia
.
Hypoxia: Underwent CTA in ED for acute hypoxia with O2sats in
70s per report. Per patient, no SOB or chest pain. CTA negative
for PE. Satting 96% on 2L on arrival to floor and rapidly weaned
to RA.
Improved with hemodialysis. Hypoxia may have been due to
pleural effusion from hypoalbuminemia.
.
Hypotension: Recent evaluation by neurology (autonomics).
Notable for abnormal tilt test and impaired parasympathetic and
sympathetic function. Likely secondary to autonomic and
peripheral neuropathy from longstanding diabetes. Unclear
whether there was a dehydration component from C difficile,
though his BP improved with better hydration status and treating
his c diff infection. He was able to tolerated HD. Initially
albumin was used during HD but per renal reports, he probably
does not need it anymore given his BP's. He should continue
taking midodrine and fludrocortisone. He should continue to
follow with the autonomic service in our hospital. Appointment
already scheduled.
He remained orthostatic while seen by PT but asymptomatic.
Further eval will be done as outpatient by the autonomic
seervice.
.
Hypoalbuminemia: Likely secondary to poor PO intake following
gastric bypass surgery.
He should be strongly encouraged to keep a good PO intake.
.
Bilateral pleural effusions: Likely secondary to third spacing
from hypoalbuminemia as well as weight gain as dialysis was
initially was limited by low BP's. Echo [**2188-5-9**] normal r/o
cardiac etiology.
Sating well on RA on discharge
.
C diff infection: Patient + for c diff. Initially on flagyl but
given poor response switched to Vancomycin PO [**2188-5-12**]. He should
complete a 14 day course.
.
Diabetes: patient placed on insulin sliding scale. Minimal
insulin requirment. He should be monitor closely. No Lantus was
administered while in house.
.
ESRD: Likely secondary to diabetic nephropathy on HD. Initially
with problems due to low [**Name (NI) **]. However, his BP improved and over
last 72 hours in house, he had no problems with HD.
.
Hx of bilateral DVTs: patient was continued on warfarin. Last
INR [**2185-5-13**] 2.7. [**5-13**] received 3 mg. Prior days 2 mg/day. Goal
INR [**12-23**].
.
Hypothyroidism: TSh normal in house. synthroid continued.
.
L ankle ulcer: evaluated by wound care consult team.
Recommendations attached with this d/c summary. Patient has a
follow up with his vascular surgeon in [**Month (only) 205**].
.
Abnormal Ct findings: Noncontrast CT abdomen on admission showed
Large cystic lesion superior to the bladder and inseparable from
the sigmoid colon that likely represents an enteric duplication
cyst; however, this is uncertain without intravenous contrast. A
pelvic MRI was recommended and done on [**2187-5-13**]. MRI final read
is stilll pending. Preliminary [**Location (un) 1131**] suggested ddx a giant
sigmoid diverticulum, duplication cyst but an unusual appearance
of a cystic gastrointestinal stromal tumor or paraganglioma was
not entirely excluded. In
order to assess further for the possibility of solid vascular
components ultrasound examination was recommended, as there was
an apparently good window from the anterior abdominal wall.
Depending on the results, CT with contrast could be considered.
This finding should be further assessed during his next PCP
appointment on [**5-28**] AT [**Company 191**]
.
.
Medications on Admission:
Vit. D 50,000 units weekly.
Heparin 2,000 units IV Tue, Thurs, Sat prior to hemodialysis.
ASA 325 mg daily.
Protonix 40 mg daily.
Coumadin 4 mg daily.
Synthroid 300 mcg daily.
Calcitriol 0.25 mcg Tues, Thurs, Sat.
Ocuflox 0.3% ophthalmic one drop 4 times a day.
Pred Forte 1% ophthalmic one drop left eye 4 times a day.
Midodrine 10 mg twice daily.
Diflucan 200 mg daily.
Nephrocaps one daily.
Zocor 10 mg at bedtime.
PhosLo 667 mg one cap three times a day with meals.
Neurontin 300 mg prn pain, max 900 mg per day.
Zaroxolyn 2.5 mg one tab on Sun, Mon, Wed, and Fri.
Lasix 80 mg one tab [**Hospital1 **] on Mon, Wed, and Fri.
Dilaudid 2 mg prn every 8 hours for pain.
Discharge Medications:
1. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
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. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM: Last INR [**5-13**] 2.7 .
5. Levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
7. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
9. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) as needed.
12. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 12 days.
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO QID (4 times a day) as needed.
14. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) as needed.
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical HS
(at bedtime) as needed.
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
17. Insulin
Insulin sliding scale. Attached to paperwork
Discharge Disposition:
Extended Care
Facility:
Highgate Manor
Discharge Diagnosis:
Orthostatic hypotension
Clostridium difficille diarrhea
Abdominal Cyst
Secondary:
End stage renal disease
Discharge Condition:
Good
Discharge Instructions:
You were admitted with hypotension. Not a clear source of
infection was located initially, but we did find that you had a
c. diff GI infection.
You should be on antibiotics for the next 12 days.
You should continue taking your midodrine, fludrocortisone as
prescribed.
Please follow all physical therapy recomendations to improve
your blood pressures
The final [**Location (un) 1131**] of your abdomen MRI is still pending. Please
keep your appointment wtih your new PCP so this issue can be
readressed.
Followup Instructions:
Please follow up with a new PCP at [**Name9 (PRE) 191**]:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2188-5-28**] 2:30
Provider: [**Name10 (NameIs) 2841**] LABORATORY Phone:[**Telephone/Fax (1) 2846**] Date/Time:[**2188-6-2**]
8:30
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 4777**] & [**Doctor First Name 4778**] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2188-6-18**] 1:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2188-5-14**]
|
[
"707.13",
"250.40",
"751.5",
"583.81",
"511.9",
"244.9",
"337.1",
"008.45",
"V45.86",
"585.6",
"273.8",
"250.60",
"V12.51",
"250.50",
"V58.61",
"362.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14488, 14529
|
7502, 12362
|
286, 300
|
14680, 14687
|
3502, 7479
|
15239, 15862
|
2783, 2902
|
13082, 14465
|
14550, 14659
|
12388, 13059
|
14711, 15216
|
2917, 3483
|
228, 248
|
328, 2225
|
2247, 2594
|
2610, 2767
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,680
| 190,759
|
34117
|
Discharge summary
|
report
|
Admission Date: [**2152-5-10**] Discharge Date: [**2152-5-26**]
Date of Birth: [**2097-9-3**] Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 7575**]
Chief Complaint:
progressive bilateral leg weakness, lower back pain and
decreased bowel/urine control
Major Surgical or Invasive Procedure:
Lumbar puncture
Plasmapheresis catheter placement and removal
Plasmapheresis
Blood transfusion
History of Present Illness:
54yo right-handed woman with PMH significant for left Bell's
palsy in [**9-22**] treated with steroids, hypertension, and
hypercholesterolemia, who presents with progressive bilateral
leg weakness, lower back pain and decreased bowel/urine control
over the 2 days prior to admission. History obtained from
patient with a Thai interpreter.
Patient reports these symptoms occurred rather suddenly. Upon
waking up on Mon morning, patient had heaviness and numbness in
her abdomen and legs bilaterally.
The following day, Tues, she couldn't sleep well secondary to
lower back pain. In particular she developed lower back pain
described as tickling and achiness.
That evening, she reports that she was no longer able to walk.
She had a BM where it was difficult to keep from losing it and
she has had urinary incontinence, but no arm involvement.
Her symptoms have continued to worsen particularly in her legs
R>L. Initially she presented to an OSH where an MRI spine
showed an abnormality, ? of thoracic lesion suggestive of
demyelination.
Interestingly, during the time when Bell's palsy was diagnosed,
she had vertical diplopia. She has not regained all of the
function and when [**Location (un) 1131**] small letters may see double. She was
on 20 days of steroids for Bell's palsy.
ROS: Denies difficulty breathing or ever having these symptoms
before.
Past Medical History:
- hypercholesterolemia
- hypertension
- left Bell's palsy in [**9-22**], tx' w/steroids
- status post bilateral cataract surgeries
Social History:
Moved to US 4 yrs ago. Works as cashier at TJ max. No tobacco,
alcohol or drugs. Lives in [**Location 47**] with husband no kids. No
recent travel to exotic destination. Reportedly received her
bachelor degress in business.
Family History:
denies MS
Physical Exam:
On admission:
T- 98.6 BP- 151/94 HR- 110 RR- 14 97 O2Sat RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: supple, no carotid or vertebral bruit
Back: No point tenderness or erythema
CV: tachycardic, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
MS:
General: alert, awake, normal affect
Orientation: oriented to person, place, date, situation
Attention: +MOYbw. Follows simple/complex commands.
Speech/[**Doctor Last Name **]: fluent w/o paraphasic errors; comprehension,
repetition, naming and [**Location (un) 1131**] intact
Memory: Registers [**1-17**] and Recalls [**1-17**] when given choices at 5
min
Praxis: Able to brush teeth
CN:
I: not tested
II,III: VFF to confrontation, PERRL 4mm to 2mm, fundi normal
III,IV,VI: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: Facial strength intact/symmetrical
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**3-20**] bilaterally
XII: tongue protrudes midline, no dysarthria
Motor: Normal bulk and mildly decr'd in legs b/l R>L; no tremor,
asterixis or myoclonus. No pronator drift.
Delt [**Hospital1 **] Tri WE FE Grip
C5 C6 C7 C6 C7 C8/T1
L 5- 5 5 5 4+ 5
R 4+ 5 4+ 5 5 5
IP Quad Hamst DF [**Last Name (un) 938**] PF
L2 L3 L4-S1 L4 L5 S1/S2
L 3+ 4- 4- 4- 4- 3
R 2 3- 2 4- 4- 4-
Reflex: No clonus. +Anal wink and no abd reflexes.
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 3 3 3 3 3 Extensor
R 3 3 3 3 3 Extensor
Sensation:
Intact to light touch and cold.
Decr'd pin at hips b/l
Decr'd vibration up to hips b/l
Decr'd proprioception up to abdomen b/l
Coordination: finger-nose-finger normal, RAMs normal.
Gait/Romberg: unable
On discharge, slightly improved - she is able to lift left leg
just off bed, extend both legs at knees, flex the left leg,
wiggle toes on the left, and sense need to urinate.
Pertinent Results:
Labs on admission:
141 104 10
------------< 165
3.8 23 0.5
Ca: 10.0 Mg: 2.2 P: 3.9
7.1 > 40.6 < 325
N:89.1 L:10.3 M:0.2 E:0.2 Bas:0.2
SED-Rate: 51
PT: 13.2 PTT: 26.5 INR: 1.1
Other studies:
[**2152-5-18**] Fibrino-453*
ESR-51*
Lymph-28 Abs [**Last Name (un) **]-5992 CD3%-67 Abs CD3-4006* CD4%-46 Abs
CD4-2737* CD8%-21 Abs CD8-1253* CD4/CD8-2.2
Iron-48 calTIBC-182* Hapto-175 Ferritn-169* TRF-140*
VitB12-1791*
HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE IgM HBc-NEGATIVE
[**Doctor First Name **]-POSITIVE Titer-1:80
HIV Ab-NEGATIVE
HERPES SIMPLEX (HSV) 2, IGG, HERPES SIMPLEX (HSV) 1, IGG, HERPES
SIMPLEX VIRUS 1 AND 2 ANTIBODY IGM -NEGATIVE
ANGIOTENSIN 1 - CONVERTING [**Last Name (un) **]-NEGATIVE
HTLV I AND II, WITH REFLEX TO WESTERN BLOT-NEGATIVE
Lyme, RPR negative
[**2152-5-11**] CSF:
WBC-70 RBC-1* Polys-2 Lymphs-75 Monos-22 Other-1
TotProt-76* Glucose-86
VZV, CMV, HSV, HHV6, EBV, MS profile negative, VDRL pending
CSF culture negative
URINE CULTURE [**5-15**] (Final [**2152-5-18**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION. Pansensitive.
BETA STREPTOCOCCUS GROUP B. 10,000-100,000
ORGANISMS/ML..
Imaging:
[**2152-5-10**]: MRI C-, T-, L-spine
1. Expansion of the cord from the thoracic T3-T11 levels, with
increased T2 signal. This appearance is consistent with
transverse myelitis due to demyelination or infection. Tumor is
a much less likely consideration.
2. Mild degenerative change throughout the spine, with a
posterior disc bulge at C5-C6 and L4-L5.
[**2152-5-11**]: MRI C- and T-spine wiht contrast:
1. Thoracic spine cord expansion with abnormal T2 signal and
enhancement. The appearance is most consistent with transverse
myelitis. Differential would include a demyelinating process or
an infectious process such as Lyme disease, herpes, etc. The
appearance is not consistent with a tumor. No enhancing vessels
or abnormal flow voids are identified to suggest dural AV
fistula or AVM. There is no evidence of hemorrhage.
2. Mild degenerative changes from C3-6, with mild posterior disc
bulge at C5-6 causing only mild indentation of the thecal sac.
[**2152-5-25**]: MRI C- and T-spine:
Compared to [**2152-5-11**], overall improvement in extent of
edema and ignal abnormality of the thoracic cord, with
resolution of enhancement. Interval development of syrinx from
T6 to T7-8 levels. Overall, the indings are thought most likely
to be due to demyelination, with an unusual presentation of
multiple sclerosis favored. Alternatively, the findings could be
explained by ADEM, perhaps recurrent and related to infectious
process such as Lyme disease or herpes as previously discussed.
Given the marked involvement of the central spinal cord, a
vascular cause cannot be entirely excluded.
[**2152-5-18**]: CT abd/pelvis:
1. Large left gluteal hematoma without evidence of active
extravasation. 2. There is no evidence of retroperitoneal
hematoma or other acute intra-
abdominal pathology.
CT neck:
Small hematoma in the left subclavicular region. Findings
suggest sequelae of subclavian line placement bilaterally.
VISUAL EVOKED POTENTIAL (08-043): After [**Month/Day/Year 78661**] of either
eye there
were well-formed evoked potential peaks with normal P100 wave
latencies,
107 ms [**First Name (Titles) **] [**Last Name (Titles) 78661**] of the right eye and 108 ms [**First Name (Titles) **] [**Last Name (Titles) 78662**]
of the left eye (upper limits of normal in this laboratory 114
ms).
Brief Hospital Course:
54 y/o woman with a questionable history of Bell's palsy in
[**9-22**] treated with steroids, hypertension and
hypercholestrolemia who presented with progressive bilateral leg
weakness, low back pain and decreased bowel/bladder control.
Her examination was notable for paraparesis, brisk reflexes
throughout and decreased sensation to T4. She initially
presented to an OSH with a cord lesion noted on MRI, given
steroids and transfered to [**Hospital1 18**] for further
evaluation/management.
An emergent MRI c-/t-spine in the ED showed expansion of the
T-spine from T3-T11 with increased T2 signal consistent with
transverse myelitis due to either demyelination or infection and
less likely tumor. She was continued on steroids x 5 days and
admitted continued management. An LP was done on [**5-11**] and
showed WBC 70 (75% lymphs), RBC 1, Protein 76, Glucose 86.
Given her previous diagnosis of Bell's palsy, a more
disseminated etiology was likely such as MS, NMO or ADEM.
Therefore a further work-up was initiated and included the
following sudies: serum - [**Doctor First Name **], ACE, HIV, HTLV, HSV, MS profile,
HHV6, TB, NMO abx, Lyme, RPR; CSF - VZV, VDRL, HSV, HSV, MS
profile, CMV, EBV, HHV6. These all returned negative other than
the CSF VDRL, which is pending on discharge. She had a head MRI
which revealed periventricular white matter lesions,
nonenhancing. Her symptoms and imaging were thought to be
consistent with demyelinating myelitis, perhaps an aggressive
form of transverse myelitis or neuromyelitis optica. Due to her
acute and aggressive presentation, she was started on
plasmapheresis on [**5-13**] with 5 treatments total.
After 2 treatments, she was found to have an elevated PTT and a
slowly dropping hematocrit. The PTT fell with discontinuation of
subcutaneous heparin alone. However, the hematocrit fell more
rapidly and she became hypotensive with SBP in the 80s.
Evaluation revealed a left gluteal hematoma. She was transferred
to the ICU. There, she was transfused two units of PRBCs with
improvement of her hematocrit. Further plasmapheresis was held.
She was stabilized in the ICU and remained stable on the floor.
She had a repeat T-spine MRI, which was improved with decreased
extent of signal abnormality and decreased cord expansion, as
well as resolution of previously seen enhancement. She did have
a new small syrinx visualized.
Clinically, she had improved minimally in leg movement, as well
as urinary and bowel control. She will go to rehab to improve
her strength, and follow up for further treatment in neurology
clinic. She will taper down the prednisone as directed to
eventual dose of 60mg every other day.
Medications on Admission:
- Asa
- Lisinopril
- Simvastatin
Discharge Medications:
1. Prednisone 20 mg Tablet Sig: asdir Tablet PO asdir: 60mg
daily alternating w/ 40mg daily x4 days then
60mg daily alternating w/ 20mg daily x4 days then
60mg daily alternating w/ 10mg daily x4 days then
60mg every other day.
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed for muscle spasm.
9. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
10. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Transverse myelitis
Heparin sensitivity
Anemia
Urinary tract infection
Constipation
Discharge Condition:
Slightly improved - able to lift left leg just off bed, extend
both legs at knees, flex the left leg, wiggle toes on the left,
sense need to urinate.
Discharge Instructions:
Take all medications as prescribed.
Prednisone should be tapered as follows: 60mg daily alternating
w/ 40mg daily x4 days then 60mg daily alternating w/ 20mg daily
x4 days then
60mg daily alternating w/ 10mg daily x4 days then 60mg every
other day.
Follow up in Dr.[**Name (NI) 25950**] office as scheduled.
Call your doctor or return to the ED with any worsening
weakness, sensation, urinary or bowel control, or with change in
mental status, difficulty speaking, vision loss, or any other
concerning symptom.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 8760**] by calling for an appointment: ([**Telephone/Fax (1) 78663**].
Call your PCP ([**Last Name (LF) **],[**First Name3 (LF) 412**] A. [**Telephone/Fax (1) 20221**]) for a follow up
appointment as well.
|
[
"V58.61",
"341.20",
"998.12",
"286.9",
"E884.4",
"E849.7",
"368.2",
"599.0",
"E934.2",
"401.9",
"272.0",
"922.32",
"280.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.71",
"03.31",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11784, 11929
|
7955, 10627
|
367, 464
|
12057, 12209
|
4445, 4450
|
12770, 13020
|
2273, 2284
|
10710, 11761
|
11950, 12036
|
10653, 10687
|
12233, 12747
|
2299, 2299
|
242, 329
|
492, 1856
|
4464, 7932
|
2659, 4426
|
1878, 2011
|
2027, 2257
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,463
| 166,360
|
10518+56154
|
Discharge summary
|
report+addendum
|
Admission Date: [**2174-8-25**] Discharge Date: [**2174-9-14**]
Date of Birth: [**2115-11-3**] Sex: M
Service: TRANSPLANT SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old man
with a longstanding history of alcohol abuse who presented
for a liver transplant on [**2174-8-25**]. The patient has been
abstaining from alcohol since [**2173**]. He first became
significantly symptomatic from his liver disease about three
to four years ago. His liver disease is complicated by
intractable ascites, hepatic encephalopathy, malnutrition, and
fatigue. His history is also significant for falling down last
year which was complicated by a compartment syndrome in the right
leg status post fasciotomy. On the day of admission, the patient
had no specific complaints except for some tingling in the right
foot. He denied any recent fevers, chills, nausea, vomiting,
diarrhea, shortness of breath or chest pain.
PAST MEDICAL HISTORY:
1. Alcoholic cirrhosis diagnosed in [**2170**], class C with
ascites, edema, esophageal varices, low grade encephalopathy.
2. Alcohol abuse, abstinent since [**2173**]
3. Eczema
4. History of right clavicular fracture
5. History of Enterobacter bacteremia
6. History of guaiac positive stools
7. History of right leg fasciotomy, status post compartment
syndrome
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Propanolol 10 mg [**Hospital1 **]
2. Lasix 40 mg [**Hospital1 **]
3. Spironolactone 100 mg 2 tablets in a.m. and 1 tablet in
p.m.
4. Mycelex 10 mg 5x a day
5. Folic acid 1 tablet qd
6. Vitamin D 1 tablet qd
7. Centrum multivitamins 1 tablet qd
8. Calcium 500 mg with vitamin D [**Hospital1 **]
9. Generlac solution 10 gm per 15 ml, 2 tablets [**Hospital1 **]
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 96.8??????, heart rate 53, blood
pressure 94/46, respiratory rate 18 on 100% room air
GENERAL: Elderly man in good spirits in no apparent
distress.
HEAD, EARS, EYES, NOSE AND THROAT: Mildly icteric and
jaundiced. The rest of the head, ears, eyes, nose and throat
exam is unremarkable.
CARDIAC: Regular rate and rhythm, no murmurs.
PULMONARY: Clear to auscultation bilaterally.
ABDOMEN: Soft with a 4 inch umbilical hernia, also evidence
of ascites with fluid shift, no tenderness, moderately
distended.
EXTREMITIES: Warm, right lower extremity laterally medially
with fasciotomy scars. Pulses present bilaterally
throughout.
NEUROLOGIC: Cranial nerves II through XII intact. Strength
grossly intact all four extremities. Sensory - decreased
sensation in the right foot, otherwise within normal limits.
ADMISSION LABORATORIES: White blood cell count 5.6,
hematocrit 28.4, neutrophils 81.5. PT 17.3, PTT 37.1, INR
2.1, fibrinogen 176, glucose 119, BUN 28, creatinine 1.3,
sodium 129, potassium 4.5, chloride 99. ALT 28, AST 45,
alkaline phosphatase 127, amylase 116, total bilirubin 3.7.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to the
transplant surgery service. He underwent orthotopic cadaver
liver transplant on [**2174-8-25**]. Intraoperatively, the patient
received 30 units of packed red blood cells, 7 units of
platelets, 35 units of fresh frozen plasma, 30 units of Cryo.
The procedure was without complications. Please see the full
operative report for details. The patient remained intubated
and was transferred to the Surgical Intensive Care Unit
immediately after the procedure. The patient was started on
CellCept and Solu-Medrol. He was also started on TPN. The
patient also received prophylaxis with fluconazole, Bactrim,
Valcyte and Unasyn. Cyclosporin was also added to the
immunosuppression regimen on postoperative day 1. The
patient continued to be intubated in the SICU with good urine
output. The patient was extubated on postoperative day 1.
His vital signs remained stable. He appeared to tolerate the
extubation procedure well.
On [**2174-8-26**], a liver ultrasound was performed to evaluate
hepatic blood flow. The ultrasound showed a patent portal
vein with antegrade flow, widely patent and hyperdynamic
hepatic venous flow. Patent hepatic left artery. However,
there was no detectable right hepatic artery signal detected. He
underwent a hepatic angiogram that demonstrated patency of the
left and right hepatic arteries as well as the accessory right
hepatic artery that was anastomosed to the stump of the splenic
artery of the donor. On postoperative day 1, while still in the
SICU, the patient received 150 mg of Cyclosporin via an
intravenous over a two hour period. As a result, his serum
creatinine was noted to be increasing from 1.4 on postoperative
day 0 to a high of 2.4 on postoperative day 2 after he received
his intravenous Cyclosporin. On postoperative day 1, status post
extubation, the patient appeared to have metabolic alkalosis. The
patient's urine output slowly recovered. An echocardiogram
was obtained on [**2174-8-29**] which showed overall left
ventricular systolic function moderately depressed. The
patient also underwent a bronchoscopy which showed
Methicillin resistant Staphylococcus aureus. A liver
ultrasound was repeated on [**2174-8-29**]. As before, arterial
flow could not be demonstrated in the segments of the right
lobe of the liver. However, arterial flow was seen within
the left lobe of the liver.
The patient also had a series of chest x-rays obtained while
in the Surgical Intensive Care Unit which showed congestive
heart failure which slowly resolved over time. Being
reintubated for possible aspiration pneumonia, the patient
was maintained on vancomycin and clindamycin. The patient
was again extubated on postoperative day 5 which he tolerated
well. The patient was continued on TPN. The patient was
continued on immunosuppression medication which included
Solu-Medrol, Neoral and CellCept. His chest tube was removed
on postoperative day 8. He remained somewhat confused above
his baseline. On the same day, he was transferred to the
regular transplant floor. A repeat chest x-ray obtained on
[**2174-9-3**] showed no acute cardiopulmonary changes. Due to the
continued confusion, psychiatry consult was obtained. Per
their recommendations, Haldol was used with good response.
The liver function tests continued to improve.
On postoperative day 10, the patient was noted to be more
confused and had an increasing white blood cell count. Urine
and blood cultures were obtained which showed no growth. His
chest x-ray was clear as well. The patient's kidneys
regained function after intravenous Cyclosporin with serum
creatinine dropping to 0.8 on postoperative day 10. All
antibiotics were discontinued. The TPN was slowly weaned,
and the patient was eventually able to tolerate po's. The
patient also had diarrhea, but his Clostridium difficile test
was negative.
On postoperative day 12, the patient complained of increasing
pain in the periumbilical region where he has a known
umbilical hernia. The hernia was reduced manually with some
relief to the patient. On [**2174-9-9**], the patient went to the
Operating Room for the repair of his umbilical hernia. He
tolerated the procedure well. There were no complications.
Please see the full operative for full details. On the same
day, the patient was also noted to be hyperkalemic with a
serum potassium of 6.0. The patient continued to be
persistently hyperkalemic on [**9-10**] and 18th, which had
to be corrected on several occasions. In addition, on
postoperative day 16 and 2, the patient was noted to have
increasing liver function tests, with alkaline phosphatase
increasing to 546, total bilirubin increasing to 3.3.
On [**2174-9-12**], the patient received no Neoral due to the
concern that his rising liver function tests and his
hyperkalemia were due to increased Cyclosporin levels. The
patient's hyperkalemia ultimately improved. His liver
function tests improved as well. Given concern for an acute
rejection of his new liver, a liver ultrasound was obtained
on [**2174-9-11**]. The ultrasound showed patent portal veins and
hepatic arteries with normal flow. The left hepatic vein
could not be visualized due to technical limitations of the
study. The study also did not show any ductal dilatation.
The patient continued to do well. He was seen by physical
and occupational therapy. The patient was having bowel
movements, ambulating and voiding on his own. Liver function
tests continued to improve. A liver biopsy was obtained on
[**2174-9-12**] which did not show any evidence of rejection.
Please see the full pathology report for details.
On [**2174-9-14**], the patient was discharged to [**Hospital1 **]
Rehabilitation Center.
DISCHARGE CONDITION: Good
DISCHARGE STATUS: [**Hospital1 **] Rehabilitation Center
DISCHARGE DIAGNOSES:
1. Alcoholic liver cirrhosis, status post orthotopic
cadaveric liver transplant.
2. Pneumonia.
3. Acute renal failure.
4. Incarcerated umbilical hernia, status post repair.
5. Confusion.
DISCHARGE MEDICATIONS:
1. Neoral 100 mg po bid
2. Protonix 40 mg po q 12 hours
3. Lasix 40 mg po qd
4. Prednisone 15 mg po qd
5. CellCept 1 mg twice a day
6. Lopressor 12.5 mg [**Hospital1 **]
7. Fluconazole 400 mg po q 24 hours
8. Bactrim DS 1 tablet qd
9. Valcyte 450 mg po bid
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2174-9-14**] 11:15
T: [**2174-9-14**] 12:02
JOB#: [**Job Number 34661**]
cc:[**Hospital1 34662**] Name: [**Known lastname 6144**], [**Known firstname 651**] Unit No: [**Numeric Identifier 6145**]
Admission Date: [**2174-8-25**] Discharge Date: [**2174-9-14**]
Date of Birth: [**2115-11-3**] Sex: M
Service: TRANSPLANT Surgery
Addendum:
The patient was discharged on [**2174-9-14**] as described in the
discharge summary.
surgeon, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], as scheduled. The patient will
obtain laboratory tests which include CBC, liver function
tests, electrolytes twice week, namely Monday and Thursday
while at the rehabilitation center. The patient is to be
transferred by the ambulance from the rehabilitation center
to see Dr. [**Last Name (STitle) **].
on Neoral 100 mg po bid. In addition, please add heparin
subcutaneous 500 units [**Hospital1 **] to the rest of the medication
regimen stated in the discharge summary.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**], M.D.,Ph.D. 02-366
Dictated By:[**Last Name (NamePattern1) 6146**]
MEDQUIST36
D: [**2174-9-14**] 14:12
T: [**2174-9-19**] 14:19
JOB#: [**Job Number 5707**]
|
[
"552.1",
"584.9",
"571.2",
"789.5",
"512.1",
"276.7",
"428.0",
"276.3",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.11",
"99.15",
"53.49",
"88.47",
"38.93",
"33.24",
"34.04",
"96.71",
"96.04",
"50.59",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
8699, 8764
|
8785, 8978
|
9001, 10743
|
2936, 8677
|
1779, 2907
|
179, 942
|
964, 1757
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,564
| 105,165
|
16306
|
Discharge summary
|
report
|
Admission Date: [**2160-6-18**] Discharge Date: [**2160-6-21**]
Date of Birth: [**2076-10-24**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Motrin / Penicillins
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonscopy
Mesenteric Angiography without embolization
History of Present Illness:
83 y/o PMHx of sick sinus s/p PCM, GERD, h/o LGIB and
diverticulosis who presented after 2 episodes BRBPR this
morning. Pt reported feeling well the night before with good
appetite and normal BM. However, after the episodes of BRBPR, he
felt dizzy with change in position and called his PCP prior to
coming into the ED.
.
In the ED, initial vs were: T 97.7 HR 70 BP 173/70 RR 16 Sats
99% on RA. Rectal exam revealed a scant amount of bloody stool.
He was given Protonix 40mg IV, 1L NS IVF, 2 large PIV placed and
he was typed and crossed for 4u prbcs. GI was consulted and
recommended admission for c-scope.
.
On arrival to the ICU, pt was feeling well and denying CP, SOB,
abd pain, nausea or lightheadedness. He denied any further
episodes of BRBPR or recent use of NSAIDs
.
Review of systems:
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies rhinorrhea or congestion. Denies productive cough
or shortness of breath. Denies chest pain palpitations, nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits.
Past Medical History:
1)hx of LGIB in [**2-22**] and [**9-21**] with c-scope showing
diverticulosis & internal hemmorrhoids
2)Sick sinus syndrome s/p pacemaker
3)Hyperlipidemia
4)GERD
5)Asthma
6)Wilson's disease carrier
Social History:
Pt lives alone in [**Location (un) 3146**] Beach, widowed, 2 children (live in
[**Hospital1 **] and [**Location (un) **]), 4 grandchildren (ages 15-24); formerly
worked in real estate and bartending; denies tobacco and drug
use, occ alcohol.
Family History:
4 of 6 sibs with pacemakers, brother died of stroke at 81yo,
father w/ stroke at 62yo, brother w/ CAD and colon ca, mother w/
cancer, father w/ wilson's disease
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2160-6-18**] 09:17PM HCT-33.9*
[**2160-6-18**] 05:12PM HCT-31.7*
[**2160-6-18**] 01:39PM HCT-32.7*
[**2160-6-18**] 10:40AM LACTATE-1.6 K+-4.2
[**2160-6-18**] 10:30AM GLUCOSE-100 UREA N-13 CREAT-1.0 SODIUM-138
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-28 ANION GAP-12
[**2160-6-18**] 10:30AM WBC-6.0 RBC-4.30* HGB-11.9* HCT-37.2* MCV-87
MCH-27.8 MCHC-32.1 RDW-14.4
[**2160-6-18**] 10:30AM NEUTS-71.5* LYMPHS-21.6 MONOS-5.3 EOS-1.3
BASOS-0.3
[**2160-6-18**] 10:30AM PLT COUNT-260
[**2160-6-18**] 10:30AM PT-12.7 PTT-29.1 INR(PT)-1.1
[**2160-6-21**] 08:00AM BLOOD WBC-5.8 RBC-3.74* Hgb-10.6* Hct-32.5*
MCV-87 MCH-28.3 MCHC-32.5 RDW-14.2 Plt Ct-244
IMAGING:
Mesenteric Arteriography:
Provisional Findings Impression: [**First Name9 (NamePattern2) 46497**] [**Doctor First Name **] [**2160-6-19**] 11:18 PM
Mesenteric arteriography including selective arteriograms of
SMA, [**Female First Name (un) 899**],
ileocolic, right colic, middle colic arteries were performed and
no active
contrast extravasation was noted concerning for bleeding.
Therefore no
intervention was performed.
Colonoscopy:
Impression: Diverticulosis of the whole colon with active
bleeding in the ascending colon with 2 visible clots
Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum
Recommendations: The cause of bleeding is most likely
diverticula in the ascending colon.
Recommend emergent angiogram for possible embolization
Continue to follow serial crit
Brief Hospital Course:
83 y/o M with PMhx of sick sinus syndrome s/p PCM,
diverticulosis and lower GI bleed who presents with BRBPR.
BRBPR: Found to be secondary to diverticulosis. Patient's
hematocrit remained stable without the need for blood
transfusion. No active bleeding in ICU or on floor. Colonscopy
performed showed bleeding in ascending colon. Patient was
transferred from colonoscopy suite directly to angiography for
possible intervention. Angiography did not show active bleeding
so no intervention was performed. Patient was monitored for 24
more hours and no active bleeding occured. Patient's hematocrit
remained stable. He tolerated po's and had brown bowel
movements. He was discharged with close follow up with his PCP.
Hyperlipidemia: continued home simvastatin 20mg daily.
Anxiety/Depression: continued home Citalopram 10mg daily.
Medications on Admission:
Citalopram 10mg
Omeprazole 20mg
Simvastatin 20mg
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Diverticulosis s/p bleed from ascending colon
Secondary:
SSS s/p PPM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because you had a lower gastro-intestinal
bleed found to come from diverticulosis. Your bleeding resolved
on its own and no intervention was performed. Your blood levels
remained stable.
You should continue your medications as prescribed with the
following important changes.
1. Omeprazole 40 mg to be taken daily
Followup Instructions:
You have the following appointments scheduled:
***NOTE***Dr. [**Last Name (STitle) 46498**] will contact you [**Name (NI) 766**] to make your
appointment sooner than what is scheduled below. If you do not
hear from them on [**Name (NI) 766**], please call [**Telephone/Fax (1) 1579**] to schedule a
hospital follow up appointment in [**2-16**] weeks.
You do not need to follow up with gastroenterology at this time.
Department: CARDIAC SERVICES
When: [**Date Range **] [**2160-7-21**] at 1:30 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DERMATOLOGY
When: TUESDAY [**2160-7-22**] at 1:30 PM
With: [**Name6 (MD) 6821**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1971**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital1 18**] [**Location (un) 2352**]
When: [**Location (un) **] [**2160-10-13**] at 11:30 AM
With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1579**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
|
[
"562.12",
"493.90",
"272.4",
"285.1",
"427.81",
"455.0",
"V45.01",
"300.4",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
5341, 5347
|
4091, 4924
|
298, 355
|
5469, 5469
|
2605, 4068
|
5977, 7327
|
1943, 2105
|
5023, 5318
|
5368, 5448
|
4950, 5000
|
5620, 5954
|
2120, 2586
|
1179, 1447
|
253, 260
|
383, 1160
|
5484, 5596
|
1469, 1668
|
1684, 1927
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,365
| 143,200
|
4567
|
Discharge summary
|
report
|
Admission Date: [**2140-10-6**] Discharge Date: [**2140-10-17**]
Date of Birth: [**2089-12-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
2 weeks of SOB and mild throat pain on exertion
Major Surgical or Invasive Procedure:
[**2140-10-12**] Coronary bypass grafting x4; left internal mammary
artery to left anterior descending coronary; reverse saphenous
vein single graft from aorta to the first diagonal coronary
artery; reverse saphenous vein single graft from the second
obtuse marginal coronary artery; as well as reverse saphenous
vein single graft from the aorta to the distal right coronary
artery.
History of Present Illness:
50yr-old male with 40yr history of type 1 diabetes complicated
by nephrotomy, retinopathy and hyperlipidemia. He was seen by
his Endocrinologist recently and mentioned to her that he has
had increased SOB associated with mild throat pain which
occurred with exertion. He was referred for stress echo and ETT
both of which were significant for single vessel CAD and
inducible ischemia with exercise. He therefore underwent cardiac
cath on [**10-6**] which revealed significant [**3-8**] vessel disease. He
was seen by the cardiac surgery service and accepted for CABG.
Past Medical History:
Hypertension with microalbuminuria
Type 1 diabetes
Nephropathy
Retinopathy
Hyperlipidemia
Legally blind
Chronic lower extremity edema
Depression
Past Surgical History:
Appendectomy
Bilateral cataract surgery (left eye in [**Month (only) 958**] Right eye in
[**Month (only) **])Laser surgery left eye two weeks ago
Social History:
Lives with:alone legally blind has seeing eye dog for 20yrs
Contact: [**Name (NI) **] [**Name (NI) 19417**] Phone #[**Telephone/Fax (1) 19418**]
Occupation:[**Location (un) 5263**] self employed
Cigarettes: Smokes 3 cigars [**12-6**] a week, smokes MJ occasionally
Other Tobacco use:
ETOH: < 1 drink/week [x] [**1-11**] drinks/week [] >8 drinks/week []
Illicit drug use:MJ occasionally
Family History:
No premature coronary artery disease.
Physical Exam:
Pulse:65 Resp: 16 O2 sat: 98%
B/P Right:137/70 Left:126/70
Height: 5ft 11" Weight:265lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [x] Edema [x] +1 lower
extremity_____ Varicosities: None []
Neuro: Grossly intact [x]
Pulses:
Femoral Right:+1 Left:+1
DP Right: +1 Left:+1
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right:+2 Left:+2
Carotid Bruit Right: None Left:None
Pertinent Results:
[**2140-10-7**] Cath: LAD prox 50-60% stenosis with mid 50% stenosis,
2mm diag with 95% stenosis. LCx: diffuse disease om1, mod size
om2 distal 70% stenosis. RCA: mid vessel 50% stenosis with
diffuse distal disease.
[**2140-10-12**] Echo: PRE BYPASS No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy
with normal cavity size. Regional left ventricular wall motion
is normal. Overall left ventricular systolic function is mildly
depressed (LVEF= 40 %). The right ventricle displays mild global
free wall hypokinesis. There are simple atheroma in the
ascending aorta. There are simple atheroma in the aortic arch.
There are simple atheroma in the descending thoracic aorta. 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. Trivial 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 being atrially paced. There is normal
biventricular systolic function with a left ventricular ejection
fraction of 60%. There is no change in valvualr function. The
thoracic aorta is intact after decannulation.
[**2140-10-17**] 04:19AM BLOOD WBC-7.2 RBC-3.08* Hgb-9.3* Hct-27.0*
MCV-88 MCH-30.1 MCHC-34.3 RDW-11.9 Plt Ct-213
[**2140-10-16**] 02:22AM BLOOD WBC-5.7 RBC-3.01* Hgb-9.0* Hct-26.8*
MCV-89 MCH-29.8 MCHC-33.5 RDW-12.1 Plt Ct-191
[**2140-10-17**] 04:19AM BLOOD Glucose-106* UreaN-42* Creat-2.4* Na-138
K-4.2 Cl-100 HCO3-26 AnGap-16
[**2140-10-16**] 02:22AM BLOOD Glucose-223* UreaN-49* Creat-2.6* Na-137
K-3.9 Cl-100 HCO3-27 AnGap-14
Brief Hospital Course:
The patient was brought to the operating room on [**10-12**] where the
patient underwent:
Coronary bypass grafting x4; left internal mammary artery to
left anterior descending coronary; reverse saphenous vein single
graft from aorta to the first
diagonal coronary artery; reverse saphenous vein single graft
from the second obtuse marginal coronary artery; as well as
reverse saphenous vein single graft from the
aorta to the distal right coronary artery. 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. He did have an elevated baseline crea 2.4 and peak
creatinine post operatively was 3.4. Renal service was consulted
and his renal function slowly improved and was back to baseline
at the time of discharge. He was ambulating and became
bradycardic and light-headed on POD 3, lasix and lopressor were
decreased with no subsequent bradycardia with ambulation. He
had issues with hyperglycemia and had insulin regimen adjusted
by [**Last Name (un) **] who follows him as an outpatient. Blood sugars were
well controlled at the time of discharge. Plavix was resumed
for stents. 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 5 the patient was ambulating with
assistance, the wound was healing and pain was controlled with
oral analgesics. The patient was discharged to [**Hospital3 **],
[**Location (un) 86**] in good condition with appropriate follow up
instructions. His service dog will visit him at rehab to work
with the patient and assess safety prior to discharging home.
Medications on Admission:
ASA 81mg daily, diltiazem 240mg daily, lipitor 40mg daily,
losartan/hctz 100-25mg daily, alprazolam 0.5mg [**Hospital1 **], wellbutrin
SR 100mg daily, celexa 30mg daily, lantus 50-55units daily,
lispro 15units tid or ASDIR, vit C, vit D 2000units buccal route
[**Hospital1 **], flaxseed oil 1000mg daily, MVI daily, Max epa 1000mg daily,
folic acid 1mg daily, garlic/cayenne daily, fluticasone 50mcqs
daily, prednisolone 1 drop 4x day
Discharge Medications:
1. alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
2. bupropion HCl 100 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
6. insulin glargine 100 unit/mL Solution Sig: Fifty (50) units
Subcutaneous once a day.
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. 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*
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for temperature >38.0.
12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO QAM (once a day (in the morning)).
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO QPM (once a day (in the evening)).
16. Cepacol Sore Throat 15-2.6 mg Lozenge Sig: One (1) Mucous
membrane four times a day as needed for throat discomfort: prn.
17. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
18. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
19. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
21. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
22. insulin glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous once a day: 45 Units Lantus Qam.
23. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous four times a day: per attached Humalog Sliding
Scale.
24. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 weeks: 40mg [**Hospital1 **] x 1 week, then please re-evaluate need for
ongoing diuresis.
25. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO twice a day for 1
weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Coronary Artery Disease, s/p Coronary artery bypass graft x 4
Past medical history:
Hypertension with microalbuminuria
Type 1 diabetes
Nephropathy
Retinopathy
Hyperlipidemia
Legally blind
Chronic lower extremity edema
Depression
Past Surgical History:
Appendectomy
Bilateral cataract surgery (left eye in [**Month (only) 958**] Right eye in
[**Month (only) **])Laser surgery left eye two weeks ago
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right and Left - healing well, no erythema or drainage.
Edema 2+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] ([**Telephone/Fax (1) 170**]) on [**2140-11-14**] at 1:45pm
at [**Last Name (NamePattern1) **].[**Hospital **] Medical Office.
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], please call and make appointment
for 2 weeks
Please call to schedule appointments with:
Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**] ([**Telephone/Fax (1) 133**]in [**3-8**] 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:[**2140-10-17**]
|
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"276.69",
"V58.67",
"250.43",
"458.29",
"357.2",
"585.9",
"701.1",
"583.81",
"250.63",
"272.4",
"278.00",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.13",
"39.61",
"37.22",
"36.15"
] |
icd9pcs
|
[
[
[]
]
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9681, 9751
|
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|
10193, 10418
|
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2161, 2829
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272, 321
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9856, 10001
|
1695, 2091
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,195
| 185,233
|
42022
|
Discharge summary
|
report
|
Admission Date: [**2187-11-24**] Discharge Date: [**2187-11-27**]
Date of Birth: [**2161-9-19**] Sex: F
Service: MEDICINE
Allergies:
Reglan / Erythromycin Base / Effexor
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
LLQ pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
26 year old female with recent history of recent ([**10/2187**]) acute
liver injury secondary to Tylenol OD complicated by pancreatitis
and C. diff colitis presents with complaint of left lower
quadrant pain.
Pain similar to her prior endometriosis pain, in LLQ,
non-radiating, no alleviating factor. She has a history of
endometriosis requiring surgery in 08/[**2186**]. She has been on
OCPs which were discontinued in [**Month (only) **] during her Tylenol OD
in 11/[**2186**]. She was more recently hospitalized for 3 days on
[**11-19**] for left and right lower quadrant pain attributed to
endometriosis after discontinuation of her OCPs. A transvaginal
ultrasound demonstrated a stable hemorrhagic cyst. Gyn was
consulted and OCP restarted. With regards to her RUQ pain, it
was felt the patient may have had a mild recurrence of her
pancreatitis versus exacerbation of gastritis. Given her
AST/ALT ratio, EtOH was considered a trigger. Serum and urine
toxicology were negative except for opiods. An abdominal
ultrasound was obtained and normal. Her Protonix was increased
to twice daily. Her hospitalization was complicated by a large
morphine requirement. Psychiatry was consulted and felt
adjustment disorder contributing to her poor pain control and
felt close outpatient follow-up would be preferential to
initiating inpatient psychopharmacy. She was maintained on
morphine 4mg IV q3hrs with good control. She was transitioned to
morphine sulfate 15-30mg every 6 hours on discharge with a 1
week supply.
Since discharge 3 days ago she reports. Her mother reports that
the patient has been taking large doses of morphine up to 21
tablets (of 15mg tabs). After the patient slept all day on
Thursday, her morphine was taken away by the mother on [**Name (NI) 2974**].
This morning, she awoke at 10:30 AM and complained of severe
left lower quadrant pain. She denied associated nausea, emesis,
diarrhea, constipation, fever, or chills. She has not had any
vaginal bleeding, dysuria, melena or BRBPR. No history of
gallstones. She further denies using over the counter
medications for pain control including tylenol or ibuprofen. She
denies recent EtOH use. Last sexual encounter.
In the ED initial vitals were, 99.5 170 137/109 22 99% room air.
Labs were significant for a negative urine toxicology screen
and unremarkable cbc and chem10. A pelvic ultrasound
demonstrated a complex left ovarian cyst of reduced size when
compared to recent imaging in early [**Month (only) 1096**] consistent with a
resolving hemorrhagic cyst. A UCG was negative. She was given
5mg morphine x 3, 1mg IV Dilaudid and 2mg IV Ativan x 2 and 5mg
PO valium x 2. Her heart rate was persistently in the 150s
prompting transfer to the ICU. Vitals on transfer were: 154 20
113/73 100% RA with 7/10 pain.
On arrival to the ICU, initial vitals were: 99 149 142/82 100%
RA. She complained of [**5-18**] pain and significant anxiety,
tremulousness, and mild palpitations.
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:
1. Asthma since childhood
2. depression
3. acute liver failure secondary to Tylenol overdose
unintentional
4. acute pancreatitis
5. acute renal insufficiency
6. healthcare-associated pneumoni
7. C. diff colitis status post p.o. vancomycin
8. reflux for ~ 14 years ("since 8th grade)
9. endometriosis s/p surgery in [**7-/2187**]
Social History:
-Home: Single. Lives in RI with her mother. Also has 2 brothers
who live with their father. [**Name (NI) **] good family support.
-Occupation: on FMLA but otherwise works as a nurse on the
surgical and cardiac floors of a hospital in RI
-EtOH: None. Last drink was in [**2187-9-8**] prior to
tonsillectomy.
-Tobacco: None.
-Illicits: None.
Family History:
Father w/ COPD, HTN, AAA s/p repair (long time smoker), peptic
ulcer disease.
Mother w/ diverticular bleed.
Aunt with diverticulosis.
Physical Exam:
Admission exam:
Vitals: 99 149 142/82 100% RA.
General: Alert, oriented, no acute distress, appears anxious and
tremulous
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: +BS, soft, LLQ tenderness, non-distended, no rebound
tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: +BS, soft, LLQ tenderness, non-distended, no rebound
tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs:
[**2187-11-24**] 01:40PM BLOOD WBC-8.6 RBC-3.99* Hgb-12.3 Hct-36.4
MCV-91 MCH-30.7 MCHC-33.8 RDW-12.5 Plt Ct-454*
[**2187-11-24**] 01:40PM BLOOD Neuts-64.5 Lymphs-30.2 Monos-3.4 Eos-1.5
Baso-0.4
[**2187-11-24**] 01:40PM BLOOD Glucose-121* UreaN-14 Creat-1.0 Na-139
K-4.9 Cl-100 HCO3-25 AnGap-19
[**2187-11-24**] 01:40PM BLOOD ALT-47* AST-58* LD(LDH)-331* CK(CPK)-PND
AlkPhos-92 TotBili-0.7
[**2187-11-24**] 01:40PM BLOOD Lipase-53
[**2187-11-24**] 01:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Urine tox: + opiates
Imaging:
Pelvic Ultrasound [**2187-11-24**]:
Complex left ovarian cyst measures 1.5 x 0.8 x 1.3 cm which is
smaller than [**2187-11-17**]. Findings consistent with a resolving
hemorrhagic cyst.
Brief Hospital Course:
26 y/o female with recent acute liver injury secondary to
Tylenol OD complicated by pancreatitis and cdiff colitis, known
endometriosis, presents with complaint of left lower quadrant
pain in the setting of her recently prescribed narcotic pain
medications being taken away.
# SINUS TACHYCARDIA: HR in 170s upon presentation to ED.
Etiology concerning for poorly controlled pain related to
endometriosis/hemorrhagic ovarian cyst, anxiety, opioid
withdrawal and benzodiazepine withdrawal. Most likely
multifactorial, involving all of the above. In addition,
patient endorsed poor PO intake with a Cr bump from 0.5 baseline
to 1.0, so hypovolemia likely contributed. Infection unlikely
in the absence of localizing symptoms, no cough, sick contacts,
urinary symptoms, fevers, chills, N/V/D. Recurrent pancreatitis
possible, however lipase was normal. PE less likely as patient
recently on subcutaneous heparin in the hospital, OCP only
restarted a few days ago, no sign/symptoms of DVT. TSH within
normal limits. Urine toxicology negative, so toxic ingestions
unlikely. Once pain medication was restarted (at doses given
during most recent hospitalization), tachycardia resolved. In
addition, patient was given IVF then was taking good oral fluid
intake. She was transferred to the floor where she remained
stable with HR ranging 90s-low 100s. She was given IVF and
encouraged to drink. She tolerated po fluids and food well and
was ambulating without difficulty. At the time of discharge she
was medically stable with no acute medical issues.
# ABDOMINAL PAIN: recurrent issue leading to multiple
hospitalizations. Patient seen by psychiatry (they have seen
patient during all of her prior hospitalizations) who felt
likely adjustment disorder in setting of uncontrolled pain which
may likely be exacerbated by removal or pain medications.
Recurrent pancreatitis ruled out with normal labs. Abdomen soft
with only mild tenderness to palpation. Gynecology was
consulted who felt that there was nothing further to do while
inpatient, as hemorrhagic cyst was improving on transvaginal
ultrasound, and that patient should follow-up as outpatient. In
addition, they encouraged patient to continue OCPs. RUQ u/s was
again performed and was unremarkable. Suspect a large component
of pain is somatization at this point, given the negative work
up. Pain should be improving, not getting worse, if it was [**1-10**]
cyst, which is resolving. Pain was managed as below under
"substance abuse."
# substance abuse/depression: pt now has two episodes of
"accidental overdose" over the span of only 3-4 months.
Initially pt overdosed on tylenol secondary to percocet use
after tonsillectomy, developed acute liver injury and almost
required transplant. Now patient has overdosed on oral morphine
IR, taking 315mg over the course of one day, prompting second
ICU stay for overdose. Pt was stabilized in ICU and started on
mirtazipine by psychiatry. She was transferred to the floor on
hospital day 2. She was maintained on IV morphine on the floor
initially, but the evening of transfer, nurse reported finding
patient had adjusted the infusion rate on her morphine drip
after going to the bathroom with her IV pole. Patient denied
adjusting the morphine drip, which had been increased to the
maximum rate. At this time patient was switched to oral pain
medications (oxycodone). Of note, pt is a nurse and is aware of
the proper use of these medications, as well as use on IV
equipment. It was concerning that despite her knowledge, she
claimed her overdoses were accidental on both occasions. though
pt seen by psych in past and denied SI/HI, at this visit she
stated that she took the morphine because she was "sick and
tired of being in pain and just wanted to make it stop." These
words were concerning for possible self-harm. Pt also
expressing poor judgment and impulsivity, making it unsafe for
her to be sent home with pain medications again. Due to
patient's abuse of tylenol and narcotics, as well as her h/o
gastritis, she is now contraindicated for tylenol, NSAIDs, and
all opioids. Consulted pain service and psych who all agreed
pt's only options are rehab/psych hospitalization vs home with
no narcotics. Given her extensive narcotic use, oxycodone and
lorazepam will need to be tapered. She is currently on oxycodone
5mg every 4 hours as needed for pain. This can be tapered to
every 8 hours in the next couple of days then Q12h then to daily
then off. Similarly, lorazepam can be tapered in the same
fashion. Chronic pain service recommended that if pain persists,
gabapentin 300mg TID can be started. Pt was medically stable so
plan was made to arrange for rehab program on discharge.
# ANEMIA: History of normocytic anemia with baseline hct around
30. Hematocrit 36 on admission suggesting hemoconcentration.
Recent normal iron level. B12/folate within normal limits and
hemolysis labs negative.
# [**Last Name (un) **]: baseline Cr 0.5-0.7. Creatinine returned to [**Location 213**] on HD
1 with fluid rehydration.
# ASTHMA: continued on home advair and singulair
# GASTRITIS: continued home protonix
# TRANSITIONAL ISSUES:
- follow-up appointment with PCP [**Last Name (NamePattern4) **]: new antidepressants until
psychiatrist is established
- follow-up appointment with gynecology
- follow-up appointment with hepatology (missed appt during this
admission)
Medications on Admission:
- albuterol sulfate 90 mcg/Actuation Inhaler 1 puff q6H
SOB/wheezing
- fluticasone-salmeterol 250-50 [**Hospital1 **]
- Protonix 40 mg [**Hospital1 **]
- Singulair 10 mg daily
- Junel FE 1.5/30 (28) 1.5-30 mg-mcg daily
- morphine 15 mg [**12-10**] tab Q6H prn pain
- lorazepam 1 mg q6H prn anxiety
- Zofran 8 mg q8H prn nausea
Discharge Medications:
1. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Junel FE 1.5/30 (28) 1.5-30 mg-mcg Tablet Sig: One (1) Tablet
PO daily ().
3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on, 12 hours off.
4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for Pain. Tablet(s)
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Location (un) 86**]
Discharge Diagnosis:
substance abuse
opioid withdrawal
dehydration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital because you were in pain and your heart
was racing. You were admitted to the ICU for suspected opioid
withdrawal and dehydration. A pain specialist and psychiatrist
were called to evaluate you and all agreed that it is unsafe for
you to go home or to continue to take narcotics. You are being
discharged to Deaconness 4 for further management.
Followup Instructions:
You will be followed by an inpatient team while you are
hospitalized. In addition, please be sure to keep the following
appointments:
Department: [**Hospital3 249**]
When: [**Hospital3 **] [**2187-12-14**] at 4:10 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: WEDNESDAY [**2188-2-20**] at 2:35 PM
With: [**Name6 (MD) **] [**Name6 (MD) 28883**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
|
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"304.10",
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"617.9",
"285.9",
"620.2",
"296.20",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13229, 13299
|
6391, 11530
|
308, 314
|
13389, 13389
|
5604, 5604
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|
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13320, 13368
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260, 270
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11553, 11790
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3797, 4128
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4144, 4486
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,913
| 184,459
|
45498
|
Discharge summary
|
report
|
Admission Date: [**2132-8-11**] Discharge Date: [**2132-8-19**]
Date of Birth: [**2075-1-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
hypotension in setting of decubitus ulcer
Major Surgical or Invasive Procedure:
code called [**2132-8-12**] for respiratory arrest, chest compressions
Aline [**2132-8-12**]
History of Present Illness:
HPI: 57 YO F with history of poorly controlled Type II DM,
osteomyelitis of L heel s/p L BKA [**6-20**], ESRD on HD, HTN and
sacral decubitus ulcer with numerous attempts at debridement,
all refused by patient. Pt found to be hypotensive in [**Hospital1 1099**] ER to 60s systolic, right femoral line placed and pt
given 250 NS bolus X 2 with SBP improved to 80s, started on
vanco/unasyn/levo, blood cx sent. Also with decr po intake and
failure to thrive, refusing tx at OSH. On arrival to ED [**Hospital1 18**],
BP 90/30, 102/39, 82/47. No other complaints. No CP/SOB. No
N/V/D/C. Feels cold but no fever or chills. No abd pain. At
baseline, gets out of bed with physical therapy transferring pt
to her wheelchair.
Past Medical History:
Past Medical History:
1.)Hypertension
2.)DM2
3.)ESRD on HD
4.)Hypercholesterolemia
5.)Anemia
6.)Left thalamic and basal ganglia infarcts
7.)Osteomyelitis of L heel s/p L BKA
8.)Pathologic fracture of R tibia & fibula
9.)Sacral decubitus ulcer, Stage IV
Social History:
[**Location (un) 86**] native, never married, no children, lived alone in
[**Location (un) 686**]. Master's degree in administration and management,
worked in public relations for FEMA. Mother by adoption, [**Name (NI) **]
[**Name (NI) 97073**], adopted her as an adult to look after her. She is one
HCP. [**Name (NI) **] HCP is [**Name (NI) 1692**] [**Name (NI) 1059**], friend. [**11-18**] ppd X 10 years, quit
many years ago. No Etoh, no IVDA.
Family History:
Non-contributory
Physical Exam:
Vital signs: Temp: 94.9 BP: 76/29 P: 97 RR: 16 Oxygen sat:
97% RA
NAD, reluctanct to interact with examiner, answers some
questions; marked bitemporal wasting
HEENT: PERRL, EOMI, MMM, thrush present on mucous membranes
Lungs: Pt refused lung exam.
CV: RRR S1 and S2 audible. systolic murmur at RUSB
Abd: Soft, NT, ND, Pos bs, no masses.
Peripheral ext: Left leg amputated at the knee, right leg with
black discoloration around toes, small ulceration right lower
leg.
Sacrum: With large Stage IV decubitus ulcers with overlying
green crust, +foul odor, open areas. Upper thighs anteriorly
with erythema, skin breakdown.
Pertinent Results:
ECHO [**2132-8-12**], EF<25%
Conclusions: 1. The left ventricular cavity size is normal.
There is severe global left ventricular hypokinesis. Overall
left ventricular systolic function is severely depressed.
2. The right ventricular cavity is dilated. Right ventricular
systolic
function appears depressed. 3. The aortic valve leaflets (3)
are mildly thickened. Trace aortic regurgitation is seen. 4.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
5. Moderate [2+] tricuspid regurgitation is seen. There is mild
pulmonary
artery systolic hypertension. 6. Compared to the findings of
the prior study of [**2131-9-11**], left ventricular systolic function
has deteriorated.
.
[**2132-8-13**], CT Angiogram of the chest
CONCLUSION:
1. Positive study for acute pulmonary embolus involving
segmental branches in the posterior basal segment of left lower
lobe.Other area may represent a more subacute or chronic
process.
2. Large bibasilar dependent pleural effusion. Almost complete
collapse of the left lower lobe and partial atelectasis of the
dependent portion of right lower lobe.
3. Central line and endotracheal tube are in good position. Some
nonocclusive (likely mucus) noted in the left central airways.
.
[**2132-8-11**] GLUCOSE-94 UREA N-11 CREAT-1.7* SODIUM-145
POTASSIUM-3.5 CHLORIDE-112* TOTAL CO2-25 CALCIUM-7.8*
PHOSPHATE-1.3* MAGNESIUM-1.8; WBC-13.2* RBC-2.79* HGB-8.5*
HCT-26.5* MCV-95 MCH-30.4 MCHC-32.1 RDW-16.7* with NEUTS-91*
BANDS-2 LYMPHS-5* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-1*
MYELOS-0 NUC RBCS-1*; PLT COUNT-74*
[**2132-8-11**] LACTATE-1.7
[**2132-8-11**] GLUCOSE-106* UREA N-11 CREAT-1.8*# SODIUM-144
POTASSIUM-2.9* CHLORIDE-110* TOTAL CO2-28 ANION GAP-9
[**2132-8-17**] Fibrino-122*, [**2132-8-14**] Fibrino-131*, [**2132-8-13**]
FDP-80-160*
[**2132-8-12**] FDP-80-160*, with Peripheral Smear negative for
schistocytes or helmet cells. Positive for Burr cells.
[**2132-8-13**] Anemia Workup: Ret Aut-0.8*, [**2132-8-14**] LD(LDH)-216,
Haptoglobin 20, [**2132-8-12**] 07:56AM BLOOD ALT-22 AST-46*
LD(LDH)-287* CK(CPK)-42 AlkPhos-145* TotBili-0.3
[**2132-8-14**]: Cortstim negative: Not adrenally insufficient
.
[**2132-8-18**] CXR An orogastric tube terminates below the diaphragm. A
left PICC line terminates in the left axilla, a left internal
jugular vascular catheter terminates at the junction of the
superior vena cava and right atrium, and an endotracheal tube is
in satisfactory position. The heart size is normal. Bilateral
pleural effusions, moderate on the right and small on the left
are again demonstrated. Previously present perihilar haziness
has resolved in the interval and the cardiac silhouette appears
smaller, likely due to improving volume status of the patient.
.
RIGHT ANKLE 3 VIEWS [**2132-8-14**]: RIGHT ANKLE, THREE VIEWS:
Comparison is made to prior study dated [**2132-6-26**]. Again
seen are fractures of the distal tibia and fibula with mild
impaction of the tibial component. There is evidence of interval
callus formation, although fracture lines remain conspicuous.
There is asymmetry about the ankle mortise. There is severe
diffuse osteopenia and extensive vascular calcifications. There
is no gross osseous destruction. No subcutaneous gas is
identified.
IMPRESSION: Mild interval healing of distal tibial and fibular
fractures as above in the setting of severe diffuse osteopenia.
.
[**2132-8-13**] 6:29 pm SWAB
Source: superficial and deep wound cx-sacral decubitus
ulcer base.
**FINAL REPORT [**2132-8-17**]**
GRAM STAIN (Final [**2132-8-13**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
WOUND CULTURE (Final [**2132-8-16**]):
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).
UNABLE TO R/O OTHER PATHOGENS DUE TO OVERGROWTH OF
SWARMING PROTEUS
SPP..
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE
GROWTH.
PROTEUS SPECIES. MODERATE GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
QUANTITATION NOT AVAILABLE. SECOND STRAIN.
ENTEROCOCCUS SP.. SPARSE GROWTH.
ANAEROBIC CULTURE (Final [**2132-8-17**]): NO ANAEROBES ISOLATED.
.
[**2132-8-11**] 2:15 pm BLOOD CULTURE NO SITE NOTED.
**FINAL REPORT [**2132-8-18**]**
AEROBIC BOTTLE (Final [**2132-8-18**]):
PROTEUS MIRABILIS.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM
ANAEROBIC BOTTLE.
ANAEROBIC BOTTLE (Final [**2132-8-18**]):
REPORTED BY PHONE TO [**Doctor Last Name **],STEPENIE @ 2220 ON [**2132-8-12**].
PROTEUS MIRABILIS. FINAL SENSITIVITIES.
PROTEUS MIRABILIS. 2ND TYPE. FINAL SENSITIVITIES.
Trimethoprim/Sulfa sensitivity available on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| PROTEUS MIRABILIS
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- =>32 R =>32 R
CEFAZOLIN------------- 16 I <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ 32 R 16 I
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ =>16 R 8 I
LEVOFLOXACIN---------- =>8 R =>8 R
MEROPENEM------------- 1 S <=0.25 S
PIPERACILLIN---------- =>128 R =>128 R
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ 8 I 2 S
.
[**2132-8-11**] 3:00 pm SWAB LEFT LEG AMPUTATION.
**FINAL REPORT [**2132-8-15**]**
GRAM STAIN (Final [**2132-8-11**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final [**2132-8-15**]):
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 NEGATIVE ROD #1. MODERATE GROWTH.
PROTEUS SPECIES. MODERATE GROWTH.
STAPH AUREUS COAG +. MODERATE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**5-/2433**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
Brief Hospital Course:
IMPRESSION: 57 y/o AAF with h/o Type II DM, HTN, L BKA, sacral
decubitus ulcer, presents with hypotension, hypothermia, sepsis
most likely [**12-19**] infected decubitus ulcer.
.
1. Hypotension/SEPSIS- On admission, the pt was hypothermic to
94.9 (placed on warming blankets, improved to 97.0 and remained
97s throughout admission), hypotensive (SBP 70s-80s), felt most
likely to be septic picture. She was immediately started on IV
Zosyn and Vancomycin on admission (empirically treated, and then
cultures came back positive from blood and wounds). The pt was
felt to be septic from her infected Stage IV decubitus ulcer
wound cx growing out Proteus, Enterococcus and Corynebacterium
diphtheriae, and her L BKA stump swab cx growing out Proteus.
On [**2132-8-11**], her blood cx grew GNR in aerobic bottle with Proteus
mirabilis in anaerobic bottle, sensitive to Zosyn. Her mean
arterial pressure was maintained >60 with fluid boluses and 2
pressors, levophed and vasopressin, both titrated to maintain
her MAP. She initially presented with metabolic acidosis with
elevated lactate. Over the course of her stay, her lactate
trended down, but she remained acidotic. Her cortstim test was
negative, thus she was not adrenally insufficient. In the
Emergency Dept, she adamantly refused surgical debridement. On
arrival to ICU, she refused surgery, which was documented in the
chart. The pt understood the risks of not undergoing surgery,
and the benefits of surgical debridement, however, she declined
surgical intervention several times. This was documented in her
chart. The pt requested IV antibiotics and wound care, and
other supportive measures, however. Multiple meetings with the
health care proxy, Mr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1059**], and her adopted mother, Ms.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 97073**], was held. The pt showed no signs of improvement
over her stay in the ICU. She remained persistently
hypothermic, hypotensive requiring two pressors, and was not
able to wean from the ventilator (see below, respiratory
arrest). On [**2132-8-19**], it was decided by Mr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1059**], Ms.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 97073**], and the medical ICU team (including Ethics,
Psychiatry, and the ICU physicians) to make the patient "Comfort
Measures Only". The patient was extubated, made comfortable,
and pressors were withdrawn. She expired the evening of [**2132-8-19**],
with her adopted mother at her side.
.
# RESPIRATORY ARREST [**2132-8-12**] with Pulseless Electrical Activity:
Her respiratory arrest was with unclear etiology, and ddx
included altered mental status from hypoxia vs. sepsis vs.
pulmonary embolism vs. medication-induced vs. hypovolemia. She
was not acidotic at time (labs drawn peri-code). Did not suspect
tamponade, tension pneumothorax or pericardial effusion, last
echo TTE 1 month ago showing EF 60%, no valvular deficits. Did
not suspect toxic ingestion of medication. However, pulmonary
embolism was considered, and a CTA on [**8-13**] demonstrated small
acute PE in peripheral segmental branch of posterior segment
LLL; large lilateral pleural effusions with collapse of LLL and
partial atelectasis of RLL, 2 old areas for PE also. We did not
start heparin and did not feel that this is the cause for her
respiratory arrest/PEA, given the small size of the PE. We also
held off on heparin because we were ruling the pt out for
heparin induced thrombocytopenia. Her CXR was stable, no acute
pulm process, heart size WNL. The pt was unable to be weaned
from the ventilator. She was felt too sick, with her 2 pressor
requirement, persistent hypothermia and elevated WBC ct. She
also had a metabolic acidosis, (with lactate trending down at
this time), that worsened with a weaning trial.
.
2. Sacral decubitus ulcer: seen by vascular surgery and general
surgery, with pt refusing operative intervention documented in
ED, and on admission to Intern and Resident in [**Hospital Unit Name 153**]. A wound
care consult was obtained. As stated prior, her deep wound cx
on [**2132-8-13**]: wound cx deep and superficial, swab growing 3+GNR,
3+GPR, 1+GPC in pairs, wound cx: Corynebacterium diphtherioids
moderate, Proteus moderate, Enterococcus, no anaerobes. On
[**2132-8-11**] her Left below the knee amputation stump swab culture
grew out Gram negative rods, found to be Proteus, as well as
coagulase-positive Staphylococcus. IV antibiotics were
continued until she was made "comfort measures only".
.
3. Anemia: She had no clear bleeding source. Her hemolysis labs
were as follows: LDH 287, 216, haptoglobin 20 (low), retic
0.8%. She was guiaic negative. We supported her Hct with blood
transfusions. Her Hct stabilized, and near the end of her stay
she did not require transfusions.
.
4. Thrombocytopenia. DDX includes PE, DIC, HIT. Initially DIC
was considered, however peripheral smear failed to reveal
schistocytes or helmet cells, only Burr cells. Her DIC panel
was: fibrinogen 193, FDP 80-160, PT, PTT not overly elevated to
suggest DIC. We resent her fibrinogen study, which did have a
low level at 131, however, literature did not support
cryoprecipitate for a level less than 100, so did not transfuse.
We checked a HIT antibody, which was pending at the time of her
death. [**Name8 (MD) **] RN pt received NO heparin and NO heparin flushes.
Her HD cath is lined with heparin when they change it out during
HD, but it did not travel systemically and is only coated the
length of the catheter.
.
5. Distal tibia and fibula fracture, old, and seen on prior
radiologic studies from prior admissions. Her physical exam
demonstrated a lax joint, no sensation. Ankle XR reviewed with
radiologist [**2132-8-14**]: Distal fx of both tibia and fibula, vs.
?osteomyelitis, osteopenia evident.
.
6. ESRD on HD: A Renal consult was obtained. One hemodialysis
attempt was made, however the patient's blood pressure dropped
dramatically, and HD was immediately ceased. Given her labs,
which did not indicate an immediate requirement for HD, it was
decided to hold off on HD or CVVH. For her acidosis, we treated
pt with 150mEq of HCO3 in 1L of D5W. Her lactate had trended
down to WNL during her stay, however she remained in metabolic
acidosis, non-gap.
.
7. PSYCHIATRY/ETHICS/GOALS OF CARE/MEDICAL COMPETENCY:
Psychiatry consult called [**2132-8-13**]: Psychiatry felt that the pt
was not competent to make medical decisions for herself and is
infact encephalopathic. Family meeting called for [**2132-8-15**] with
both HCP and Attending to discuss goals of care/prognosis. She
will clearly not get better without surgical debridement of her
decubitus ulcer, however now she is septic and likely too sick
to go to the OR. Ethics consult called to assist in this
situation. Prior to intubation, pt clearly expressed that she
did not want surgery. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 97073**] has been informed of all
events and kept up to date re: pt status, as well as Mr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 97076**], the HCP. [**Name (NI) **] [**Name2 (NI) **] was present at several family
meetings as well. It was decided on [**2132-8-18**] to make the patient
Comfort Measures Only, and withdraw care. This was documented
in the chart. Mr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1059**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 97073**] took part in the
decision, and both in agreement. No h/o depression per psych,
unclear why she was on wellbutrin and abilify at admission.
Psych meds were held during her admission.
.
8. Type II DM
We checked FSBS qid and the pt's blood sugar was well-controlled
on an insulin sliding scale.
.
9. HTN
We held her BP meds for given hypotension with sepsis. At home,
she was on lopressor, catapres, prinivil.
.
10. CODE STATUS: Initially the pt was full code discussed with
pt, did not want surgery but wants IV abx, fluids, meds. HCP
was also updated and informed. She was then transitioned to
DNR/DNI with CMO status, when it was evident she was not
improving, and refusing surgical debridement of her decubitus
ulcer, which was infected and causing her sepsis. The pt
expired on [**2132-8-19**].
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Sepsis
2. Respiratory Arrest with Pulseless Electrical Activity
3. Stage IV Decubitus Ulcer
4. End Stage Renal Disease on Hemodialysis
5. Thrombocytopenia
6. Anemia
7. Type II Diabetes Mellitus
8. Hypertension
Discharge Condition:
Expired on [**2132-8-19**]
Completed by:[**2132-8-27**]
|
[
"585.6",
"285.9",
"785.52",
"403.91",
"707.03",
"287.5",
"518.81",
"112.0",
"415.19",
"276.52",
"038.49",
"272.0",
"997.62",
"995.92",
"250.00",
"397.0",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"39.95",
"99.60",
"96.04",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
18797, 18806
|
10374, 18774
|
313, 407
|
19070, 19127
|
2607, 10351
|
1924, 1942
|
18827, 19049
|
1957, 2588
|
231, 275
|
435, 1163
|
1207, 1440
|
1456, 1908
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
460
| 145,034
|
24598
|
Discharge summary
|
report
|
Admission Date: [**2117-5-28**] Discharge Date: [**2117-5-30**]
Date of Birth: [**2117-5-25**] Sex: F
Service: NB
HISTORY: Baby girl [**Known lastname 62103**] was admitted to the newborn
intensive care unit at 3 days of age for evaluation of fever.
Her birth weight was 4.22 kg, 39 week female. She
was born to a 36-year-old G2, P1, now 2 female. Prenatal
screens A negative, antibody negative, RPR nonreactive,
rubella immune, hepatitis B surface antigen negative, GBS not
documented. No history of herpes infection. Uncomplicated
pregnancy. Elective repeat cesarean section under spinal
anesthesia. Rupture of membranes at delivery. Apgars were 9
and 9. In newborn nursery breast and bottle feeding. Hypo-
glycemia protocol started in light of LGA status. Stable
dextrosticks. Transitional murmur resolved. Blood type AB
positive, Coombs negative. Hepatitis B vaccine given on [**5-28**]. Bili on [**5-28**] was 10.5/0.3. Temperature has been
increasing beginning late in the evening of [**5-27**] from 99.8 to
100.5 to 101.3. She was admitted to the newborn intensive care
unit for evaluation.
PHYSICAL EXAMINATION: This is an LGA term female with
decreased activity and slow capillary refill. Temperature 102,
pulse 180, respiratory rate 52, blood pressure 92/60 with a
mean of 74, oxygen saturations in room air 98. Weight on
admission 4.055 kg, length 56 cm, head circumference 35 cm.
Anterior fontanel, soft and flat. Nondysmorphic. Intact
palate. Clear, equal breath sounds. No murmurs. Normal
pulses. Soft abdomen. Dry cord. Normal bowel sounds. No
hepatosplenomegaly. Normal female genitalia. Patent anus.
Mucousy yellow stool with some small areas of gross blood in
diaper. No fissure noted. Lax hips. Sacral dimple, unable
to see end of tract. 4 second capillary refill. Decreased tone
and activity.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY: The baby has been stable in room air during her
admission to newborn intensive care unit.
CARDIOVASCULAR: She received one bolus of normal saline for
capillary perfusion. Otherwise she has been cardiovascularly
stable.
FLUIDS, ELECTROLYTES AND NUTRITION: Birth weight was 4.220
kg, admission weight was 4.055 kg. Discharge weight was kg.
The infant was initially started on 60 cc per kg per day of
D10W in light of the frankly blood stool. KUB remained stable
and reassuring. Feeds were restarted and the infant is currently
ad lib feeding by breast and bottle.
Electrolytes on admission shows sodium of 138, potassium of
5.3, chloride of 107, total CO2 of 20. ALT 8, AST 24,
alkaline phosphatase 105.
GASTROINTESTINAL: Bilirubin on admission was 10.2/0.2. She
has not required any phototherapy.
HEMATOLOGY: Hematocrit on admission was 39.7. She has not
required any blood transfusions. The patient's blood type is
AB positive, Coombs' negative.
INFECTIOUS DISEASE: Based on fever in a three day old, the
differential diagnosis included sepsis and herpes. A full
evaluation was done. CBC and blood culture were obtained on
admission. CBC was benign. White count was 10.8, 77 polys, 1
band, platelet count 234. LP was within normal limits with white
blood cell count of 2, red blood cell count of 1, protein 36,
glucose 65. She was started on ampicillin, gentamicin and
acyclovir. An HSV PCR is pending on the CSF. It should be
ready on [**Last Name (LF) 766**], [**2117-5-31**], at Quest Labs, telephone No.
[**Telephone/Fax (1) 40616**]. Other cultures that were sent include stool
culture for enterovirus, rotavirus and Campylobacter as well as
viral cultures for HSV. CSF and Blood culture remain negative to
date. She completed a 48 hour rule out of ampicillin and
gentamycin. The plan was to continue acyclovir until HSV PCR
results were obtained on [**5-31**] and negative. IV access became
unobtainable late on [**5-29**] despite multiple attempts by nurses,
nurse practitioners and the neonatologist, therefore acyclovir
was held and the infant was monitored clinically overnight. There
was no recurrence of fever or issues of clinical concern,
therefore she was discharged with the plan for close follow up
with the pediatrician (Dr. [**Last Name (STitle) 31097**]. The parents were involved
in the decision making to hold further HSV therapy.
Of note she also developed a macular and morbiliform rash
consistent with viral syndrome on day 3, it resolved late on day
4. Also of note her 15 month old sister had a very similar
presentation and course during her neonatal period without an
etiology found.
NEUROLOGY: She has been appropriate for gestational age.
OTHER: She has a sacral dimple with a blind track. Sacral
ultrasound was ordered for [**5-31**]. It has not been done.
Consideration should be given to sacral ultrasound as an
outpatient.
AUDIOLOGY: Hearing screen was performed with automated
auditory brain stem responses and was passed.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 31097**]. Telephone
No. [**Telephone/Fax (1) 51637**].
FEEDS AT DISCHARGE: Continue ad lib feeding of breast milk
MEDICATIONS: None.
CARE RECOMMENDATIONS: Routine. Sacral ultrasound should be
considered. Results for HSV PCR and viral studies will need to
be followed.
THE STATE NEWBORN SCREEN: The last State Newborn Screen was
sent on [**2117-5-28**], and is pending.
IMMUNIZATIONS RECEIVED: The infant received Hepatitis B
vaccine on [**2117-5-28**].
DISCHARGE DIAGNOSES:
1. Term female
2. LGA
3. Fever of unclear etiology, resolved
4. Sepsis ruled out with antibiotics.
5. Rule out HSV.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Last Name (NamePattern1) 56045**]
MEDQUIST36
D: [**2117-5-29**] 23:19:09
T: [**2117-5-30**] 01:09:21
Job#: [**Job Number 62104**]
|
[
"685.1",
"771.89",
"778.4",
"V72.1",
"V30.01",
"V05.3",
"766.1",
"772.4",
"079.99",
"V29.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.55",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
4946, 5111
|
5537, 5924
|
5210, 5516
|
1885, 4888
|
1152, 1857
|
5126, 5187
|
4913, 4922
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,483
| 117,482
|
33760
|
Discharge summary
|
report
|
Admission Date: [**2124-1-19**] Discharge Date: [**2124-3-14**]
Date of Birth: [**2048-2-29**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Acute Pancreatitis
Major Surgical or Invasive Procedure:
Open Tracheostomy [**2124-2-4**]
Open G/J tube placement [**2124-2-11**]
History of Present Illness:
This is a 75 year old male admitted from [**Location (un) 14663**] with acute
pancreatitis, (amylase 2698, lipase 3327 at OSH). He reports no
ETOH, and imaging reveals no gallstones, his TG were 114.
A CT ([**1-17**] - OSH) abd/pelvis showed nonspecific inflammatory
changes in anterior pararenal space, extending from above
pancreas in pelvis and involving R retroconal fashion. Fatty
liver. Small amount ascites, borderline enlarged pelvic lymph
nodes. Gallbladder WNL. A RUQ U/S ([**1-17**] - OSH) showed CBD 4mm, no
gallstones. At the OSH, he was treated with ABX, NPO, IVF. His
repeat lipase/amylase showed a downward trend, but transferred
to [**Hospital1 18**]. He was admitted to ICU for tachycardia to low 100s,
tachypnea in 30s, PaO2 66 on 4L NC; also hypocalcemic.
Past Medical History:
PMH:CAD s/p MI [**30**] years ago; HTN, hyperlipidemia, obesity, OA,
BPH, duodenal ulcer
PSH:B TKR (most recent R TKR [**1-5**])
Social History:
Retired contractor, living with 2nd wife. [**Name (NI) **] a daughter and 4
sons. Quit smoking 15 yrs. ago. No history of alcohol and
IVDU.
Family History:
Parents - hypertension
Mom - CVA
Pertinent Results:
[**2124-1-20**] 12:22AM BLOOD WBC-21.5* RBC-3.02* Hgb-9.0* Hct-27.7*
MCV-92 MCH-29.8 MCHC-32.4 RDW-13.8 Plt Ct-334
[**2124-1-26**] 01:18AM BLOOD WBC-22.3* RBC-2.50* Hgb-7.3* Hct-23.9*
MCV-96 MCH-29.3 MCHC-30.7* RDW-14.5 Plt Ct-326
[**2124-1-20**] 04:56AM BLOOD Glucose-272* UreaN-60* Creat-1.6* Na-140
K-3.9 Cl-107 HCO3-22 AnGap-15
[**2124-1-26**] 01:18AM BLOOD Glucose-111* UreaN-39* Creat-1.6* Na-146*
K-4.4 Cl-117* HCO3-22 AnGap-11
[**2124-1-20**] 04:56AM BLOOD Lipase-225*
[**2124-1-26**] 01:18AM BLOOD Lipase-24
[**2124-1-26**] 01:18AM BLOOD Calcium-7.6* Phos-4.3 Mg-2.0
.
CT ABDOMEN W/CONTRAST [**2124-1-20**] 4:29 AM
IMPRESSIONS:
1. No evidence of pulmonary embolus.
2. Moderate-to-severe acute pancreatitis, with little to no
enhancement of the pancreatic neck and head, focal ileus and
moderate associated ascites. No evidence of associated vascular
compromise.
.
Cardiology Report ECG Study Date of [**2124-1-20**] 1:29:16 AM
Sinus tachycardia. Non-diagonstic repolarization abnormalities.
No previous tracing available for comparison.
Rate PR QRS QT/QTc P QRS T
107 160 100 356/438 30 -18 6
.
TTE (Complete) Done [**2124-1-21**] at 11:43:28 AM
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 70%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is moderately dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is no pericardial effusion.
.
CT ABDOMEN W/CONTRAST [**2124-1-23**] 11:57 AM
1. Diffuse peripancreatic edema/phlegmonous change. No
pseudocyst or abscess present at this time. Mild hypoenhancement
of the pancreatic head likely related to the acute inflammatory
process. Small amount of ascites.
2. Mildly dilated proximal small-bowel loops likely representing
focal localized ileus. No small-bowel obstruction. Inflammatory
thickening of the 2nd and 3rd portions of the duodenum as well
as the hepatic flexure.
3. Markedly enlarged prostate.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2124-1-24**] 9:17 AM
1. Limited exam. The liver is coarsened and echogenic consistent
with fatty infiltration. More advanced liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded. No
focal hepatic lesion is identified.
2. No evidence of gallstone or intra/extrahepatic biliary
dilatation.
3. Ascites.
.
CHEST (PORTABLE AP) [**2124-1-25**] 8:52 AM
INDICATIONS: A 75-year-old man intubated, with increasing
leukocytosis and fever. Question pneumonia.
CHEST, AP PORTABLE SEMI-UPRIGHT: Comparison is made to the prior
day, also with limited review of a recent CT from [**2124-1-20**]. The
patient remains intubated. The endotracheal tube again
terminates at the carina. A nasogastric tube passes into the
stomach, although its distal course is not well visualized for
technical reasons. The lung volumes are low, and the film
lordotic in orientation. Persistent bibasilar opacities are
present, most suggestive of atelectasis. There is no
pneumothorax, definite effusion or pulmonary edema.
IMPRESSION: Endotracheal tube terminating at the carina.
Probable bibasilar atelectasis
R KNEE 2 VIEW PORTABLE [**2124-1-27**] 9:31 AM
History: 75-year-old male with erythema and pain. Evaluate for
fluid or
infection.
1. Large joint effusion.
2. Intact total knee arthroplasty without signs for loosening.
CT TORSO [**2124-1-28**] 1:43 PM
INDICATION: Pancreatitis, abdominal distention, and pain
1. Interval progression of changes of acute pancreatitis,
including hypoenhancement of the pancreatic head suspicious for
pancreatic necrosis.
2. Probable developing pseudocysts about the pancreas and
gastric fundus, but no walled-off collections suggestive of
abscess. Increased ascites.
3. Dilated small bowel loops with air-fluid levels are
suggestive of ileus.
4. Unchanged hepatic flexure colonic edema, likely reactive.
5. Bilateral pleural effusions, unchanged. Increased
atelectasis and patchy consolidation that could relate to
infectious or inflammatory process
6. Endotracheal tube terminating in proximal right main stem
bronchus.
Brief Hospital Course:
This is a 75 year old male transferred from [**Location (un) 14663**] with
acute pancreatitis, (amylase 2698, lipase 3327 at OSH). He
reportedly had no gallstones, no ETOH, and TG 114.
.
Neuro: While he was intubated with ETT, he received a
combination of propofol and midazolam for sedation. These were
weaned off [**1-29**] and Precedex was started. This was weaned off
on [**2-4**] after his tracheostomy. His pain was controlled with
intermittent fentanyl, toradol x3 days and dilaudid. As of [**2-6**]
he has been maintained on intermittent ativan and morphine for
sedation/pain control. He was transferred to the floor on
[**2124-3-6**] with tylenol, ibuprofen, and a clonidine patch for pain
control.
.
CV: On HD [**1-16**], he began having rapid Afib. He received Lopressor
IV and Diltiazem, but did not seem to be responding. Cardiology
was consulted and it was recommended he be cardioverted. An ECHO
was perfomed prior and cardioversion was attempted twice, but
was unsucessful. He was started on an heparin drip, amiodarone &
esmolol drips. He remained in Afib and converted to NSR on
[**2124-1-21**] after being placed on a procainamide drip. He continued
on Amio and Lopressor for rate control and heparin drip for
anticoagulation. On [**2-7**], he was transitioned to PO amiodarone.
He reconverted to Afib after his open G-tube on [**1-/2045**] and
required rebolusing of amiodarone. However, he eventually
converted back to NSR and was maintained on PO amiodarone.
Throughout his ICU course, he did require some low dose
neosynephrine for pressure control but was able to be weaned
off. He was transferred to the floor on PO amiodarone and
metoprolol and has remained in normal sinus rhythm. He was
transferred to ICU on [**2124-3-12**] for a-fib. He was started on
Diltiazem drip and converted to sinus rhythm. He is currently
sinus on PO Lopressor and PO Amiodarone.
.
Pulm: He was tachypnic and developed pulmonary effusions. He
received Lasix for diuresis. He was intubated for the
cardioversion. He was eventually extubated on [**1-26**]. CXR showed
bilateral atelectasis with decreased lung volumes. On [**1-28**] he
had progressive increased work of breathing and tachypnea. CXR
demonstrated even lower lung volumes and he was electively
re-intubated. He was initially requiring high ventilator
support but he was progressively weaned down. He received an
open tracheostomy on [**2124-2-4**] by the trauma surgery team. He was
able to be weaned to trach mask and is currently tolerated a
Passy-Muir valve. On the floor he was triggered twice on
[**2124-3-7**] for decreasing oxygen saturations. The first event
occurred after a vigorous bowel movement and he returned to
baseline within minutes. A CXR revealed bilateral pleural
effusions. The second trigger occurred after a coughing fit
caused an episode of emesis. Due to concerns for aspiration, a
repeat speech and swallow evaluation was ordered, which he
passed. He is receiving suctioning every 4 hours by the nurse
or MD.
.
GI: On admission he was made NPO, started on IVF resuscitation
and TPN (goals: 1.5gAA/kg, 25Kcal/kg). He was improving and NGT
was D/C'd on HD 9 and he was started on sips. However, his
abdominal distension increased and he was made NPO and an NGT
was replaced. KUB on [**1-28**] demonstrated dilated small bowel
loops consistent with an ileus. His NGT output gradually
decreased and he started to pass flatus. The NGT was removed on
[**2-5**]. On [**1-/2045**] an open GJ-tube was placed. During surgery ~2L
ascites were drained. He was started on Peptamen tube feeds the
next day and was eventually advanced to goal. He underwent
placement of percutaneous cholecystostomy tube and he continues
to have significant amount of bile draining from this tube. We
have been refeeding this bile through through his J-tube.
Please continue to do the same. He passed his speech and
swallow evaluation and is able to eat soft foods with thin
liquids.
.
Pancreatitis: His Amylase and Lipase trended down and his
abdominal pain resolved. A US on [**1-24**] showed no evidence of
gallstone or intra/extrahepatic biliary dilatation. CT abd on
[**1-28**] demonstrated: Interval progression of changes of acute
pancreatitis, including hypoenhancement of the pancreatic head
suspicious for pancreatic necrosis; probable developing
pseudocysts about the pancreas and gastric fundus, but no
walled-off collections suggestive of abscess; increased ascites;
dilated small bowel loops with air-fluid levels suggestive of
ileus. Repeat CT abd [**2124-2-16**] that showed marked interval
progression of peripancreatic fluid collections which now appear
much larger and more organized; one of these involves the
inferior right lobe of the liver and a distended gallbladder.
The peripancreatic fluid collection (below liver) and
gallbladder were percutaneously drained on [**2-17**], yielding ~500cc
serosanguinous fluid and 270cc sludgey bile, respectively. He
will need a follow up CT scan of pancrease 1 month from time of
discharge. He will need follow up with the result of CT.
.
FEN: He was maintained on bowel rest and TPN until resolution of
his acute pancreatitis. He was started on tube feeds 24 hours
after he received an open G-tube on [**1-/2045**]. He became
hypernatremic on [**2-10**] and this resolved with free water boluses.
.
Heme: As of [**2-13**], he was transfused a total of 4 units of blood
for anemia (i.e. Hct <22). He was maintained on a heparin drip
given his runs of Afib. Goal PTT was 60-80. He was eventually
bridged over to coumadin (first dose [**2-13**]).
.
ID: Since his admission, his WBC was elevated to ~20's with the
differential significant for mostly PMNs. He also had
intermittent fever spikes. He was initially started on empiric
antibiotics including vanco/zosyn/flagyl. The only cultures
that grew out were a BAL (1 out of 4) with MRSA on [**1-25**] and
sputum on [**1-30**] with rare yeast. For the presumed MRSA
pneumonia, he was treated with vancomycin for 8 days (ID service
was in agreement). He was started on meropenem [**1-28**] and there
was an associated significant decrease in his WBC. This was
stopped after ~2weeks of treatment. On [**2-12**], his WBC began to
climb once again. He was pancultured and lines were resited.
On [**3-8**] Vancomycin was restared for gram positives in sputum.
Final cultures showed MSSA and gram negative rods. Vancomycin
was discontinued and Nafcillin and Cipro was started on [**2124-3-10**].
He should continue w/ Nafcillin and Cipro until the [**2124-3-17**]. He
continues to have leukocytosis and we believe this is secondary
to his chronic pancreatitis.
.
Endo: He was on an Insulin drip for BG control. His HgA1C was
7.2 around the time of admission. He was eventually switched to
SQ insulin. Cushings work-up was negative.
.
MSK: He had question of warmth in R knee and given his history
of bilateral knee replacements, a xray and orthopedics consult
were obtained. The R Knee xray showed a large joint effusion
with ntact total knee arthroplasty without signs for loosening.
Ortho did not feel an infection was present and that any
intervention was required on [**2124-1-27**]. His knees were stable
ever since.
.
GU: Urine output was monitored with a Foley and it was
marginally adequate throughout his stay. A lasix drip was
started to aid in diuresis. His creatinine bumped up on [**2-13**]
from 1.0 to 1.4 and continued to increase. His lasix drip was
held. He has not required diuresis recently and has been
autodiuresing.
.
Micro (recent):
[**3-7**] BAL: MSSA and sparse GNR x 2.
[**3-8**] urine: NG
[**3-11**] Cdiff: neg
[**3-12**] blood: Pend
[**3-12**] urine: Pend
[**3-12**] sputum: Pend
.
Imaging:
[**1-17**] (OSH) CT abd/pelvis: nonspecific inflammatory changes in
anterior pararenal space, extending from above pancreas in
pelvis and involving R retroconal fashion. Fatty liver. Small
amount ascites, borderline enlarged pelvic lymph nodes.
Gallbladder WNL.
[**1-17**] (OSH) RUQ U/S: CBD 4mm, no gallstones
[**1-19**] CXR: low lung volumes, no PTX, no PNA, no effusions
[**1-19**] CTA: No PE, moderate-to-severe acute pancreatitis, with
little to no enhancement of pancreatic neck and head and a focal
ileus and moderate associated ascites. No evidence of associated
vascular compromise.
[**1-21**] ECHO EF 70%
2/11 RUQ U/S: No gallstones, CBD 5mm, +ascites.
[**3-11**] CT Chest/Abd/Pelv: 1. Extensive pancreatic necrosis and
inflammatory change, similar to the prior study. Multiple
peripancreatic fluid collections redemonstrated. The largest
collection along the inferior edge of the liver has a pigtail
catheter within it and is smaller in size. Other peripancreatic
collections are unchanged.
2. Decrease in volume of ascites.
3. No change in moderate bilateral pleural effusions and
atelectasis of the
dependent lower lobes.
Medications on Admission:
atenolol 25mg'; omeprazole 20 mg"; HCTZ 20 mg'; lisinopril 40
mg";finasteride 5 mg'; terazosin 10 mg'; simvastatin 20
mg';arixtra 2.5 mg'
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO Q6H (every
6 hours) as needed.
2. Bisacodyl 10 mg Suppository [**Month/Year (2) **]: One (1) Suppository Rectal
HS (at bedtime) as needed.
3. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day) as needed.
4. Amylase-Lipase-Protease 30,000-8,000- 30,000 unit Tablet [**Month/Year (2) **]:
1-2 Tablets PO TID (3 times a day).
5. Simvastatin 40 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO DAILY (Daily).
6. Olanzapine 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Paroxetine HCl 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
9. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours).
10. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]:
One (1) Inhalation Q6H (every 6 hours).
11. Insulin NPH Human Recomb 100 unit/mL Suspension [**Last Name (STitle) **]: 35
Units Subcutaneous every twelve (12) hours.
12. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: Sliding
Scale Injection every six (6) hours: Insulin SC Sliding Scale
Q6H
Regular
Glucose Insulin Dose
0-60 mg/dL [**12-15**] amp D50
61-120 mg/dL 0 Units
121-160 mg/dL 3 Units
161-200 mg/dL 6 Units
201-240 mg/dL 9 Units
241-280 mg/dL 12 Units
281-320 mg/dL 15 Units
> 320 mg/dL Notify M.D.
.
13. Magnesium Hydroxide 400 mg/5 mL Suspension [**Month/Day (2) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
14. Ciprofloxacin 500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
15. Nafcillin in D2.4W 2 gram/100 mL Piggyback [**Month/Day (2) **]: Two (2) gm
Intravenous Q6H (every 6 hours) for 5 days.
16. Amiodarone 200 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times
a day).
17. Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) **]: 1.5 Tablets PO TID (3
times a day).
18. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: One (1) PO BID (2
times a day).
19. Miconazole Nitrate 2 % Powder [**Month/Day (2) **]: One (1) Appl Topical QID
(4 times a day) as needed.
20. Zolpidem 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO HS (at bedtime).
21. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection TID (3 times a day).
22. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
[**Month/Day (2) **]: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day).
23. Phenazopyridine 100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID (3
times a day) for 3 days.
24. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Month/Day (2) **]: Two
(2) ML Intravenous DAILY (Daily) as needed.
25. Sodium Chloride 0.9 % 0.9 % Syringe [**Month/Day (2) **]: Three (3) ML
Injection DAILY (Daily) as needed.
26. Lorazepam 2 mg/mL Syringe [**Month/Day (2) **]: 0.25 mg Injection Q6H (every
6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Acute Pancreatitis
Rapid Atrial Fibrilation
Malnutrition
Deconditioning
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* No heavy lifting (>[**9-27**] lbs) for 6 weeks.
* Monitor your incision for signs of infection
* You may shower and wash. No tub baths or swimming. Keep your
incision clean and dry.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2124-4-17**]
11:45
Please arrive for CT of Pancreas at 9:30am to [**Hospital Ward Name 23**] [**Location (un) **].
Completed by:[**2124-3-14**]
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8,796
| 104,763
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16338
|
Discharge summary
|
report
|
Admission Date: [**2117-3-4**] Discharge Date: [**2117-3-17**]
Date of Birth: [**2042-3-1**] Sex: M
Service: NEURO/MEDICINE
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 13712**] is a 75 year-old man
with a past medical history of hypertension, type 2 diabetes,
end stage renal disease requiring hemodialysis who presented
to the hospital less then one hour after sudden onset of
right sided weakness. The history on presentation was
verbalize answers. Mr. [**Known lastname 13712**] was at home with his wife the
evening of admission in his usual state of health.
At around 7:00 p.m. the evening of admission the patient sat
down in a chair and suddenly he developed right sided facial
droop and began to drool from the right side of his mouth.
His speech also became slurred/dysarthric. The patient was
to take the patient to the car to bring him to the hospital,
but he was unable to ambulate without great difficulty,
therefore she called EMS shortly thereafter.
The patient's wife denies any recent trauma, surgery, falls,
reported no symptoms prior to the onset of weakness, no
headaches. The patient's wife denied any recent or distant
history of GI or urinary bleeding, recent anticoagulation
agents, no seizure like activity or history of stroke. No
previous intracranial hemorrhage or surgery.
PAST MEDICAL HISTORY:
1. End stage renal disease on dialysis Monday, Wednesday and
Friday, dialyzed via fistula in left arm.
2. Insulin dependent diabetes.
3. Hypertension.
ALLERGIES: Valtrex, which is given for herpes zoster roughly
two months prior to admission and resulted in hallucinations.
MEDICATIONS:
1. Insulin NPH.
2. Nephrocaps.
3. Epogen at dialysis.
4. Lipitor.
5. Antihypertensive unknown at the time of admission which
type.
SOCIAL HISTORY: The patient lives with his wife in
[**Name (NI) 8**]. He denies smoking, drugs or alcohol history.
PHYSICAL EXAMINATION: On admission he was afebrile with a
blood pressure ranging from 178 to 210 and a heart rate of
78. In general he was able to open and close his eyes on
command. He appeared anxious. The patient was aphasic. On
neurological examination pupils are equal, round, and
reactive to light and accommodation. His visual fields were
grossly intact. Extraocular movements intact. Normal facial
sensation. Tongue midline. Motor examination his left upper
extremity was 5 out of 5 throughout. On right upper
extremity examination he was able to lift his arm against
gravity to 30 degrees, unable to open and close fist. Right
upper extremity strength was 2 out of 5. Lower extremities
were 5 out of 5 bilaterally. Sensory examination was grossly
normal throughout and coordination was grossly normal. There
are no other physical examination findings documented on
presentation.
LABORATORIES ON PRESENTATION: Hematocrit 38.7, hemoglobin
12.7, white count 5.6, platelet count 219, MCV 99, PT 12.5,
PTT 29.4, INR 1.0. Chemistries 142, 4.3, 101, 27, 39, 7.7
and 138.
The patient had a CT on admission that showed evidence of
multiple small areas of increased density suggestive of old
cerebrovascular accidents. No evidence of acute bleed.
IMPRESSION ON ADMISSION: This is a 75 year-old man with a
complicated past medical history including hypertension and
end stage renal disease now with a witnessed stroke effecting
his right side. The patient received tissue plasminogen
activator within 55 minutes of reaching the hospital,
therefore roughly two hours after the onset of his symptoms.
His right sided weakness subjectively improved after tissue
plasminogen activator administration. The patient was
initial placed on a labetalol drip to decrease his systolic
to less then 170 and was transferred to the Neuro ICU.
The prior is a summary of the [**Hospital 228**] hospital course prior
to transfer to the Medicine Service on [**2117-3-12**].
HOSPITAL COURSE: On the [****] the patient
developed worsening of his right sided hemiparesis acutely.
This was thought to be secondary to hypotension, therefore
the Labetalol drip was discontinued. The patient's blood
pressure had dropped to a systolic of 100. He was placed on
neo-synephrine drip to maintain systolics greater then 140.
The patient had an MRI on [**2117-3-6**] that showed an acute left
sided parietal infarct. He continued to improve clinically
with increased right sided strength.
The patient was transferred out to the floor on [**2117-3-6**] to the
Neurological Service. On [**2117-3-7**] the patient developed atrial
flutter with a rate of 130 to 140. The patient was
asymptomatic and his blood pressure was stable. He received
a total of 20 mg of intravenous Diltiazem and Lopressor had
no effect. The patient was ruled out for a myocardial
infarction and it was decided to consult cardiology.
On the [**3-8**] the patient had acute mental status
changes and was not responsive and was quite agitated. He
was given Haldol and Ativan. There was no improvement in his
agitation with Haldol and Ativan and his agitation actually
worsened. Therefore it was decided to electively intubate
and sedate the patient and he was transferred to the MICU.
In the MICU Cardiology was consulted and recommended
Amiodarone for the patient's atrial flutter. After the
patient was intubated and sedated he was placed on
intravenous Amiodarone. Arterial blood gas at the time of
intubation was 7.36, 44 and 87. The patient was placed back
on a neo-synephrine drip with a goal systolic pressures of
150s and 160s.
A head CT was done that was negative for acute bleeding in
the setting of mental status changes. The patient was rate
controlled with intravenous Diltiazem.
On the [**3-9**] the patient had a transesophageal
echocardiogram that showed no evidence of thrombus.
Transesophageal echocardiogram also noted left ventricular
hypertrophy and a normal left ventricular function with an EF
of greater then 50%. The patient had been anticoagulated on
heparin intravenous since admission. He had DC cardioversion
on the day of [**2117-3-9**] and was cardioverted into a wandering
pacemaker rhythm with a rate of 80 to 90.
On [**2117-3-10**] the patient was started on tube feeds. Overnight
he spiked to 101 and his white blood cell count increased
from 9.6 to 20. The patient was started empirically on
intravenous Vancomycin and Levofloxacin. The reason these
antibiotics were chosen is that on chest x-ray the patient
had a left lower lobe consolidation and on blood cultures
that were drawn at the time of temperature spike 1 out of 4
showed gram positive cocci and clusters.
On [**2117-3-11**] the patient was noted to have decreased movement of
his right side acutely. It was recommended by the
Neurological Service to keep the patient's partial
thromboplastin time around 60 to prevent hemorrhagic
transformation. The patient also received 1 unit of packed
red blood cells for a hematocrit of 29 on this day and his
target SBP was now 130 systolically as per Neurologic. On
[**2117-3-12**] the patient was no longer requiring neo-synephrine to
maintain systolics of 130 and he was extubated successfully.
The patient was continued on heparin. He was placed on po
Amiodarone 400 po q.d.
The patient also had a speech and swallow evaluation at the
bedside on this day to rule out aspiration as the etiology of
his left lower lobe consolidation. Bedside evaluation was
negative for aspiration and a video swallow was scheduled.
As previously stated the patient was transferred to the
Medicine Service on [**2117-3-12**].
His medications on transfer included an insulin sliding
scale, aspirin 325 q.d., Atorvastatin 10 q.d., Ranitidine 150
po q day, Epogen with hemodialysis, Heparin GTT with a goal
partial thromboplastin time of 60 to 80. Amiodarone 400 po
q.d. times seven days to then be switched to 200 po q
daytime one month, date of initiation [**2117-3-10**]. Levofloxacin
250 mg po q 48 hours for left lower lobe consolidation, start
date [**2117-3-10**]. Vancomycin 1 gram intravenous dose per level at
hemodialysis start date [**2117-3-10**].
The patient's physical examination on transfer to the Medical
Floor included, vital signs temperature afebrile. Blood
pressure 132/74. Heart rate 68. Respiratory rate 20.
Saturation 95% on 3 liters. On physical examination he was
in no apparent distress. He was alert, oriented and
appropriate. He responded to questions. He continued to
have a right sided facial droop and drooling with talking.
HEENT pupils are equal, round and reactive to light.
Extraocular movements intact. Right sided facial droop.
Dysarthric speech. Heart S1 and S2. Regular rate and
rhythm. Soft systolic ejection murmur at right upper sternal
border. Lungs bibasilar crackles roughly one third of the
way up bilaterally. No wheezing. Abdomen soft, nontender,
nondistended. Positive bowel sounds. Extremities no
clubbing, cyanosis or edema.
Neurological right sided facial droop, 5 out 5 strength lower
extremities bilaterally, 4 out of 5 strength in the right
upper extremity and 5 out of 5 strength in the left upper
extremity.
Data on transfer to the Medicine Service: The patient had an
x-ray on [**2117-3-12**] that showed a left lower lobe consolidation
and mild cardiomegaly unchanged from prior examination. His
partial thromboplastin time was 61.5 and his INR was 1.4. As
far as microbiologic data, the patient had one anaerobic
bottle from the blood cultures sent from his [**2117-3-9**] spike
that grew out coag negative staph. All other blood cultures
were negative.
1. For the patient's left parietal cerebrovascular accident
it was decided to try and keep the patient's systolic blood
pressure in the 120s to 130 range per Neuro. The patient did
not require pressor support to maintain his blood pressure.
He was continued on a heparin drip until his INR was
therapeutic. The heparin drip was shut off on [**2117-3-16**] as the
patient's INR at this point was greater then 2.0. His INR
was therapeutic on [**2117-3-15**], but it was decided to overlap the
heparin drip and Coumadin at therapeutic level times 24
hours.
The patient was evaluated by physical therapy and
occupational therapy and was said to be an excellent
candidate for rehabilitation. He continued to have his right
sided facial droop, but his right upper extremity weakness
remained stable with 4 out of 5 to 5 out of 5 strength in the
right upper extremity. This varied depending on the
patient's fatigue level.
2. Cardiac: As stated above the patient was status post DC
cardioversion for atrial flutter on [**2117-3-9**]. On the evening
of [**2117-3-14**] the patient was noted to go back into atrial
flutter during the evening. The patient was asymptomatic.
The rate was 120. He maintained a stable blood pressure with
this and had no palpitations, no shortness of breath. The
patient was managed with po Lopresor. He had been started on
12.5 Lopressor po b.i.d. on [**2117-3-13**] for blood pressure control
as his systolic blood pressures were ranging from 150 to 170.
Cardiology continued to follow the patient once he was on the
Medicine Service. After the patient was given a dose of po
Lopressor on the evening of the 9th he did convert to a
wandering atrial pacemaker with a rate between 80 and 90.
However, again on the evening of [**2117-3-15**] the patient
reentered atrial flutter, this time with a rate of 130 to
140. At this time he was symptomatic and he dropped his
blood pressure to 80/60. He felt weak and described right
sided weakness with this blood pressure. He denied chest
pain, palpitations or shortness of breath.
Of note, this happened after the patient had been
hemodialyzed during the day with removal of 1.5 kilograms of
fluid. The patient was orthostatic on examination. His
blood pressure responded to two 500 cc normal saline boluses
and when his blood pressure stabilized he was given another
dose of po Lopressor 12.5 times one. His heart rate then
dropped to 100 to 110 still with atrial flutter.
Cardiology impression of this was that the atrial flutter was
likely exacerbated by hypertension and that for now the
patient would be best managed medically with Amiodarone po
with the potential for repeat DC cardioversion three to four
weeks after discharge. The decision to ablate the patient
was considered, however, it was thought that this was not
ideal as the patient has recently suffered a stroke.
The patient was to be followed by Cardiology upon discharge
to rehabilitation and Dr. [**Last Name (STitle) 73**] from the
Electrophysiology Department would be following his ECG at
the rehab and dosing his Amiodarone accordingly.
3. Infectious disease: The patient had a left lower lobe
pneumonia. He was continued on Levofloxacin 250 mg po q 48
hours. His white count trended down to 10.0 after a peak of
20. The Vancomycin was discontinued as the coag negative
staph and one out of four blood cultures was deemed a
contaminant. Aspiration as the cause of the pneumonia was
considered, however, the patient had a negative bedside
speech and swallow evaluation and a negative video swallow,
therefore his diet was advanced as tolerated.
4. Renal: The patient continued to be dialyzed on Monday,
Wednesday and Fridays. He was given Epogen during
hemodialysis.
5. Diabetes: For the patient's diabetes he was kept on a
regular insulin sliding scale and his blood sugars were
well controlled ranging from 100 to 150.
DISCHARGE STATUS: The patient was discharged to [**Hospital **]
Medical Rehabilitation for neurological rehab.
DISCHARGE DIAGNOSES:
1. Left parietal stroke with residual right sided facial
droop.
2. Left lower lobe pneumonia.
3. Atrial flutter status post DC cardioversion [**2117-3-9**] with
recurrent atrial flutter developing five days after
cardioversion.
DISCHARGE MEDICATIONS:
1. Ranitidine 150 mg po q day.
2. Lopresor 12.5 po b.i.d.
3. Amiodarone 400 q.d.
4. Regular insulin sliding scale.
6. Aspirin 325 mg q.d.
7. Atorvastatin 10 q.d.
8. Tylenol 350 to 650 q 4 to 6 hours prn.
9. Coumadin to be dosed for an INR of 2 to 3, dosage on
discharge is 2.5 mg q.h.s.
10. Sevelamer 800 mg po t.i.d.
DISCHARGE INSTRUCTIONS:
1. At rehab the patient should have daily ECGs.
2. Hemodialysis on Monday, Wednesday and Friday. Of note
the dialysis technician should be careful with the amount of
fluid removal/filtration as the patient's atrial flutter
worsens when the patient is made too dry.
3. As stated above the patient is to with Dr. [**Last Name (STitle) 73**] from
[**Hospital1 69**] Cardiology Department
who will look at the patient's ECGs and manage his Amiodarone
dosing. His office is [**Telephone/Fax (1) 902**].
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Last Name (NamePattern1) 45275**]
MEDQUIST36
D: [**2117-3-17**] 08:23
T: [**2117-3-17**] 08:33
JOB#: [**Job Number 46544**]
|
[
"486",
"434.11",
"250.40",
"518.81",
"599.7",
"458.2",
"403.91",
"427.32",
"780.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"88.72",
"96.6",
"99.10",
"39.95",
"96.71",
"99.62",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13599, 13831
|
13854, 14181
|
3903, 13578
|
14205, 14981
|
1929, 3184
|
172, 1336
|
3199, 3885
|
1358, 1788
|
1805, 1906
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,220
| 105,058
|
41889
|
Discharge summary
|
report
|
Admission Date: [**2114-9-19**] Discharge Date: [**2114-9-25**]
Date of Birth: [**2035-5-30**] Sex: M
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Ciprofloxacin
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
loss of balance
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a 79 year-old R-handed man with hx of prostate ca s/p
brachytherapy, HTN, HL, headaches and bladder ca s/p resection
surgery [**2114-8-13**] who presented with a R inraparenchymal
hemorrhage.
Patient reports that he felt unsteady on his feet since his
resection surgery at the end of [**Month (only) 216**], and for the last 3 weeks
he had a sense of urinary urgency, for which he was "rushing to
the bathroom". On [**9-9**] he started noticing that he was "tilting
to the left, even when sitting", and that he then fell multiple
times in an effort to get to the bathroom. His urologist
prescribed him for nitrofurantoin for presumed UTI. He went to
the ED on [**9-11**] where he was given IVF and sent home with a
diagnosis of "dizziness". He still felt very unsteady and fell
that night in the bath and hit the back of his head without LOC.
He then continued to feel off balance, but no focal
numbness/weakness/tingling. When his dizziness and unsteadiness
did not improve, he went to see his PCP [**Last Name (NamePattern4) **] [**9-13**], who told him he
should go the ED, which he did. There, he was admitted with
plans for IVF and urological exam. He was started on IV
ceftriaxone for his UTI (confirmed on U/A and found on UCx to be
proteus sensitive to ceftriaxone) and was monitored. On [**9-18**]
OSH
notes some uncoordination in his L arm, and ordered a head CT.
Per the pt, his son had insisted that an MRI be done "for many
days of the admission", and it was only done on [**9-18**]. Patient
denies any new neurological sx at that time. The MRI showed a R
frontal IPH, and he was transfer to [**Hospital1 18**] was arranged for [**9-19**].
.
On neuro ROS, the pt denies current headache, loss of vision,
blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- magnesium oxide 200mg QD
- meloxicam 7.5mg QD
- MVI QD
- nitrofurantoin (started on [**9-13**] by urologist)
- prilosec 20mg QD
- simvastatin 5mg QD
- vicodin 5/500mg Q6H PRN pain
Social History:
Lives with wife in a house with no stairs, he does much
of the daily activities around te house because his wife has MS.
He smoked a 1/2ppd from age 16 to his early 60's, denies alcohol
or drug use, his children live close by.
Family History:
his father died of lung cancer (was a smoker) at age
65; mother died from an ischmemic/embolic stroke at age 52; his
oldest brother had lung cancer (was a smoker).
Physical Exam:
ADMISSION PHYSICAL EXAM:
Physical Exam:
Vitals: T: 97.9 P:84 R: 19 BP: 139/64 SaO2: 100%RA
General: Awake, cooperative, NAD.
HEENT: no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally, but skin on legs cool.
Skin: no rashes or lesions noted.
.
Neurologic:
-Mental Status: Alert, oriented x 2 (knew the hospital name,
year
and month, but thought it was Monday instead of Wednesday, and
couldn't recall the date). Able to relate history without
difficulty. Attentive, able to name DOW backward without
difficulty, but for [**Doctor Last Name 1841**] had one omission and one error.
Language
is fluent with intact repetition and comprehension. Normal
prosody. There were no paraphasic errors. Pt. was able to name
both high and low frequency objects. Able to read without
difficulty. Speech was not dysarthric. Able to follow both
midline and appendicular commands. Pt. was able to register 3
objects and recall [**1-18**] spontaneously and [**2-15**] with cues at 5
minutes. The pt. had good knowledge of current events. There
was no evidence of apraxia or neglect.
.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted. Slowed RAMs in L hand
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5- 5 4+ 5- 5 5 4 4+ 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
.
-Sensory: Decreased vibratory, temperature and proprioceptive
sensation from mid shins down; increased pinprick sensation in
same distribution. Otherwise, above mid shins no deficits to
light touch, pinprick, cold sensation, vibratory sense,
proprioception throughout. No extinction to DSS.
.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was mute bilaterally; pt's natural toe position
is up, no tensor fascia lata contraction seen bilaterally.
.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
.
-Gait: Deferred, pt in ICU for cerebral hemorrhage.
on discharge
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Patient is convinced he is at his house, but otherwise is awake
and oriented
Mild left pronator, mild 5- weakness at left delt, tri. Mild Ip
weakness
Pertinent Results:
ADMISSION LABS:
[**2114-9-19**] 03:10PM BLOOD WBC-6.9 RBC-4.15* Hgb-13.4* Hct-40.1
MCV-97 MCH-32.4* MCHC-33.5 RDW-12.0 Plt Ct-280
[**2114-9-19**] 03:10PM BLOOD PT-12.7 PTT-31.2 INR(PT)-1.1
[**2114-9-19**] 03:10PM BLOOD Glucose-93 UreaN-17 Creat-0.8 Na-141
K-4.2 Cl-101 HCO3-29 AnGap-15
[**2114-9-19**] 03:10PM BLOOD ALT-29 AST-27 CK(CPK)-27* AlkPhos-140*
TotBili-0.3
[**2114-9-19**] 03:10PM BLOOD CK-MB-2 cTropnT-<0.01
[**2114-9-19**] 03:10PM BLOOD Calcium-9.6 Phos-4.0 Mg-2.4 Cholest-147
[**2114-9-19**] 03:10PM BLOOD %HbA1c-5.2 eAG-103
[**2114-9-19**] 03:10PM BLOOD Triglyc-94 HDL-49 CHOL/HD-3.0 LDLcalc-79
DISCHARGE LABS:
IMAGING:
CT HEAD [**2114-9-19**]: IMPRESSION: Stable appearance of right frontal
intraparenchymal hemorrhage.
ECHO [**2114-9-20**]: Conclusions
The left atrium is mildly dilated. 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) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: No intracardiac source of thromboembolism
identified. Normal left ventricular cavity size and wall
thickness with preserved global and regional biventricular
systolic function. No clinically significant valvular disease.
Indeterminate pulmonary artery systolic pressure.
CAROTIDS [**2114-9-20**]: normal
Brief Hospital Course:
79 year-old R-handed man with hx of prostate ca s/p
brachytherapy, HTN, HL, headaches and bladder ca s/p resection
surgery [**2114-8-13**] who presented from an OSH with a R
inraparenchymal hemorrhage. Upon review of his imaging, there
is no evidence of obvious malignancy or vasculitis that would
cause his hemorrhage, nor is there evidence that this is
obviously a venous clot. There are some small DWI lesions in
the ACA territory that are suggestive of an embolic infarct with
subsequent hemorhagic conversion. His hemorrhage could also
likely be from amyloid. In addition, his subdural hematoma
could have been caused by his head strike, but could also be
from a rupture of his more frontal hematoma into the subdural
space. He will need close close monitoring to ensure he is
stable and then likely rehabilitation.
.
# NEURO: patient was evaluated for possible cause of his stroke.
His echo was unremarkable and his carotid duplex showed 0%
stenosis bilaterally. It is likely that the bleed is a result
of amyloid but we are not sure. We stopped his statin as it was
low dose and there is some increased risk of bleeding, and there
is not a significant benefit for this medication. The patient
did well and continued to improve - he does have a fixed belief
that he is in his home, despite being aware of the evidence that
he is not - likely reduplicative paraamnesia as a result of his
bleed. This should likely improve.
# CARDS: we held pt's home dose simvastatin as he was only on
5mg and we felt that amyloid was a likely source of his bleed,
making his statin contraindicated. We got an echo, which was
unremarkable and kept pt's SBP <160. He had one episode of
chest pain and his tpns and EKG were normal. We did start him
on a baby aspirin and metoprolol as he was hypertensive and was
placed on an aspirin for prophylaxis
# ID: patient came from OSH with a documeted proteus UTI. He
had been started initially on macrobid as an outpatient, which
was continued at the OSH until [**9-17**], when he was started on
ceftriaxone. We continued him on the ceftriaxone for a planned
7 day course.
# CODE/CONTACT: Full [**Name2 (NI) 7092**]; [**Name (NI) 2048**] (wife) [**Telephone/Fax (1) 90938**] or son
[**Telephone/Fax (1) 90939**]
PENDING RESULTS:
TRANSITIONAL CARE ISSUES:
Pt will need rehabilitation, but is the primary caregiver for
his wife who is at home with MS. Social work was involved and
spoke with his family. He was seen by PT and they indicated
that he would need rehab and he was set up for an acute [**Last Name (un) **].
Medications on Admission:
- magnesium oxide 200mg QD
- meloxicam 7.5mg QD
- MVI QD
- nitrofurantoin (started on [**9-13**] by urologist)
- prilosec 20mg QD
- simvastatin 5mg QD
- vicodin 5/500mg Q6H PRN pain
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for prophylaxis.
4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Primary: right sided frontal hemorrhage
Secondary: hx of bladder and prostate ca
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Patient is convinced he is at his house, but otherwise is awake
and oriented
Discharge Instructions:
Dear Mr. [**Known lastname 90940**],
You were seen in the hospital for difficulty with your balance.
You were found to have had a right sided bleed in your brain
causing you to have some left sided weakness. You were
monitored, and when it was determined your bleed was stable you
were able to be sent to a rehabilitation facility to get
stronger and improve your balance.
You were dicharged to a rehab facility
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
Department: NEUROLOGY
When: MONDAY [**2114-11-19**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"530.81",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11742, 11816
|
8274, 10550
|
333, 340
|
11941, 11941
|
6568, 6568
|
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|
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|
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|
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|
368, 2709
|
6585, 7179
|
11956, 12145
|
2731, 2915
|
2931, 3161
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
638
| 176,623
|
5116+55636
|
Discharge summary
|
report+addendum
|
Admission Date: [**2153-12-6**] Discharge Date: [**2153-12-8**]
Service: [**Hospital Unit Name 196**]
HISTORY OF THE PRESENT ILLNESS: Mrs. [**Known lastname **] is an 84-year-old
female with a past medical history significant for coronary
artery disease, status post one vessel CABG in [**2147**], status
post MI in [**2149**], status post aortic valve replacement, with
atrial fibrillation, status post cardioversion times three,
CHF with ejection fraction of 55%, who presented to the [**Hospital6 1760**] for elective cardioversion.
The patient had a recent admission in [**2153-10-8**] for
CHF and atrial fibrillation. At that time, she was started
on anticoagulation with Coumadin and Amiodarone. The patient
presented to [**Hospital1 18**] for admission in [**2153-11-7**] for left
facial droop and slurred speech with evaluation significant
for a negative head CT and carotid Dopplers. The patient was
discharged to [**Hospital3 **] and returns today for
elective cardioversion.
On arrival to the [**Hospital6 256**], she
was noted to be hypotensive with systolic blood pressure in
the 80s and a heart rate in the 70s, in atrial fibrillation.
She was asymptomatic at the time. She received 150 cc of
normal saline with an increase in her systolic blood pressure
to the 90s. Oxygen saturation was 80% on room air and 100%
on 2 liters nasal cannula. Her DC cardioversion was
uneventful and she returned to sinus rhythm. Currently, the
patient denied any lightheadedness, chest pain, shortness of
breath, nausea, vomiting, palpitations, diaphoresis, or
radiating pain. She has no recent fevers, chills, or night
sweats. No abdominal pain, no cough. She does note pain at
the site of her sternotomy which has been ongoing for three
or more years. There is an erythematous area that she notes
is improving in the last three to four months.
CT Surgery evaluated the patient in the holding area of the
Catheterization Laboratory and recommended sternal wire
revision. The patient was admitted to the Cardiology Floor
for monitoring due to her postprocedure hypotension and for
heparinization while her INR came down so that she could have
sternal wire revision procedure on Monday with a normal INR.
PAST MEDICAL HISTORY:
1. Atrial fibrillation, status post cardioversion times
three.
2. Coronary artery disease, status post MI, status post one
vessel CABG in [**2147**].
3. Status post aortic valve replacement.
4. Status post pacemaker in [**2151-8-8**].
5. Status post bilateral breast cancer, status post right
lumpectomy and XRT in [**2139**] and radical left mastectomy in
[**2146**].
6. Congestive heart failure with an ejection fraction of 55%
on an echocardiogram in [**2153-10-8**].
7. Hypertension.
8. TIA.
9. Status post TAH/BSO.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Coumadin 2.5 mg q.d.
2. Amiodarone 200 mg q.d.
3. Aspirin 325 mg q.d.
4. Lasix 60 mg q.d.
5. Atenolol 50 mg q.d.
SOCIAL HISTORY: The patient is widowed and lives at the
Alzheimer's Home. She denied any alcohol use and states that
she quit smoking at the age of 50.
FAMILY HISTORY: Positive for ovarian cancer.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Afebrile
with a pulse of 68, blood pressure 96/40, respirations 18,
oxygen saturation 100% on 2 liters. General: She was a
frail-appearing female in no acute distress responding to all
questions appropriately. The examination was significant for
a dry oropharynx, JVP at 8-9 cm with prominent EJ pulsations,
rales in the lungs present a third of the way up the left
lung field posteriorly with decreased breath sounds in the
right lung field a third of the way up posteriorly. No
dullness to percussion. Moderate air movement. Heart:
Regular with a I/VI systolic ejection murmur heard at the
left upper sternal border. Abdomen: Benign. Extremities:
Warm with 2+ pitting edema bilaterally from the feet to the
knees. Skin: Notable for prominent sternotomy wires and an
area of erythema and warmth over the third sternal wire and
extreme tenderness to touch over all sternotomy wires.
LABORATORY/RADIOLOGIC DATA: Significant for a hematocrit of
42, platelets 172,000 and an INR of 1.9.
EKG showed atrial pacer spikes and a rate of 69 beats per
minute with left bundle branch block.
HOSPITAL COURSE: The patient was admitted to the Cardiology
Service.
1. STERNOTOMY SITE INFLAMMATION: The CT Surgery Service was
consulted and felt that the sternotomy site inflammation was
not due to infection but was due to erosion of the skin over
the wire. They were not able to see the patient on Monday
and, therefore, suggested arranging an outpatient appointment
for her at a further date. It was, therefore, decided that
the patient would go home on her Coumadin and remain on
Coumadin for three weeks in order to prevent increased stroke
risk during the three weeks after cardioversion and will
follow-up with CT Surgery for sternotomy wire revision at a
later time once she is no longer in the window of increased
stroke risk after cardioversion. The patient was, therefore,
discontinued from her heparin and restarted on her Coumadin
doses.
2. ATRIAL FIBRILLATION: The patient remained in sinus
rhythm with rates between 68 and 100 beats per minute with no
events other than one run of three minutes of ventricular
tachycardia which was asymptomatic. Other than that,
telemetry was uneventful. The patient was continued on her
Coumadin with a goal INR of [**3-11**].5.
3. HYPOXIA: After diuresis with Lasix and Diuril, the
patient's oxygen saturation improved. She was continued on
diuresis.
4. CORONARY ARTERY DISEASE: The patient was continued on
her aspirin, beta blocker, and statin.
5. BLOOD PRESSURE: The patient was hypotensive
postprocedure with blood pressures as low as 70 systolic.
She received 1 liter of fluids and still appeared dry with
low blood pressures in the 80s to 90s systolic. She was,
therefore, transfused with packed red blood cells in order to
increase her intravascular volume and minimize the fluid to
her periphery as it was deemed that she was intravascularly
depleted but total volume overloaded.
6. LEFT LOWER EXTREMITY EDEMA: The patient was given
pressure stockings which decreased the edema in her feet;
however, there was still 2+ edema in her legs. She was
continued on her Lasix and Zaroxolyn.
7. HEMATOLOGY: The patient's hematocrit decreased to 29 on
the second day of admission. Therefore, she was transfused 2
units of packed red blood cells with Lasix in between.
DISPOSITION: The patient was discharged to [**Hospital3 1761**] Center. She will return to see Dr. [**Last Name (STitle) 952**] as
an outpatient in four weeks for sternal wire revision.
CONDITION ON DISCHARGE: Fair.
DISCHARGE STATUS: To [**Hospital3 **] Center.
DISCHARGE DIAGNOSIS:
1. Atrial fibrillation.
2. Hypotension.
3. Anemia.
DISCHARGE MEDICATIONS:
1. Metoprolol 25 mg p.o. b.i.d.
2. Aspirin 325 mg p.o. q.d.
3. Colace 100 mg p.o. b.i.d.
4. Simvastatin 20 mg p.o. q.h.s.
5. Warfarin 2.5 mg p.o. q.h.s.
6. Metolazone 2.5 mg p.o. b.i.d.
7. Amiodarone 200 mg p.o. q.d.
8. Furosemide 40 mg p.o. b.i.d.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) 952**] in
four weeks for sternal wire revision. Call [**Telephone/Fax (1) 170**] for
an appointment. The patient is to stop taking her Coumadin
one week before her appointment for sternal wire revision.
The patient is to have her INR checked daily and the results
sent to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**]. The patient is to follow-up with
Dr. [**Last Name (STitle) 73**] in one to two weeks.
[**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**MD Number(1) 2144**]
Dictated By:[**Last Name (NamePattern1) 5615**]
MEDQUIST36
D: [**2153-12-7**] 06:50
T: [**2153-12-7**] 19:21
JOB#: [**Job Number 21017**]
cc:[**Last Name (NamePattern4) 21018**] Name: [**Known lastname 3487**], [**Known firstname 3441**] Unit No: [**Numeric Identifier 3488**]
Admission Date: [**2153-12-6**] Discharge Date: [**2153-12-17**]
Date of Birth: [**2069-9-20**] Sex: F
Service: C-MEDICINE
HOSPITAL COURSE: This is a discharge addendum to a prior
discharge summary that covers hospital course from [**2153-12-6**],
to [**2153-12-8**]. This summary will cover the hospital course
from [**2153-12-8**], to [**2153-12-17**].
1. Cardiac - The patient received two units of packed red
blood cells on [**2153-12-8**], for hematocrit of 29.0 as she was
thought to be intravascularly depleted with a tachycardia and
low blood pressure (as low as 73/38) with low jugular venous
pressure. As the patient had peripheral edema and rales on
lung examination, it was thought that the red blood cells
would be the most appropriate fluid for volume repletion
since she had trouble maintaining fluid intravascularly. The
patient desaturated to 88% in room air posttransfusion
requiring Lasix for diuresis. Over the next few days, the
patient continued to have low oxygen saturation with rales on
examination and therefore, diuresis was continued with Lasix.
A chest x-ray showed increased bilateral pleural effusions
since admission with a possible loculated effusion on the
right. A CT scan was obtained which showed a loculated right
effusion and a smaller left effusion. Pulmonary service was
consulted and they thought that the effusion was most
consistent with congestive heart failure since the patient
had a documented chronic right effusion by chest x-ray since
[**2149**], and since on prior thoracentesis the fluid had been
transudative (in [**2151**]). Thoracentesis was entertained,
however, the patient's INR was 4.8 and therefore the decision
was made not to reverse her Coumadin for thoracentesis.
Instead, she was diuresed with Lasix. The patient's pedal
edema resolved but she remained with rales in her lungs.
Effusions were decreased on chest x-ray but still present.
The CT was reviewed again and it was felt that the effusion
was not loculated but that it appeared so due to pleural
fibrosis from prior radiation injury. The patient began to
have oxygen desaturations with increasing lethargy and
somnolence and with her systolic blood pressure falling to
the 70s on [**2153-12-12**]. Therefore, she was transferred to the
CCU for Swan guided therapy. However, once in the CCU, the
patient refused any invasive interventions and improved with
hydration and with Dopamine infusion as well as with Digoxin.
She was transferred back to the floor and by discharge, her
oxygen saturation was 98% on two liters nasal cannula.
2. Atrial fibrillation - The patient converted back into
atrial fibrillation on [**2153-12-8**], and remained in atrial
fibrillation throughout her hospital stay. She was rate
controlled on Metoprolol. She was maintained on Amiodarone
and Coumadin.
3. Pulmonary - The patient began to desaturate on [**2153-12-8**],
after blood transfusion. Although she initially improved,
she began to have increasing oxygen requirements over the
next few days. An arterial blood gas was obtained which
showed a pH of 7.35, pCO2 of 83, and a pO2 of 206 on six
liters oxygen by nasal cannula. Her bicarbonate was 43. The
patient was transferred to the CCU for possible noninvasive
ventilation and possible Swan guided therapy, however, she
refused interventions once she arrived in the CCU. The
patient was hydrated gently and improved with Dopamine and
Digoxin.
4. Coronary artery disease - The patient was continued on
her Aspirin, beta blocker and statin with no episodes of
chest pain throughout her hospital stay.
5. Gastrointestinal - The patient complained of abdominal
pain intermittently throughout her hospital stay. She had
two episodes of nausea and vomiting, one with 20cc of blood.
There was a transient elevation of amylase and lipase which
resolved the following day. Abdominal films were obtained on
two occasions which showed a bowel full of stool. The
patient was treated with an aggressive bowel regimen and her
pain resolved. The patient was guaiac positive at one point
during the hospital stay but was guaiac negative on the day
of discharge.
6. Hematology - The patient was transfused two units for a
hematocrit of 29.0. She responded well to transfusion. She
had no signs of acute blood loss. She did have an INR of 1.8
on [**2153-12-12**], and therefore her Coumadin was held for several
days. Her INR had returned to her goal of 2.0 to 3.0 by
discharge.
7. Renal - The patient began to develop renal failure in the
setting of Lasix diuresis. Her creatinine rose from 2.0 to
2.6 and then to 3.4 in the course of 48 hours. Fractional
excretion of urea was less than 30% suggesting prerenal
failure likely due to diuresis. The patient had a
contraction alkalosis with a bicarbonate of 40. The patient
was fluid challenged with 250cc saline boluses but did not
respond until Dopamine was started. The patient responded
very well to Dopamine at 2.0 mcg/kg/hour with excellent urine
output. The patient was weaned off Dopamine after two days
of treatment. Creatinine on discharge was 1.3.
8. Nutrition - The patient had very poor oral intake and
therefore was seen by nutrition consultation who recommended
Boost supplement three times a day. She should have
nutrition follow her at rehabilitation with possible calorie
counts.
9. Speech and swallow - The patient was evaluated by Speech
and Swallow as nursing was concerned for possible aspiration.
Their impression was that the patient did well with all fluid
consistencies but did not chew her food and therefore she
should be given pureed solid diet.
10. Code Status - Code status was discussed with [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 3489**], the patient's nephew, and [**Name (NI) **], the patient's niece,
as well as the primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 84**] [**Last Name (NamePattern1) 85**].
Initially, the patient insisted that she wanted to be a full
code. However, as her condition deteriorated and it became
clear that full code status involved many interventions,
which were at times painful and which te patient refused
(such as arterial blood gases, A line, central line), her
wishes became more unclear and it seemed that she wanted few
interventions and for the emphasis to be placed on her
comfort and quality of life. Her main wish was to leave the
hospital. At the time of this dictation, code status is
still being discussed with the family and with Dr. [**Last Name (STitle) 85**].
11. Disposition - The patient was seen by physical therapy
who thought she was extremely weak and deconditioned and
would benefit from acute care rehabilitation. In addition,
the patient has oxygen requirements of two liters by nasal
cannula to maintain an oxygen saturation above 95%.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To [**Hospital6 908**].
DISCHARGE DIAGNOSES:
1. Atrial fibrillation, status post cardioversion.
2. Anemia.
3. Congestive heart failure.
4. Hypotension.
5. Acute renal failure.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg one capsule twice a day.
2. Senna 8.6 mg one tablet twice a day p.r.n. constipation.
3. Simvastatin 10 mg two tablets q.h.s.
4. Acetaminophen 325 mg one to two tablets q6hours p.r.n.
5. Warfarin 2.5 mg one tablet q.h.s.
6. Amiodarone 200 mg two tablets once daily.
7. Aspirin 325 mg one tablet once daily.
8. Magnesium Hydroxide 30ml p.o. q6hours p.r.n.
9. Pantoprazole 40 mg one tablet q24hours.
10. Bisacodyl 5 mg two tablets once daily p.r.n. as needed
for constipation.
11. Acetaminophen 325 mg one to two tablets p.o. q6hours
p.r.n.
12. Metoprolol 50 mg 0.25 tablet p.o. twice a day.
13. Digoxin 0.125 mg tablet one half tablet p.o. once daily.
14. Heparin flush once daily.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) 384**] for
sternal wire revision. The patient is to stop taking
Coumadin one week before her appointment for sternal wire
revision. The patient is to follow-up with Dr. [**Last Name (STitle) 85**] in one
to two weeks. The patient is to follow-up with Dr. [**Last Name (STitle) **]
in one to two weeks.
DISCHARGE INSTRUCTIONS: The patient's INR should be
maintained at a goal of 2.0 to 3.0. The patient may need
gentle diuresis with Lasix 20 mg p.o. once daily for
increasing volume overload and may need gentle hydration with
normal saline for decreased blood pressure.
[**Doctor First Name 1332**] [**Name8 (MD) 1333**], M.D. [**MD Number(1) 1334**]
Dictated By:[**Last Name (NamePattern1) 662**]
MEDQUIST36
D: [**2153-12-17**] 17:23
T: [**2153-12-17**] 20:34
JOB#: [**Job Number 3490**]
cc:[**Female First Name (un) 3491**]
|
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82,762
| 180,136
|
42682
|
Discharge summary
|
report
|
Admission Date: [**2198-12-17**] Discharge Date: [**2199-1-3**]
Date of Birth: [**2129-6-11**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
15-foot fall from ladder with sternal fx/mediastinal hematoma, R
PTX, R rib fxs [**6-24**], T6-10/12 fx, L hemothorax
Major Surgical or Invasive Procedure:
[**12-17**]: R chest tube placement
[**12-18**]: L chest tube placement
[**12-20**]: IVC filter placement
[**12-19**]: R chest tube placement
[**12-24**]: R chest tube placement
History of Present Illness:
69M s/p fall from a ladder, approximately [**9-30**] feet. He was
initially managed at an OSH where he received CT scans of the
head, c-spine, chest, abdomen, and pelvis which revealed a
sternal fracture at the manubrium with associated hematoma,
right [**6-24**] rib fractures with pneumothorax, T6-10, T12 vertebral
fractures, and subcutaneous air near the neck. Patient was
intubated and a right sided chest tube placed to evacuate the
pneumothorax. Upon arrival to [**Hospital1 18**] he was evaluated by the
Acute Care Surgery service who also consulted Thoracic Surgery
to evaluate possible tracheobronchial injury.
Patient was admitted to TSICU, and blood pressures remained low
despite aggressive fluid rescucitation. Patient was placed on
low dose Levophed and bedside TTE and TEE performed. A hematoma
slightly compressing the left atrium was visualized on ECHO and
CTA, deemed to be likely slow venous bleed. A left chest tube
was placed that drained 300 cc sanguinous fluid. Several
fractures of the thoracic spine visualzed on MRI, and abdominal
brace in place.
Past Medical History:
None
Social History:
Patient lives at home with his wife. [**Name (NI) **] does home remodeling for
work. He denies tobacco, alcohol, and illicit drug use.
Family History:
NC
Physical Exam:
BP: 113/73 HR:88 R 17 O2Sats 100% CPAP
Gen: Sedated and non-arousable at time of assessment. Per
report he was AOx3
at time of presentation to OSH.
HEENT: Pupils: 1 and MR
Resp: Intubated, coarse ventilator sounds, CTA
anteriorly, unable to auscultate posteriorly due to precautions
for spinal fractures. Right sided chest tube with a 1 chamber
air leak and serosanguinous discharge. Small amount of
sanguinous staining on right chest tube dressing. Small amount
of crepitus over right chest, no crepitus palpable in neck or
left chest.
Neck: cervical collar in place
Lungs: R chest tube
MAE spontaneously off sedation, not following commands.
Pertinent Results:
Na:144 K:1.7 Cl:133 TCO2:10 Glu:51
Lactate:2.1
BUN 23 Cr. 1.2
Ca: 8.5 Mg: 2.1 P: 4.6
20.5 > 12.3/37.4 < 242
PT: 11.4 PTT: 24.7 INR: 1.1
Fibrinogen: 212
Serum Benzo Pos
Serum ASA, EtOH, [**Last Name (LF) 92274**], [**First Name3 (LF) **], Tricyc Negative
Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative
ABG: pH 7.23 pCO2 48 pO2 77 HCO3 21 BaseXS -7
[**2197-12-17**]
Fast negative
CXR: R CT in place, resolution of pneumothorax
CT head : No acute process
CT spine : Net . T 4 / 6 -10 / 12 Vertebral fx ? Dedicated T
spine CT
CT Chest R 7-8-9 Rib fx, Sternal fx / Retrosternal hematoma,
Subcutaneos emphysema
CT Abdomen : Neg for intrabdominal injury
[**2198-12-18**]:
TTE Preserved [**Hospital1 **]-ventricular systolic function. Trivial
pericardial effusion. Concern for mechanical external
compression of the left atrial wall.
CXR: There again is widening of the superior mediastinum.
Indistinctness is seen of the aortic arch, possibility of
post-traumatic bleeding. Engorgement of pulmonary vessels is
consistent with elevated pulmonary venous pressure. Hazy
opacification in the left hemithorax suggests pleural effusion
with opacification tracking upward along the lateral chest wall.
The possibility of this supervening consolidation would be
difficult to exclude in the appropriate clinical setting.
CXR: Interval placement of the left chest tube. Left deep sulcus
sign with small radiolucent area concerning for a small
pneumothorax.
CTA CHEST: Slight enlargement of hematoma surrounding the
descending intrathoracic aorta most likely from a venous source
as there is no evidence of active arterial extravasation or
aortic injury. The hematoma may be causing slight mass effect on
the left atrium. Shortening of the thoracic AP diameter due to
multiple displaced posterior right rib fractures, likely
contributing to mild left atrial compression. Small
hemopericardium, unchanged since the outside hospital study
performed one day prior. No evidence of tamponade. Small
bilateral pleural effusions, left greater than right. The left
hemothorax has slightly increased in size since one day prior.
Pneumothorax has nearly resolved with only a tiny right anterior
pneumothorax remaining. Retrosternal hematoma remains stable in
size. No evidence of active extravasation. Significant right rib
fractures, comminuted sternal fracture, and vertebral body
fractures as described above.
CT TSPINE: Multiple thoracic spine compression fractures as
described in with retropulsion of the inferior aspect of T8 and
T9 vertebral bodies. Associated findings consistent with
enlargement of
hematoma surrounding the descending intrathoracic aorta,
subcutaneous
emphysema, bilateral pleural effusions, multiple rib fractures.
MRI CSPINE/ TSPINE: 1. Multiple thoracic vertebral fractures
with retropulsion of the posterior cortex at T8 and T9 levels.
The retropulsed posterior cortex contacts the spinal cord at [**Name (NI) 59724**]
with a suspicious area of increased cord signal at this level
concerning for cord edema/contusion. Close attention on followup
imaging is recommended. 2. Interspinous ligament injury at T7-T8
and T8-T9 levels. 3. Increased signal intensity along the
posterior paraspinal soft tissues, suggestive of soft tissue
injury.
4. Bilateral pleural effusions and prevertebral hematoma are
similar to that seen on the prior CT. 5. Unremarkable MRI of the
cervical spine.
[**2198-12-20**] KUB Fluoroscopic assistance was provided to the surgeon
without the radiologist present. Total fluoroscopy time was 81.8
seconds. A single fluoroscopic spot view demonstrates a deployed
IVC filter with its tip at the lower edge of L2 vertebral body.
Please refer to the operative note for further details.
[**2198-12-20**] CXR Bilateral chest tubes remain in place, with no
visible
pneumothorax. Indwelling support and monitoring devices are
similar in position with endotracheal tube terminating about 2.4
cm above the carina. Cardiomediastinal contours are unchanged.
Bibasilar atelectasis is again demonstrated, slightly worse on
the right, but improving on the left. Small pleural effusions
are also demonstrated.
[**2198-12-21**] CXR: No evidence of active bleeding. Unchanged positions
of bilateral chest tubes and endotracheal tube.
[**2198-12-22**] CXR: interval increase in bilateral pleural
effusions. Multiple rib fractures on the left are better
appreciated as well as the right rib fractures than on the prior
examination. The patient is also in pulmonary edema.
[**2197-12-23**] : The ET tube tip is 6.5 cm above the carina. The right
subclavian line tip is at the level of mid SVC.
Cardiomediastinal silhouette is unchanged. Right lung opacity
and left basal consolidation are unchanged. Mild pulmonary edema
is unchanged. The NG tube tip is in the stomach. Overall no
substantial change since the prior radiograph is demonstrated.
No interval development of pneumothorax is seen.
Brief Hospital Course:
Mr. [**Known lastname 92275**] was evaluated in our trauma bay with physical survey
and imaging showing the following injuries:
Sternal fx
Mediastinal hematoma
Pulmonary contusion
R pneumothorax
L hemothorax
T-spine fx t6-10 & 12
By system:
Neuro: CT of the T-spine showed multiple T-spine fractures
(T4,T6-T10,T12), with possible unstable T8 & T10 fractures.
This was followed with an MRI showing spinal cord contusion at
T9 but stable ligaments throughout. Patient's neurologic exam
was within normal limits. Neurosurgery recommended non-operative
management with a TLSO brace which was maintained through his
hospitalization.
Mr. [**Known lastname 92275**] was intubated and sedated upon arrival at [**Hospital1 18**].
His sedation was a challenging issue, especially in the setting
of weaning the ventilator and preventing harmful movements while
in TLSO brace. He was initially tried on precedex but did not
tolerate well (became hypotensive and agitated, requiring
intermittent haldol). He was ultimately adequately sedated but
required a multi-drug regimen consisting of clonidine, dilaudid,
ativan, zyprexa, propofol. When his acute delirium issues
resolved, his regimen was tapered and he was alert and oriented
x 3 and appropriate for the remainder of his [**Hospital **] hospital
course.
CV: Hypotensive requiring aggressive resuscitation on arrival
(7L crystalloid and 2 units PRBC on admission to ICU) with
pressors in addition. Central lines and a-lines placed. A
bedside TTE on HD 2 showed a left pleural effusion with poor
visulaization of the heart. A TEE showed potential compression
of the left atrium due to the hematoma with a CTA confirming
decreased AP diameter due to hematoma as well as rib fractures.
A chest tube was placed with 300 cc blood drained immediately.
Oxygenation improved and hew as weaned off of pressors on HD 3.
He remained HD stable through the rest of his course, not
requiring additional pressors support.
Resp: He had a right sided pneumothorax which was treated with
a right CT placed at the outside hospital. He had a left sided
hemothorax which was treated with a left sided chest tube placed
on admission to the [**Hospital1 18**] TSICU. These remained in place,
serial radiographs demonstrated resolution and they were dc'd on
HD 5 without complication. Over the course of the next few
days, daily CXRs demonstrated increased opacification of this
right lung field with blunting of his right costophrenic angle.
His ventilator weans (see below for more information) were also
equally challenging with very little respiratory reserve. A CT
scan was obtained on HD 12 to assess further and demonstrated a
moderate to large amount of fluid, likely old blood, in his
right chest cavity. A chest tube was inserted at bedside and
drained approximately 800 cc of old sanguinous fluid and then
250 cc the next day followed by minimal output on its third day
(HD 14). It was removed on HD 14 and post-pull CXR demonstrated
a pneumothorax, prompting reinsertion of a chest tube on HD 15.
The pneumothorax resolved, the chest tube was placed to
waterseal to good effect and on HD 17, the chest tube was
removed without complication.
He was intubated upon arrival. There were weaning trials
post-operative from the IVC filter on HD 4 but unable to
successfully wean to pressure support as he became increasingly
tachypneic and agitated. Lasix diuresis was continued over the
course of the next several days and he was ultimately weaned to
pressure support but continued to struggle with settings in the
face of agitation and low pulmonary reserve (see neuro and above
re: hemothorax). It was determined that he would benefit from a
trach for continued ventilator wean and on HD 10 he had a
tracheostomy. This was used for ventilator weans thereafter.
He failed a speech & swallow eval on HD 16 but then passed it on
HD 18 at which point he was fitted for a PMV.
Was treated for a presumed VAP starting on [**2198-12-21**] (HD 5).
Please see ID section for further information.
GI: Had an OGT initially through which was started on Replete
with Fiber tube feeds on HD 3 and gradually advanced to goal.
Tolerated without difficulty. The OGT was replaced with a
dobhoff on HD 8. Patient had a swallow study on HD 18.
GU: Foley catheter was placed to record urine output. Lasix was
used intermittently to remove excess fluid. No major issues.
Heme: Hct was stable throughout his course. IVC filter was
placed on [**2198-12-20**]. SQH resumed in later portion of his hospital
course.
ID: Started on VAP bundle (vanc/cefep/cipro) for a presumed
pneumonia on HD 5. Bronchoscopy did show secretions and BAL
grew staph aureus 10-100K. Pan cultured for fever [**12-22**], blood
and urine NGTD. Patient completed at 14 day course of antibiotic
therapy for his pneumonia.
Medications on Admission:
None
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Sternal fracture with mediastinal hematoma
Pulmonary contusion
R pneumothorax
L hemothorax
T-spine fractures from T6-10 & 12
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance
Discharge Instructions:
You were admitted after a traumatic fall from a ladder and
sustained multiple injuries. You are now ready to continue to
recover in your rehab facility. Please follow these
instructions:
- Walk daily, full weight bearing. Please leave TLSO on when
patient's head is above 30 degrees.
- Continue tube feeds and flush PEG q4h with 50 cc of water.
Please gradually increase po intake and wean tube feeds
- Continue your antibiotics until [**2199-1-11**]
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
PICC Line:
*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is
significantly soiled for further instructions
Followup Instructions:
Please follow up in 6 weeks at [**Hospital 4695**] clinic on [**2199-2-15**] at
11am for xrays at the Spine center at [**Location (un) 830**] ([**Location (un) 1385**] of the [**Hospital Ward Name 23**] Building). You will meet with the surgeon
in the Spine Center at 11:30 AM.
Please follow up with Dr. [**Last Name (STitle) **] in Acute Care Surgery clinic
on [**2199-1-29**] at 1:30 pm.
|
[
"276.69",
"293.0",
"263.9",
"518.51",
"806.25",
"807.03",
"287.5",
"807.2",
"458.29",
"E915",
"860.4",
"482.41",
"861.21",
"933.1",
"958.4",
"429.89",
"427.89",
"041.11",
"997.31",
"805.2",
"922.1",
"E881.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"33.24",
"33.23",
"96.6",
"38.7",
"96.72",
"43.11",
"34.04",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
12437, 12537
|
7548, 12382
|
421, 600
|
12706, 12706
|
2591, 7525
|
14686, 15080
|
1902, 1906
|
12558, 12685
|
12408, 12414
|
12864, 14663
|
1921, 2572
|
264, 383
|
628, 1705
|
12721, 12840
|
1727, 1733
|
1749, 1886
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,194
| 178,564
|
3146
|
Discharge summary
|
report
|
Admission Date: [**2166-12-11**] Discharge Date: [**2166-12-17**]
Date of Birth: [**2096-4-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 7227**]
Chief Complaint:
Mental status changes
Fever
Major Surgical or Invasive Procedure:
placement of subclavian line
left wrist arthrocentesis
arterial line placement
History of Present Illness:
70 y.o. female with hx of mult admissions for fever, UTI (mult
resitant klebsiella) and hypoglyecemia presents from home with
mental status changes and fever. Pt had just finished a 10 day
course of Bactrim for UTI. Per daughter, she began to have
slurred speech yesterday and had not voided all day. Subjective
fevers at home and occ productive cough. Daughter reports that
this is the way the pt always gets when she is septic. No N/V.
Pt has chronic diarrhea. Pt has R foot pressure ulcer which the
daughter says has become slightly worse and she recently
restarted using her debriding cream. Pt has hx of MRSA infection
in this wound.
.
On arrival to [**Name (NI) **] pt found to be verbal but confused. Fever to
101. Foley placed and thick, purulent urine came out without
blood. Found to be febrile to 101, pressure low in 100's but has
always been difficult to obtain BP due to habitus. Pt received
Vanc and Levaquin in ED. BP improved with IVF. Pt found to have
acute on chronic reanl failure and u/a consitent with UTI.
Past Medical History:
Right Femur Fx S/P ORIF ([**10/2165**]: Tripped Over Commode), HTN,
Hyperlipidemia, DMII, Peripheral Neuropathy, Obesity, IBS
(Chronic Constipation, Abdominal Pain and Intermittent
Diarrhea), Chronic LBP/Sciatica (Osteoporisis, DJD/OA, Spinal
Stenosis), Depression/Anxiety, Panic Disorder, Parotid Gland
Tumor S/P Resection, S/P Multiple Falls, H/O Herpes Zoster, S/P
CCY, B/L Cataract Removal.
Social History:
She lives with her daughter, who is very involved with her care.
She had 11 children, and one passed away. She was a homemaker.
She quit smoking 20 years ago and had between [**4-29**] py. She uses
ETOH rarely (<1x/month).
Family History:
Her mother had DM. She knows nothing of her father. [**Name (NI) **] sister
died of [**Name (NI) **] at 60.
Physical Exam:
VS: 101 rectal HR 89 BP 160/119-->106/60 RR 15 O2 100% on 3L NC
gen: obese F lying in bed, sleeping.
HEENT: PERRL. NO sceral injection. EOMI. MM dry.
Neck: Iunable to appreciate JVP 2/2 habitus.
CV: RRR. [**1-26**] blowing systolic murmur.
Lungs: decreased BS throughout [**1-22**] body habitus. no wheezes/
crackles.
Abd: obese. large pannus. [**Female First Name (un) 564**] and minimal skin breakdown
beneath pannus. soft. NT. No masses.
Back: unable to examine [**1-22**] size
Extr: 1+ edema sl greater on R than L. Dp 1+ B/L. no c/c/e.
Neuro: unable to follow commands.
Pertinent Results:
[**2166-12-11**] 07:32PM LACTATE-1.7
[**2166-12-11**] 07:20PM GLUCOSE-208* UREA N-53* CREAT-4.5*#
SODIUM-132* POTASSIUM-5.8* CHLORIDE-101 TOTAL CO2-16* ANION
GAP-21*
[**2166-12-11**] 07:20PM ALT(SGPT)-17 AST(SGOT)-20 CK(CPK)-153* ALK
PHOS-179* AMYLASE-38 TOT BILI-0.3
[**2166-12-11**] 07:20PM LIPASE-17
[**2166-12-11**] 07:20PM cTropnT-0.04*
[**2166-12-11**] 07:20PM CK-MB-3
[**2166-12-11**] 07:20PM CALCIUM-8.6 PHOSPHATE-7.4*# MAGNESIUM-1.1*
[**2166-12-11**] 07:20PM WBC-18.0*# RBC-3.02* HGB-8.9* HCT-27.0*
MCV-89 MCH-29.4 MCHC-32.9 RDW-14.4
[**2166-12-11**] 07:20PM NEUTS-85.1* BANDS-0 LYMPHS-11.9* MONOS-2.7
EOS-0.3 BASOS-0.1
[**2166-12-11**] 07:20PM PLT COUNT-331#
[**2166-12-11**] 07:20PM PT-15.1* PTT-29.9 INR(PT)-1.5
[**2166-12-11**] 07:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
[**2166-12-11**] 07:20PM URINE RBC- WBC- BACTERIA-MANY YEAST-NONE
EPI-
.
CXR:CHEST, ONE VIEW: Comparison with [**2166-10-17**]. The
cardiac and mediastinal contours are stable. There are low lung
volumes, what appears to be crowded pulmonary vasculature. No
upper zone redistribution, pneumothorax, consolidations, or
pleural effusion.
IMPRESSION: No definite pneumonia or CHF
.
IMPRESSION:
1. Osteopenia and advanced first CMC degenerative changes.
2. Chondrocalcinosis. This can be seen with CPPD,
hyperparathyroidism, or hemachromatosis. Is acute CPPD a
clinical consideration?
3. Equivocal superimposed osteopenic foci, which could
represent small cysts or erosions. I strongly suspect this is
technical, but clinical correlation is requested -- does the
patient have focal tenderness along the ulnar border of the
fifth carpometacarpal joint?.
Brief Hospital Course:
A/P: 70 y.o. female with fever, hypotension and mental status
change with associated ARF, hyperkalemia, pyuria and
leukocytosis. Hx of recurrent UTIs, as well as chronic right
foot ulcer.
#. Fever/Mental Status Changes - patient presented in urosepsis
and was admitted to the MICU. She transiently required pressor
support, but was weanted off by day two. Her metabolic
acidosis, thought secondary to lactic acidosis resolved. Urine
culture grew Klebsiella pneumoniae sensitive to only Zosyn and
Meropenem. She was treated with Zosyn, and was discharged with
plans to complete a 14day course. Midline placed prior to
discharge. CXR showed no pneumonia. Right foot ulcer was not
felt to be source of sepsis. Urinary tract infection was most
likely source. Patient remained hemodynamically stable from day
two onward, and was discharged to rehab for continued iv
antibiotics.
.
#. Acute renal failure: Creatinine 4.5 on admission, elevated
from baseline 1.1. Differentinal diagnosis included prerenal vs
ATN in setting of septic hypotension. No casts seen, and
responded to iv fluids. Creat was trending down daily, and was
1.4 on the day of discharge. She was hyperkalemic on admission,
thought secondary to acute renal failure. She recieved
kayexelate and iv fluids, and this corrected by day two.
.
#. Acidosis: Patient had an anion gap metabolic acidosis
secondary to renal failure and elevated lactate. This corrected
to normal by day two.
.
#. Pain - Long history of chronic pain on a complicated regimen
including high doses of Oxycontin, Zanaflex, Neurontin, Doxepin
and oxycodone for breakthrough. Medications were initially held
with her relative hypotension. Once transferred to the floor,
doses were gradually increased. Patient was tolerating her
outpatient regimen by the time of discharge. Although patient
does not have any respiratory suppression, she was lethargic and
slept frequently during the day on this regimen.
.
#. Anemia: basline Hct 26-30. stable during hospitalization.
.
#. TIIDM: Patient's glyburide was held and she was supplemented
on slidign scale insulin. Blood sugar well controlled on this
regimen with recent A1c in the 5's. Glyburide was resumed prior
to discharge.
.
#. Right heel ulcer: H/o MRSA wound infection, previously
treated. Wound care was consulted and daily dressing changes
continued.
.
# Left wrist: patient complained of pain in left wrist, which
was noted to be swollen erythematous, and warm. Erythema
subsided and swelling decreased. An x-ray showed chronic
changes c/w CPPD. Rheumatology was consulted and found findings
consistent with pseudogout. Pain control by her chronic pain
regimen.
.
#. Anxiety/ depression/Panic Disorder: Celexa continued.
Klonopin initially held due to sepsis. Medications resumed
prior to discharge per outpatient regimen.
.
#. PPX: Patient requires standing bowel regimen given high
narcotic dose regimen.
.
#. Dispo: Patient was discharged to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] rehab. She
will complete 14days iv Zosyn. She will follow-up with Dr.
[**Last Name (STitle) **] her PCP [**2166-1-20**]. She will also f/u in rheumatology
clinic. She is a full code.
Medications on Admission:
Lisinopril 5 mg daily
Miconazole TP
Lidocaine TP
Neurontin 300 mg [**Hospital1 **]
Oxycontin 50 mg [**Hospital1 **]
MVI
Zyprexa 10 mg qhs
ASA 325 mg daily
Vitamin B12 1000mcg daily
Glipizide 5 mg qd
Protonix 40 mg daily
Prozac 20 mg daily
Lipitor 20 mg daily
Zanaflex 4 mg qhs
Doxepin 50 mg qhs
Senna/colace/dulcolax
Asacol 800 mg TID
Klonopin 2 mg qhs
Oxycodone prn
Folic Acid 1 mg daily
Elidel TP
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
11. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: Two (2)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
13. OxyContin 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO twice a day.
14. Doxepin 25 mg Capsule Sig: Four (4) Capsule PO HS (at
bedtime).
15. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
16. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
17. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for anxiety.
18. Oxycodone 5 mg Tablet Sig: 1-4 Tablets PO Q4-6H (every 4 to
6 hours) as needed for breakthrough pain.
19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
20. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
21. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
22. Zosyn 2.25 g Recon Soln Sig: 2.25 g Intravenous four times
a day for 10 days.
Disp:*qs ml* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
Urosepsis
Pseudogout
Type II diabetes mellitus
Chronic pain
Depression/Anxiety
.
Secondary:
Hypertension
Discharge Condition:
Stable
Discharge Instructions:
1. Please continue to take all medications as prescribed
2. You will continue on iv antibiotics for another 10days
3. If you develop fever >101.3, chest pain, shortness of
breath, decreased urination or any other concnerning symptom,
please contact your primary care physician [**Name Initial (PRE) **]/or return to the
emergency department
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14865**], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2167-1-14**] 9:00 -- Rheumatology
.
Please follow-up with Dr.[**Last Name (STitle) **], your primary care physician,
[**2166-1-20**] at 2:10pm
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2167-1-20**] 2:10
|
[
"599.0",
"275.49",
"585.9",
"311",
"707.07",
"403.91",
"038.9",
"995.92",
"276.7",
"712.33",
"276.2",
"250.00",
"584.9",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10232, 10305
|
4643, 7861
|
346, 427
|
10463, 10472
|
2883, 4620
|
10864, 11294
|
2162, 2271
|
8310, 10209
|
10326, 10442
|
7887, 8287
|
10496, 10841
|
2286, 2864
|
279, 308
|
455, 1485
|
1507, 1905
|
1921, 2146
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,375
| 169,540
|
51742
|
Discharge summary
|
report
|
Admission Date: [**2152-4-6**] Discharge Date: [**2152-4-15**]
Date of Birth: [**2077-3-4**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Transferred for management of iatrogenic bile duct injury
Major Surgical or Invasive Procedure:
Roux-en-Y Hepatico-jejunstomy
History of Present Illness:
75y, caucasian, male with recent hx of cholecystitis and
cholangitis ([**1-21**]), initially managed medically due to
concurrent NSTEMI with trop T> 84.
1. Iatrogenic bile duct injury
- Underwent interval laparoscopic, converted to open
cholecystectomy on [**4-3**]; Complicated by iatrogenic CBD injury
- Intra-op critical view was felt to be achieved; intra-op
cholangiogram did not reveal CBD injury
- Converted to open due to adherrent bowel to RUQ
- POD1: LFT, Bil noted to be raised + raised Trop T; went into
AF with RVR; cardio consult recommended doubling Toprol dose
- MRCP done in view of rising Bil: non-filling CBD ; PTC placed;
initally drained bile but now blood
- Transfered to [**Hospital1 18**] for further cardiac evaluation and
management of CBD injury
2. CAD
- No acute intervention for NSTEMI, left circumflex stenting in
[**1-21**]
- Cardiac cath [**2-18**] shoed thrombosed left circumflex stent,
unable to recannulate
- Noted to have stress-induced AFib and demand ischemia but did
not require further investigation
Past Medical History:
PMHX
1. CAD s/p left circumflex stenting with recent myocardial
infarction [**1-21**]
- Cardiac cath [**2-18**] showed thrombosed left circumflex which
cannot be recannulated
2. Diverticulosis
3. Vertigo
4. Atrial fibrillation
5. Asthma
6. Reflux
7. Benign prostate hypertrophy
8. Cholecystitis, cholangitis, history of gallstone pancreatitis
Past Sx Hx:
1. Lap converted open cholecystectomy [**65**]/04/11 c/b iatrogenic
CBD injury
Social History:
Married
Family History:
No CAD, otherwise N/C
Physical Exam:
Vitals: T 101.6; HR 83; BP 139/75; RR 24; POx 94% 4LNC
GEN: A&O, NAD, mild to moderate jaundice, tired appearing
HEENT: mucus membranes moist, no LAD, OP clear
CV: RRR, II/VI SEM
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, distended, appropriately TTP, no rebound or guarding,
normoactive bowel sounds, no palpable masses. PTC to gravity
draining brown bilious fluid, JP to bulb suction in RUQ with
sero-sanguinous drainage
INCISION: C/D/I, staples to mid-abdominal wound
EXT: No LE edema, LE warm and well perfused, 2+ DP/PT pulses
.
Pertinent Results:
- CBC: 5.3 > 30.8 < 204
- Coags: PT 13.1 / PTT 22.1 / INR: 1.1
137 / 105 / 12
- Chem: --------------< 87 Ca: 8.0 Mg: 2.0 P: 1.7
3.8 / 21 / 1.0
- LFTs: ALT 390 ([**2064**] at [**Last Name (un) 1724**]); AP 143; Tbili 8.9 (5->6.2 at
[**Last Name (un) 1724**]);
Alb 3.0; AST 119 (1221 at [**Last Name (un) 1724**]); Dbili 8.1 (3.7->4.8 at [**Last Name (un) 1724**]); [**Doctor First Name **]
73; Lip 80
- CEs: CK 365 (937->527 at [**Last Name (un) 1724**])/ MB 2 (3.6 at OSH)/ Trop-T 0.55
(4.14->2.55 at [**Last Name (un) 1724**])
- Fibrinogen: 903
.
Imaging:
- [**3-28**] CXR ([**Last Name (un) 1724**]): The chest is normal except for healed rib
fractures on the right. There is no interval change
- [**4-3**] Intra-Op Cholangiogram ([**Last Name (un) 1724**]): Opacification of the
intrahepatic biliary ductal system, probably both right and left
intrahepatic ducts, as well as dilation of a tubular structure
more inferiorly that was initially read as the common bile duct.
Further review indicates that in addition to the common bile
duct, this also could be a dilated left intrahepatic duct
projecting inferiorly due to obliquity
- [**4-4**] MRCP ([**Last Name (un) 1724**]): Common hepatic duct and proximal CBD not seen
and there is dilatation of the left greater than right
intrahepatic biliary ductal system, with postsurgical
inflammatory changes within the operative bed as well as
perihepatic fluid.
- [**4-5**] EKG: Atrial fibrillation with rapid ventricular
response,
Nonspecific ST abnormality, ST less depressed in Anterior leads
- [**4-6**] ERCP ([**Last Name (un) 1724**]): The ampulla was identified and had evidence
of
previous sphincterotomy. The bile duct was selectively
cannulated
with a balloon catheter and .025 guidewires. The distal CBD has
an estimated diameter of 6mm-7mm. There is abrubt cut-off of the
proximal CBD consistent with bile duct injury. An occulsion
cholangiogram did not result in passage of contrast beyond the
cut-off. Attempts at bridging the cut-off with a quidewire were
not successful.
Brief Hospital Course:
75M with a recent hx of cholecystitis and cholangitis ([**1-/2152**]),
managed medically due to concurrent NSTEMI w/trop >84 underwent
an interval laparoscopic converted to open cholecystectomy on
[**4-3**], which was complicated by an iatrogenic CBD transection and
cardiac enzyme elevation. The patient was transfered to [**Hospital1 18**]
for further cardiac evaluation and management of his bile duct
injury. Cardiology assessment recommended an alternative Toprol
dose but otherwise recommended no further cardiac opitimization
for surgery. The patient underwent a A PTC drain had been placed
on [**4-6**] after occlusion was noted on ERCP at an OSH.
The patient was initially admitted to the intensive care unit
for monitoring on [**4-6**]. There the patient was started on
Vanc/Pip-Tazo, omeprazole for GI prophylaxis, Dilaudid PCA for
pain control and was made NPO. Cardiac enzymes were cycled which
revealed no rising troponin levels. On [**4-7**] the Pip-Tazo were
d/c'ed and Ampicilin Sulbactam was started. The patient was then
transferred to the floor.
On [**4-8**] the patient was started on PO lopressor and dilaudid
with IV versions of both being disconitnued. The patient's PTBD
drain was found to be out by the nurse in the afternoon for
which an interventional radiology team was called for the PTBD
drain to be replaced. After the replacement of the drain the
patient returned to the floor in stable condition. At this time
the patient was continued on the Vanc and the Amp-Sulbactam.
On [**4-9**] the patient underwent preoperative evaluation.
On [**4-10**], the patient underwent a hepaticojejunostomy
successfully. The patient returned to the floor with an NGT, a
PTBD, and a bulb drain to suction. After a brief, uneventful
stay in the PACU, the patient arrived on the floor NPO, on IV
fluids and antibiotics, with a foley catheter, and a dilaudid
PCA for pain control. The patient was hemodynamically stable.
Neuro: The patient received a dilaudid PCA with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications.
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 spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, 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. The patient was
started on all home prostate medications prior to removal of
foley. The folwy was removed and pateint voided prior to
discharge.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. The patient's wound was
monitored for possible signs of infection.
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.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay. He was encouraged to
get up and ambulate as early as possible.
On [**2152-4-14**] a repeat tube cholangiogram was obtained which
demonstrated patent anastamosis.
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:
Medications prior to admission to [**Last Name (un) 1724**]: coumadin 5mg daily, ASA
325mg daily, finasteride 5mg daily, terazosin 2mg daily, Toprol
12.5mg daily, omeprazole 20mg daily, lovastatin 20mg qAM / 40mg
qPM, asthmacort, albuterol, MVI, Vit D
.
Medications on transfer to [**Hospital1 18**]: Toprol XL 25mg daily,
omeprazole 20mg daily, albuterol 2puffs q6h PRN SOB, lorazepam
0.5mg IV BID, ASA 325mg daily, HSQ 5000U TID
.
Discharge Medications:
1. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
3. docusate sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day): while on narcotics.
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain for 2 weeks. Tablet(s)
8. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please continue home dose of coumadin.
9. Outpatient [**Name (NI) **] Work
PT/PTT/INR on Monday [**2152-4-17**]
10. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
bile duct injury
afib
h/o cad
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] if you have any of
the following:
fever, chills, nausea, vomiting, jaundice, increased abdominal
pain or distension, constipation/diarrhea, incision
redness/bleeding/drainage or capped "roux tube" insertion site
appears red or has drainage.
Keep dry gauze dressing over capped drain site. Change daily.
Call if drain suture is loose or falls off. Must keep secured.
Empty JP drain and record outputs. Bring record of outputs to
next appointment with Dr. [**First Name (STitle) **]. (Disregard if drain removed
prior to discharge to home)
You may shower with soap/water, pat incision dry. Do not apply
powder/lotion/ointment to incision.
No heavy lifting/straining
No driving while taking pain medication
Followup Instructions:
Please follow up in Dr.[**Name (NI) 670**] office on Thursday [**2152-4-20**].
For details please contact [**Name (NI) 698**] [**Last Name (NamePattern1) 699**], RN coordinator at
[**Telephone/Fax (1) 17195**] if further details are needed.
Completed by:[**2152-4-17**]
|
[
"998.2",
"600.00",
"V45.82",
"411.89",
"493.90",
"412",
"444.89",
"562.10",
"427.31",
"E870.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.11",
"51.37",
"51.98"
] |
icd9pcs
|
[
[
[]
]
] |
9914, 9963
|
4654, 8481
|
358, 389
|
10037, 10037
|
2571, 4631
|
10971, 11243
|
1968, 1991
|
8965, 9891
|
9984, 10016
|
8507, 8942
|
10173, 10948
|
2006, 2552
|
261, 320
|
417, 1461
|
10052, 10149
|
1483, 1927
|
1943, 1952
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,086
| 165,729
|
53388
|
Discharge summary
|
report
|
Admission Date: [**2186-6-29**] Discharge Date: [**2186-7-11**]
Service: MEDICINE
Allergies:
Penicillins / Metoprolol / Levaquin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
resp failure/hypotension
Major Surgical or Invasive Procedure:
Intubation. Left subclavian line placement.
History of Present Illness:
89 yo M with multiple admission, with a h/o CHF, AF, PD,
hypothyroidism, and right leg ulcer, who presents with decreased
urine output and fever. Pt was treated emperically with bactrim
x 1 day for dysuria. He was brought to the ED today for low UO,
fever, and rigors.
.
In the ED, VS were notable for temp to 105, BP initially sable
and satting on RA. Exam was unremarkable except for his MS. [**First Name (Titles) **] [**Last Name (Titles) 109818**]p was unrevealing for a source of infection. Given
vancomycin, flagyl, CTX. He was given 6 LNS for presumed sepsis
with renal failure thought [**12-29**] dehydration. With this, he became
tachypneic with RR 33, using accessory muscle for breathing. He
was intubated. A left subclavian was attempted but not able to
be passed. A left IJ was placed with some difficulty of feeding
the wire. He was briefly on levofed for a low mixed venous sat.
His inital lactate was elevated to 6.3 which has decreased to
3.3. Elevated K initially treated with kayexalate, D50, insulin
with improvement to 3.9. A repeat ABG however showed an
increasing K to 5.9. Pt has another episode of bradycardia to
40's, improved with 1 amp bicarb; now on D5W w/ bicarb gtt. A CT
scan of chest and abd showed no intrabd process but a possible
pneumonia.
.
The patient has been admitted twice to [**Hospital1 18**] within the last six
months. He was admitted to the [**Hospital Unit Name 153**] on [**2-22**] for CHF
and sepsis [**12-29**] to aspiration pneumonia, requiring intubation and
[**Month/Day (2) 282**] tube placement. His second admission occurred from
[**Date range (3) 109819**] for RUL Pna, to which he was treated with
aztreonam/vanco/flagyl empirically for a 10 day course with a
PICC line placed. He was also transfused 2 units PRBCs at that
time.
Past Medical History:
1) Parkinson's disease
2) BPH
3) Large left hernia
4) s/p appy
5) s/p hernia repair 20 yrs ago
6) atrial fib: dx [**1-1**], not on Coumadin, Rate 80-100
7) h/o CHF: [**1-2**] TTE: RA mod dil, mild symm LVH, EF 45-55%, RV
fxn depression, abnl diastolic septal motion c/w RV vol
overload. [**11-28**]+ AR, [**11-28**]+ MR, 3+ TR, mild PA sys HTN
8) Fe def anemia: baseline 28-30
9) Hypothyroidism: TSH [**2186-5-16**] 4.6
10) CRI: baseline Cr 0.9-1.0
11) Left leg wound: followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12434**] and Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. Last seen [**2186-6-23**]. Exposed extensor hallicus [**Month/Day/Year 109815**].
Treated with VAC dressing.
12) PNA: serratia in sputum [**1-2**], pansensitive
Social History:
Pt lives at home with his wife and daughter. [**Name (NI) **] is retired
construction/ engineer/ realestate man. No ETOH, tobacco, or
drugs. Did occasionally smoke a pipe but quit greater than 20
years ago.
Family History:
[**Name (NI) 1094**] father had DM. Mother died of heart disease /rythm
problems. She was over 90 at her death. Daughter (alive at 47)
had Hodgkins many years ago.
Physical Exam:
ADMISSION EXAM
GEN: awake, intubated, able to nod
HEENT: intubated
NECK: left IJ, flat JVP
LUNGS: crackles bilaterally, rhonchi in upper lobes
HEART: RRR, l s1/s2, 3/6 SEM at LSB
ABDOMEN: distneded, + BS, nontender, semireducible hernia in
left inguinal area
EXT: r leg with wound vac, no edema
SKIN: no rashes
NEURO: moves all extremities, contracted in left hand
Pertinent Results:
ADMISSION LABS:
[**2186-6-29**] 10:35PM TYPE-MIX PO2-29* PCO2-39 PH-7.38 TOTAL CO2-24
BASE XS--2
[**2186-6-29**] 10:35PM LACTATE-2.5*
[**2186-6-29**] 10:35PM O2 SAT-62
[**2186-6-29**] 08:15PM TYPE-MIX PO2-40* PCO2-41 PH-7.34* TOTAL
CO2-23 BASE XS--3
[**2186-6-29**] 08:15PM LACTATE-2.7*
[**2186-6-29**] 08:15PM HGB-8.8* calcHCT-26 O2 SAT-79
[**2186-6-29**] 08:15PM freeCa-1.03*
[**2186-6-29**] 08:00PM GLUCOSE-145* UREA N-103* CREAT-3.1*
SODIUM-136 POTASSIUM-5.6* CHLORIDE-101 TOTAL CO2-22 ANION GAP-19
[**2186-6-29**] 08:00PM CK(CPK)-140
[**2186-6-29**] 08:00PM CK-MB-6 cTropnT-0.19*
[**2186-6-29**] 08:00PM CALCIUM-7.7* PHOSPHATE-4.6* MAGNESIUM-2.5
[**2186-6-29**] 08:00PM WBC-13.0* RBC-2.89* HGB-7.7* HCT-24.4* MCV-84
MCH-26.8* MCHC-31.7 RDW-18.2*
[**2186-6-29**] 08:00PM NEUTS-92.7* BANDS-0 LYMPHS-3.0* MONOS-4.3
EOS-0.1 BASOS-0
[**2186-6-29**] 08:00PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
[**2186-6-29**] 08:00PM PLT SMR-NORMAL PLT COUNT-234
[**2186-6-29**] 05:46PM TYPE-ART PO2-101 PCO2-42 PH-7.19* TOTAL
CO2-17* BASE XS--11
[**2186-6-29**] 05:46PM LACTATE-3.9* K+-5.9*
[**2186-6-29**] 04:55PM TYPE-ART PO2-236* PCO2-56* PH-7.13* TOTAL
CO2-20* BASE XS--11
[**2186-6-29**] 04:55PM GLUCOSE-255* LACTATE-3.3* K+-5.9*
[**2186-6-29**] 04:55PM HGB-7.6* calcHCT-23
[**2186-6-29**] 02:46PM LACTATE-4.0*
[**2186-6-29**] 02:37PM CREAT-3.3* POTASSIUM-6.1*
[**2186-6-29**] 02:37PM WBC-18.7* RBC-2.85* HGB-7.6* HCT-23.8* MCV-83
MCH-26.8* MCHC-32.2 RDW-18.1*
[**2186-6-29**] 02:37PM PLT COUNT-252
[**2186-6-29**] 11:41AM LACTATE-6.7* K+-6.6*
[**2186-6-29**] 11:00AM PT-12.7 PTT-23.2 INR(PT)-1.1
[**2186-6-29**] 10:20AM GLUCOSE-161* UREA N-118* CREAT-3.6*#
SODIUM-127* POTASSIUM-8.6* CHLORIDE-93* TOTAL CO2-18* ANION
GAP-25*
[**2186-6-29**] 10:20AM ALT(SGPT)-20 AST(SGOT)-105* ALK PHOS-196*
AMYLASE-42 TOT BILI-0.4
[**2186-6-29**] 10:20AM ALBUMIN-3.4 CALCIUM-9.1 PHOSPHATE-4.5
MAGNESIUM-3.1*
[**2186-6-29**] 10:20AM CORTISOL-83.0*
[**2186-6-29**] 10:20AM CRP-270.2*
[**2186-6-29**] 10:20AM WBC-20.1*# RBC-3.36* HGB-9.2* HCT-28.0*
MCV-83 MCH-27.3 MCHC-32.7 RDW-18.4*
[**2186-6-29**] 10:20AM NEUTS-95* BANDS-1 LYMPHS-3* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2186-6-29**] 10:20AM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-OCCASIONAL
POLYCHROM-OCCASIONAL TEARDROP-OCCASIONAL
[**2186-6-29**] 10:20AM PLT SMR-NORMAL PLT COUNT-315
[**2186-6-29**] 10:20AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2186-6-29**] 10:20AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2186-6-29**] 10:20AM URINE RBC-[**5-6**]* WBC-0-2 BACTERIA-RARE
YEAST-FEW EPI-0-2
[**2186-6-29**] 10:17AM LACTATE-6.3*
.
DISCAHRGE LABS:
.
MICROBIOLOGY:
[**2186-6-29**]: Urine culture: 10K-100000K yeast
[**2186-6-29**]: Blood culture: 2/4 bottles [**Female First Name (un) **] albicans
[**2186-7-1**]: >25PMNs <10epis, 1+ GPC, yeast
.
IMAGING:
[**2186-6-29**] AP CXR: FINDINGS: The ETT tube was pulled back with its
tip now projecting 4 cm above the carina. The position of the
left subclavian catheter is unchanged. The heart size is mildly
enlarged, but stable. There is bibasilar consolidations most
probably represent atelectasis. There is worsening of left
upper lobe consolidation which could represent aspiration or
developing pneumonia. There is no further pleural effusion or
pneumothorax.
.
[**2186-7-1**]: CT abdomen/pelvis: IMPRESSION:
1. Interval development of diffuse thickening of the distal
sigmoid colon and
rectum with mild surrounding inflammatory fat stranding and
intrapelvic fee
fluid consistent with proctitis/distal colitis. These findings
are most likely
infectious versus inflammatory in etiology, although given the
extensive
atherosclerosis within the major arterial vessels, ischemia is
also a
consideration.
2. Large left inguinal hernia containing a large segment of
sigmoid colon
without evidence for hernia incarceration or bowel obstruction.
3. Extensive atherosclerotic disease throughout the visualized
aorta and its
branches.
4. Extensive sigmoid-colonic diverticulosis.
5. Small pleural effusions with unchanged airspace
opacification at the
bilateral lung bases, right greater than left, which may
represent
atelectasis, however, infection/infiltrate is also a
consideration.
.
[**2186-7-3**] ECHO: The left atrium is elongated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses and cavity
size are normal. Overall left ventricular systolic function is
probably mildly depressed with inferior hypokinesis. The right
ventricular cavity is mildly dilated. Right ventricular systolic
function is borderline normal. The aortic valve leaflets are
moderately thickened. There is no aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Moderate (2+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may
be significantly UNDERestimated.] The tricuspid valve leaflets
are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is no
pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2186-1-23**],
the degree of tricuspid regurgitation and RV dysfunction is
less.
Brief Hospital Course:
Sepsis: The patient initially presented with severe sepsis,
with lymphocytosis, hypoptension fevers, lactate of 6.3 with an
anion gap acidosis, respiratory distress, and acute renal
failure. The patient was given aggressive fluid resusitation
(6L NS), vancomycin, CTX, and Flagyl. In the ED, he was started
on a levophed drip, which stabilized his BP. After 24 hours on
antibiotics and fluids, his levophed drip was discontinued with
good effect. Moreover, his lactate returned to [**Location 213**] levels
with resolution of his acidosis. He became afebrile, and his
WBC returned to [**Location 213**]. Blood and urine cultures grew out
yeast, specifically [**Female First Name (un) **] albicans. ID was consulted. He was
started on voriconazole, which was switched to Fluconazole on
[**7-4**]. A CXR showed a question of pneumonia, so the patient was
maintained on Ceftriaxone. Vancomycin was D/C'd. Moreover, an
abdominal CT showed wall thickening in the procto-sigmoid colon.
However, C. diff toxin was negative. GI was consulted, and
they thought the wall thickening was consistent with proctitis
secondary to watershed ischemia from his hypotension. We
maintained him on Flagyl, however, given a previous history of
diarrhea and ? of C. diff. A prostate exam was normal, and
ophthalmology ruled out optic endophthalmitis. An ECHO showed
changes consistent with age, but no definitive vegetations or
endocarditis. His exam did not demonstrate stigmata of
endocarditis. On transfer to the floor, his signs of sepsis had
vanished; while on the floor he remained afebrile, without
leukocytosis, and clinically continued to improve. He had no
signs or symptoms of infection at discharge. At discharge, The
patient is on oral Flucaonazole to complete a 14 day course
after being on voriconazole, started on [**6-30**] for his [**Female First Name (un) 564**]
fungemia. He has completed a 10 day course of Ceftriaxone,
which was switched to PO cefpodoxime on [**7-4**] (Started [**6-29**],
completed [**7-9**]) for his LUL pneumonia. He will complete a 14
day course of Flagyl for proctitis, to be finished on [**7-13**]. He
will follow up with Opthalmology in [**11-28**] weeks. He will follow up
with his PCP [**Last Name (NamePattern4) **] 1 week.
.
Respiratory Failure: The patient was found to be in respiratory
failure in the ED, with a respiratory rate of 33 using accessory
muscles. His failure was thought to be due to a question of
pneumonia vs. CHF. His respiratory status improved over 24
hours, and he was extubated on [**7-1**] after passing a spontaneous
breathing trial. He was maintained on 2-4L NC with good sats,
and eventually tolerated room air well with sats in the mid to
upper 90's. Once his BP was stabilized, he was given
intermittent lasix with good UOP and improvement with his
respiratory exam. On transfer to the floor, he was breathing
well on room air. While on the floor he had no further
significant respiratory issues, but did have some respiratory
secretions. He received Chest PT, Nebs PRN, and suctioning with
good results. He was restarted on his home regimen of
Furosemide 20 mg qod. He maintained O2 sats >95% on room air.
.
Acute Renal Failure: His admission creatinine was 3.3, well
above his baseline. He also demonstrated decreased UOP. After
aggressive fluid resusitation, his Cr improved steadily over the
first 72 hours. His FENa was about 1%. Moreover, his admission
anion gap metabolic acidosis resolved with fluids. Upon
transfer to the floor, his Cr was at his baseline at 1.2 and he
was making good UOP at 50-100ml/hr. His medications were
renally dosed.
.
Bradycardia/LBBB: On admission, an EKG demonstrated a LBBB with
severe bradycardia of a junctional/escape origin. This pattern
resolved upon arrival to the ICU. He ruled out by cardiac
enzymes and did not experience this phenomenon during admission.
It was thought related to his sepsis/acidosis, which resolved
over the first 24 hours. An ECHO did demonstrate mildly
depressed EF, MR [**First Name (Titles) **] [**Last Name (Titles) **], as well as changes consistent with age.
.
Vancomycin Extravasation: On [**7-3**], his vancomycin extravasated
into his left forearm prior to being D/C'd. A welt developed
around the site, and attempts at draining were unsuccessful.
Cool packs and elevation were administered after consultation
with pharmacy. His welt showed no change over 48 hours. Upon
transfer to the floor, his welt was stable with no signs of
necrosis. While on the floor the welt slowly improved and there
were no signs of necrosis at discharge. He will follow up with
his PCP for this lesion.
.
Left Leg Ulcer: His ulcer was VAC dressed by plastics. They
changed his dressing on M-W-F without complications. He will
follow up with plastic surgery after discharge.
.
Parkinson's/Hypothyroidism: Controlled well with his outpatient
regimen.
.
FEN: The patient was initially hyperkalemic in the ED, likely
related to his ARF. His potassium responded well to
kayelxalate, and returned to [**Location 213**] limits with 24 hours. he
remained asymptomatic. On [**7-4**], he was shown to be mildly
hypernatremic. It was thought to be caused by free water
depletion. His free water deficit was calculated to be between
1.5L and 2L. Upon arrival to the floor, he was started on 500ml
free water boluses throug his [**Month/Day (4) 282**] q 6 hours. He remained
asymptomatic and his hypernatremia resolved. He also received
tube feeds through his [**Month/Day (4) 282**] tube without incident. He will
continue on tube feeds at home to meet his nutrition needs. He
was evaluated by speech and swallow. He may have pureed solids
and nectar thick liquids, however, he will not be able to take
enough PO to meet his metabolic needs, therefore, he will take
PO only for pleasure. He will benefit from continued speech
therapy as an outpatient.
.
BPH: His Proscar was held until [**7-4**] when his family requested
its continuation. It was restarted on [**7-4**]. He failed a voiding
trial on [**7-8**] and again on [**7-10**]. Flomax 0.4 mg daily was
started on [**7-10**]. He will be d/c'd with a Foley in place and will
follow up with urology as an outpatient.
.
Code Status: The patient was full code during admission.
Medications on Admission:
Bactrim DS PO qDay started [**6-28**]
Carbidopa/Levo 25/100 1 [**11-28**] tab PO TID
Comtan 200mg PO TID
Mirapex 3mg PO TID
Proscar 5mg PO qAM
Levothyroxine 12.5mcg PO qAM
ASA 81mg PO qDay
Lasix 20mg PO QOD
Prevacid 30mg PO qAM
DSS 100mg PO TID
Alphagan 0.15% OPTH 1 drop OS QAM/PM
Discharge Medications:
1. Entacapone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
2. Carbidopa-Levodopa 25-100 mg Tablet Sig: 1.5 Tablets PO TID
(3 times a day).
3. Pramipexole 1 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
Disp:*QS 1 bottle* Refills:*0*
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 days: Last dose 8/17.
Disp:*6 Tablet(s)* Refills:*0*
10. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 3 days: Last dose 8/18.
Disp:*6 Tablet(s)* Refills:*0*
11. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
12. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QOD ().
14. Docusate Sodium 150 mg/15 mL Liquid Sig: 30 ML PO TID (3
times a day) as needed for constipation.
Disp:*qs 1 bottle* Refills:*2*
15. 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:*0*
16. Pantoprazole 20 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:*0*
17. Bedside suctioning unit
Bedside suction unit including Yankauer, Suction Catheter, and
Suction handle.
18. Albuterol-Ipratropium 2.5-0.5 mg/3 mL Solution Sig: [**11-28**]
puffs Inhalation every six (6) hours.
Disp:*QS 1 inhaler* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Fungemia. Pneumonia. Proctitis.
Discharge Condition:
Stable.
Discharge Instructions:
During this admission you have been treated for fungemia,
pneumonia and proctitis. Please continue to take all
medications as prescribed. If you develop fever >101, worsening
cough, feeling lightheaded, abdominal pain, or any other symptom
that is concerning to you, please seek medical attention.
Followup Instructions:
PLASTIC SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**] Date/Time: [**2186-7-14**]
1:00
UROLOGY UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2186-7-19**] 8:00 [**Hospital Ward Name 23**]
building, [**Location (un) **]
Provider: [**Last Name (NamePattern4) 19764**] BALL,O.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2186-7-17**]
2:00
Follow up with your PCP [**Last Name (NamePattern4) **] [**11-28**] weeks.
|
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50,440
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50984
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Discharge summary
|
report
|
Admission Date: [**2132-11-16**] Discharge Date: [**2132-12-6**]
Date of Birth: [**2049-2-4**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / adhesive tape / lisinopril / Enalapril / amiodarone
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
atrial fibrillation with rapid ventricular response
Major Surgical or Invasive Procedure:
[**2132-11-28**] - Attempted but unsuccessful transesophageal
echocardiogram with cardioversion
History of Present Illness:
The patient is an 83-year-old woman with a PMH significant for
non-cardiomyopathy (LVEF 25%), failed endomyocardial biopsy at
[**Hospital1 112**] secondary to induction of complete heart block (which
resolved), anterior MI s/p BMS to LAD and moderate-to-severe MR
who was initially admitted to the [**Hospital1 1516**]-Cardiology service on
[**2132-11-16**] for chest pain found to be in new-onset atrial
fibrillation with rapid ventricular rate.
.
On the day of admission, the patient noted substernal chest
discomfort, described as a dull,non-radiating and not associated
with any dyspnea, N/V, lightheadedness, or palpitations. Patient
also denied any DOE, PND, orthopnea, ankle edema, syncope or
pre-syncope prior to admission. She denies any recent fevers or
chills; no cough or dysuria.
.
In the ED, patient was noted to be in atrial fibrillation with
RVR, rate in the 140s with a BP of 116/92. Of note, Labs on
admission were notable for a Troponin of 0.17, potassium of 3.1
and magensium of 1.7. She received IV Diltiazem, was started on
Heparin gtt, and was admitted for planned cardioversion. She
then spontaneously converted to sinus rhythm, and was started on
warfarin for anticoagulation. Hoewever, she converted back into
A.fib and was then started on Amiodarone on [**2132-11-19**]. LFTs
revealed a mild transaminitis.
.
Upon admission to the Medicine floor, her course has been
notable for elevated cardiac enzymes and presumed acute systolic
CHF exacerbation with worsening hyponatremia (to nadir of 117),
[**Last Name (un) **] (peak 1.9 from baseline 0.7-0.9), transaminitis (which
worsened with AST in the 6000s and ALT in the 3000 range;
Hepatology attributing this to congestive hepatopathy vs.
Amiodarone toxicity), and an Enterococcal UTI (sensitive to
Ampicillin, 7-day course planned). Cardiac enzymes were cycled
with a peak Troponin of 0.22, CK-MB 10. MB index was 3.2. She
was diuresed with Torsemide and Metolazone and was continued on
Metoprolol for rate control. The patient also had some issues
with bloody stools which was attributed to hemorrhoidal
bleeding; she received 2 units of FFP for an INR of 4.7 at that
time. The patient was noted to again spontaneoulsy convert to
NSR overnight on [**11-21**]. In the AM of [**11-22**], she acutely became
hypotension to the 60-70 mmHg systolic range, with HR of 40-50s.
They attributed this to over-duresis, for which she received
aggressive IVF resuscitation (3L IVF). She also received
Atropine x 1 without effect. An emergent central venous catheter
and EJ were placed on the Cardiology floor with a Dopamine gtt
started peripherally. She was transferred to the MICU on [**11-22**]
for further management.
.
On arrival to the MICU, patient was awake on a NRB and answering
questions. She was continued on the Dopamine infusion, and
started on Vasopressin with initial improvement in her SBP to
110-120s and HR of 60 bpm. Antibiotics were broadened to
Vancomycin and Cefepmine IV. CVP was roughly 20, and aggressive
IVF administration ceased. Bedside 2D-Echo did not reveal a
pericardial effusion. In the setting of worsening mental status
status and poor perfusion she was switched to Dobutamine,
Levophed, and Vasopression gtts. A femoral A-line was placed,
after sveral attempts at a radial A-line were unsuccessful.
Patient was intubated in the setting of increased work of
breathing.
.
In the MICU, she was weaned off of Levophed gtt, started on 3
amps of sodium bicarbonate and Lasix IV was initiated for
diuresis. She was extubated on [**11-25**] without issues. She was
started on a Diltiazem gtt for A.fib with rapid ventricular
response with adequate rate control. The patient was transferred
to the CCU for further management.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or pre-syncope.
Past Medical History:
CARDIAC HISTORY: Hypertension
* CABG: None
* PCI: s/p BMS to proximal LAD (12/20/201)
* PACING/ICD: None
.
PAST MEDICAL & SURGICAL HISTORY:
1. Coronary artery disease (NSTEMI in [**11/2131**] with cardiac
catheterization and BMS x 1 to the proximal LAD)
2. Dilated cardiomyopathy (left ventricular cavity is mildly
dilated with moderate to severe regional systolic dysfunction;
with basal inferior and inferolateral walls contract best; LVEF
= 25%) on [**2132-11-22**]
3. Mitral regurgitation (2+) on [**2132-11-22**] 2D-Echo
4. Tricuspid regurgitation (2+) on [**2132-11-22**] 2D-Echo
5. Arthritis
6. Left breast cancer (s/p mastectomy, node dissection,
radiation, [**2113**])
7. History of gastritis (with GI bleeding)
8. Macular degeneration
9. Persumed syndrome of inappropriate ADH (SIADH); received
Tolvaptan
Social History:
Lives alone, never married, no children. Nephew [**Name (NI) **] [**Name (NI) 7049**] is
her HCP. Denies alcohol, tobacco, or illicit drug use. Former
dancer-singer on the [**First Name8 (NamePattern2) **] [**Location (un) **] Show.
Family History:
Mother died of ? stomach cancer in her 70s. Father died of
natural causes in his 70s. 9 siblings, all deceased, no medical
problems. Denies family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death.
Physical Exam:
ADMISSION EXAM:
.
PHYSICAL EXAM:
VITALS: 95.2 119/71 132(irregular) 26 97%6L NC
GENERAL: Caucasian female, speaks in [**4-1**] word sentences
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist. No xanthalesma.
NECK: JVP slightly elevated, prominent V waves
CVS: PMI located in the 5th intercostal space, mid-clavicular
line. Irregular rhythm, increased rate, II/IV systolic murmur
LLSB
RESP: Respirations labored w/ accessory muscle use, decreased
breath sounds at bases.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs. Abdominal aorta
not enlarged to palpation, no bruit.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
DERM: sacral edema
NEURO: CN II-XII intact throughout. patient refuses to answer
questions about orientation, strength 5/5 bilaterally, sensation
grossly intact.
PULSE EXAM:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
DISCHARGE EXAM:
unchanged from admission
Pertinent Results:
Admission Labs:
[**2132-11-16**] 09:05AM BLOOD WBC-8.6 RBC-4.02* Hgb-13.5 Hct-40.0
MCV-100* MCH-33.7* MCHC-33.8 RDW-14.0 Plt Ct-218
[**2132-11-16**] 09:05AM BLOOD Neuts-84.5* Lymphs-7.8* Monos-7.0 Eos-0.6
Baso-0.1
[**2132-11-16**] 09:05AM BLOOD PT-13.8* PTT-25.2 INR(PT)-1.2*
[**2132-11-16**] 09:05AM BLOOD Glucose-112* UreaN-15 Creat-0.7 Na-136
K-3.1* Cl-96 HCO3-27 AnGap-16
[**2132-11-16**] 09:05AM BLOOD CK(CPK)-317*
[**2132-11-16**] 09:05AM BLOOD CK-MB-10 MB Indx-3.2
[**2132-11-16**] 09:05AM BLOOD Calcium-9.1 Phos-3.5 Mg-1.7
[**2132-11-17**] 09:10AM BLOOD VitB12-901* Folate-GREATER TH
[**2132-11-16**] 05:00PM BLOOD TSH-2.3
.
IMAGING:
.
CARDIAC CATH ([**2131-12-17**]) - Severe one vessel coronary artery
disease: see above comments Mild systemic arterial hypertension.
Successful direct stenting of the proximal LAD with a VISION
3.0x12 mm bare-metal stent (BMS) deployed at 18 atm with
improved TIMI flow post stent deployment. (see PTCA comments) R
6Fr femoral artery sheath sutured into position post procedure
ASA indefinitely; plavix (clopidogrel) 75 mg daily for at least
one month for bare-metal stent placement. Importance of plavix
emphasized to patient.
.
[**2132-11-21**] LIVER OR GALLBLADDER US - Prominent hepatic veins
along with exaggerated phasicity of portal vein waveforms. These
findings are consistent with hepatic congestion most probably
secondary to right heart failure. Trace amount of ascites.
Bilateral pleural effusions.
.
[**2132-11-28**] TTE - The left atrium is mildly dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated. There is severe global left
ventricular hypokinesis (LVEF = 20 %). The left ventricular
mechanical activation sequence is dyssynchronous. The right
ventricular free wall thickness is normal. The right ventricular
cavity is dilated with depressed 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. An eccentric, posteriorly directed jet of
moderate (2+) mitral regurgitation is seen. Due to the eccentric
nature of the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2132-11-22**], the findings are similar.
.
[**2132-11-28**] TEE - 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. Overall left
ventricular systolic function is depressed. The mitral valve
leaflets are mildly thickened and mitral regurgitation is
present. There is no pericardial effusion. No SEC of thrombus
seen. depressed left ventricular systolic function.
.
[**2132-11-29**] CXR - Endotracheal tube and right internal jugular
central line unchanged in position. Nasogastric tube is seen
coursing below the diaphragm with the tip not identify.
Persistent layering bilateral pleural effusions. However, there
is improving pulmonary edema compared to the prior study.
Overall stable cardiac and mediastinal contours given
differences in patient positioning. No
pneumothorax.
.
MICROBIOLOGY DATA:
[**2132-11-17**] Urine culture - Enterococcus (sensitive to Vancomycin)
[**2132-11-22**] Blood culture - no growth
[**2132-11-22**] MRSA screen - negative
[**2132-11-23**] Urine culture - negative
[**2132-11-23**] Sputum culture - contaminated specimen
.
DISCHARGE LABS:
[**2132-12-6**] 08:10 WBC 9.5 RBC 3.53* Hgb 11.6* Hct 35.5* MCV 101*
MCH 32.8* MCHC 32.6 RDW 14.1 Plts 306 INR 2.2
[**2132-12-6**] 08:10 glc 94 urea 32* Cr 0.8 Na 137 K 3.3 Cl 95*
HCO3 33*
Brief Hospital Course:
83F with a medical history of dilated cardiomyopathy (LVEF 25%)
NYHA Stage II , coronary artery disease s/p BMS to proximal-LAD,
and moderate-to-severe mitral regurgitation who was initially
admitted for chest pain and dyspnea found to be in new-onset
atrial fibrillation with rapid ventricular rate with hospital
course complicated by decompensated congestive heart failure,
pneumonia, and shock liver versus congestive hepatopathy.
.
ACUTE CARE
# ATRIAL FIBRILLATION - The patient presented on [**2132-11-16**] with
new-onset atrial fibrillation, which was likely due to
chronically dilated atria from worsening mitral regurgitation.
She spontaneously converted during her early hospital course but
then went back into atrial fibrillation during her medical ICU
course. She was suboptimally rate controlled on PO Diltiazem, so
was started on a diltiazem drip and digoxin. In the setting of
her poorly controlled tachyarrythmia she developed decompensated
heart failure requiring intubation early in her hospital course.
On [**2132-11-28**], TEE/cardioversion was attempted and was unsuccessful
at restoring sinus rhythm. We felt that given her symptomatic
heart failure, intraventricular conduction delay, and low
ejection fraction that she would benefit from cardiac
resynchronization therapy. There was an attempt to place a
BiVentricular pacemaker (CRT) but the CS lead was unable to be
placed so just a permanent pacemaker (PPM) was placed. She
requires one more day of cephalexin for this. She has been rate
controlled with ventricular rates in the 70s-80s on current
doses of digoxin and metoprolol. The plan is to start amiodarone
in the future once her liver function tests normalize. Her
CHADS-2 score is 3 (age, hypertension, heart failure) and she
was maintained on Coumadin for anticoagulation with goal INR of
[**1-31**]. Her INR was 2.2 at discharge, up from 1.2 the day prior. We
would recommend rechecking an INR on Monday. If amiodarone is
started in the future, she will require close monitoring of INR.
.
# ACUTE ON CHRONIC SYSTOLIC HEART FAILURE - The patient has a
history of
systolic heart failure, likely ischemic from past myocardial
infarction, who presented with sacral edema, elevated JVP,
decreased breath sounds and imaging findings (pleural effusion)
consistent with decompensated biventricular heart failure. The
etiology is likely due to uncontrolled atrial fibrillation and
volume resuscitation patient received early in her hospital
course. A 2D-Echo this admission showed a left ventricular
cavity that was moderately dilated and severe global left
ventricular hypokinesis (LVEF = 20%). The left ventricular
mechanical activation sequence was clearly dyssynchronous. She
was diuresed with a lasix drip and metolazone and then
re-started on her home torsemide at 40mg daily, slightly lower
than her home dose of 60mg daily. We resumed her home losartan
25mg daily, increased her metoprolol to 200mg daily (for rate
control), and started her digoxin 0.125 daily and spirolactone
12.5mg daily. She was felt to be euvolemic at discharge.
.
# CORONARY ARTERY DISEASE - The patient has a history of NSTEMI
and was status-post bare-metal stenting to the LAD in [**2131**]. She
was without evidence of active ischemia this admission, with a
reassuring EKG. We continued Aspirin 81 mg PO daily.
.
# PNEUMONIA - The patient presented with shortness of breath
with a possible retro-cardiac opacity on chest imaging; athough
she remained afebrile without leukocytosis. She was started on
levaquin for this and completd a five day course. She did have
an incidental Enterococcal UTI while being treated in the
medical ICU and this was treated with IV Vancomycin. A clearance
urine culture was negative for any growth on [**2132-11-23**].
.
# TRANSAMINITIS - The patient presented with a transaminitis in
the thousands likely due to either congestive hepatopathy from
decompensated failure or shock liver from hypotension, on
admission. She had RUQ U/S on [**11-21**] that showed hepatic
congestion most likely due to right sided heart failure. Her
transaminitis continues to improve and when last checked on [**12-3**]
her ALT was 220s and AST was 60.
.
# MECHANICAL FALL: The patient had an unwitnessed fall during
the night of [**12-5**]. She denied syncopal or pre-syncopal sx,
endorsing a mechanical etiology. She did hit her head. She was
found on the floor by the RN. Her neuro exam was intact and
unchanged. She had a head CT with preliminary read negative for
bleed.
.
TRANSITION OF CARE:
.
#VOLUME STATUS: Her home torsemide was started at 40mg daily
rather than 60mg daily in setting of poor po intake and she
develops symptoms concerning for volume overload.
.
# ANXIETY - We continued her home dosing of Diazepam 2 mg TID
PRN anxiety.
.
# NUTRITION - She was followed by speach and swallow during her
hospital course. Early on she failed and thin liquids were
avoided. later this was advanced and at discharge she was
tolerating thin liquids adn moist, soft solids with meds crushed
in puree. PO intake has not been very good while hospitalized.
.
TRANSITION OF CARE ISSUES:
ISSUES TO ADDRESS AT FOLLOW UP:
1. Coumadin monitoring with INR
2. Wound care for L chest site of pacemaker incision
3. Nutrition -- patient has a very poor appetite.
4. Titration of torsemide dose.
5. Follow LFTs
CODE STATUS: FULL CODE
COMMUNICATION: [**Name (NI) **] [**Name (NI) 7049**] (nephew) [**Telephone/Fax (1) 105933**] is HCP
PENDING STUDIES: Head CT final read pending
Medications on Admission:
HOME MEDICATIONS (confirmed with patient)
1. Clotrimazole-betamethasone 1%-0.05 % cream [**Hospital1 **] PRN rash
2. Diazepam 2 mg PO QID
3. Losartan 25 mg PO daily
4. Metoprolol succinate 100 mg PO daily
5. Omeprazole 20 mg PO daily
6. Potassium chloride 20 mEq PO daily
7. Torsemide 60 mg PO daily
8. Acetaminophen 500 mg PO QID PRN pain
9. Aspirin 81 mg PO daily
Discharge Medications:
1. diazepam 2 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
2. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. torsemide 20 mg Tablet Sig: Two (2) Tablet PO once a day.
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*0*
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for fever or pain.
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. potassium chloride 20 mEq Packet Sig: One (1) PO once a day.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO once a day.
12. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
13. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injevtion Injection TID (3 times a day): please stop one INR is
therapeutic.
14. methyl salicylate-menthol Ointment Sig: One (1) Appl
Topical PRN (as needed) as needed for shoulder pain.
15. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
16. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2
times a day) as needed for hemmorhoid discomfort.
19. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 1 days.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Primary Diagnosis:
A-Fib with RVR
Secondary Diagnosis:
sCHF
HTN
Mitral Regurgitation
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms [**Known lastname 7049**],
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for your atrial fibrillation
that was beating very fast. We gave you medicines to lower the
heart rate and medicine to get rid of extra fluid. An attempt
was made to place a biventricular pacemaker to help coordinate
your heart rhythm but Dr. [**Last Name (STitle) **] was unable to place the
third lead. You still have a pacemaker to prevent your heart
rate from becoming too slow from the medicines. You cannot lift
more than 5 pounds You have been started on warfarin (coumadin)
to prevent a stroke from the atrial fibrillation. Your
medications were adjusted to help your heart work as best it
can.
Please note the following changes to your medications:
1. STARTED Coumadin 2mg by mouth once a day to prevent a stroke
2. STARTED senna, colace and miralax to prevent constipation
3. STARTED Digoxin to slow your heart rate and help your heart
pump better
4. STARTED Spironolactone to help your heart pump better
5. STARTED multivitamin to help your nutrition
6. STARTED [**Doctor First Name **] gay for shoulder pain
7. STARTED Hydrocortisone cream for your hemmorrhoids.
8. STARTED heparin shots to prevent blood clots
9. DECREASED Torsemide to 40 mg daily
10. INCREASED metoprolol to 100 mg twice daily to slow your
heart rate
11. DECREASED Valium to twice daily
Coumadin is a blood thinner. You will need to have your blood
checked often at your primary care doctor's office until your
primary care doctor determines the appropriate dose of coumadin
for you. After that, you will continue to need regular blood
checks.
Weigh yourself every morning, call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP if weight
goes up more than 3 lbs in 1 day or 5 pounds in 3 days.
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2132-12-10**] at 10:30 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2132-12-10**] at 11:00 AM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2132-12-10**] at 12:00 PM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital **] MEDICAL GROUP
When: MONDAY [**2133-1-5**] at 1 PM
With: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2400**] [**Telephone/Fax (1) 133**]
Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**]
Campus: OFF CAMPUS Best Parking: On Street Parking
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,433
| 192,462
|
42862
|
Discharge summary
|
report
|
Admission Date: [**2121-1-12**] Discharge Date: [**2121-1-18**]
Date of Birth: [**2060-11-26**] Sex: M
Service: MEDICINE
Allergies:
Tomato / aspirin
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Right IJ placement ([**2121-1-12**])
Arterial line placement ([**2121-1-12**])
Endotracheal intubation and mechanical ventilation
History of Present Illness:
60M history of IVDU, alcoholism (4 years ago), cirrhosis
secondary to Hepatitis C complicated by metabolic and hepatic
encephalopathy, CKD, seizure disorder, asthma, hypertension,
anxiety that was found down apneic and taken to [**Hospital3 12594**].
Per his girlfriend, the patient lives alone. His girlfriend of
six years went to check on him on 2:30 AM. Patient with very
tired appearing. He has was having difficulty with breathing in
a manner where he had to take "deep breaths in and out." He also
had "rattling in his chest." Girlfriend called the ambulance
given breathing and he was also difficult to arouse. Patient has
visiting [**Hospital3 269**] that distributes medications, so girlfriend feels
like he has not overdosed and has not abused drugs for quite
sometime. He also does have a tendency for pneumonia. He was
last hospitalized two weeks for bronchitis with a four day
course. He was in his otherwise normal state of health
yesterday.
He was transported to [**Hospital6 19155**] at 2:43 AM on
[**2121-1-12**]. He was found unresponsive by EMS with a RR of [**1-11**]
breaths/minute. Initial GCS was 10 (E3-V2-V5). He was found to
have pinpoint pupils and was administered Narcan 2 mg IV x 2
without effect. He was fluid resuscitated (unknown amount) and
started on neosynephrine with BP nadir of 61/43 (MAP 56) and
high of 237/118 (MAP 140). Neosynephrine was discontinued, and
levophed was initiated. Stress dose steroids were also started
(solu-cortef 100 mg IV). A CXR showed vancomycin 1 gram IV,
flagyl, ? and rocephin for ? pneumonia. Head CT scan showed
hypoattenuation in basal ganglia bilaterally suggesting
ischemia. NIH was score 11. ECG showed sub-millimeter ST
elevations in II,III,aVF with troponin 0.14 and lactate 3.3. He
was started on heparin IV infusion @ 1380 units/hr. ABG was pH
7.26 pCO2 56, pO2 63, HCO3 251 with BE -2.7.
Labs were significant for Na 140, K 4, CL 88, HCO3 24, BUN 18,
Cr 1.9 (unknown baseline), Glc 163. WBC 15.6 Hgb 13.5, Hct 40.9,
Plt 156. CK 93 CK-MB 5.2, AST 29, ALT 22. Tox screen was
positive for benzodiazepine and opiates. Coags were PT 12.3, INR
1.1, PTT 28, Troponin 0.14.
He was intubated by [**Location (un) **] for poor mental status/airway
protection in order to transport him to [**Hospital1 18**]. He was given
succinylcholine 1.5 mg/kg IVP, etomidate 20 mg IVP. Intubated
was uncomplicated. He was given fentanyl 100 mg IV x 2,
midazolam 1 mg IV x 1. He was on levophed 12 mcg/min.
In the [**Hospital1 18**] ED inital vitals were not given in signout and
charting is not available for review in documents from ER.
In the [**Hospital1 18**] ER, multiple interventions were performed. ECG
showed ST-elevations not meeting criteria (< 1mm) in the
inferior (II,aVF) and lateral leads. Cardiology was consulted,
and performed a bedside ECHO showing normal EF, no hypokinesis,
no effusion. There was no evidence of endocarditis or overt
valvular pathology. Heparin infusion was stopped given STEMI
thought to be unlikely.
Levophed was discontinued with resultant BP of 60/40. CVC was
placed with no CVP performed. Urine output not commented.
Patient was also placed in a C-collar given C-spine was never
cleared given patient unconscious.
Exam was significant for petechiae on RLE.
He was given zosyn for broader coverage.
It is overall uncertain how much fluid he received in [**Hospital1 18**] ER
and OSH ER as these are not documented clearly in chart or
documents not available.
Labs were performed. Coags were PT 14.8, PTT 49.5, INR 1.4.
Chemistry panel was within normal limits except K 5.4 (H), BUN
16, Cr 1.2 (unknown baseline, eGFR 62), glucose 180 and normal
anion gap.
Lactate was 2.5.
CBC showed WBC 12, Hgb 12.5 (unknown baseline), Plt 138 (unknown
baseline) with neutrophilia.
Initial TropnT was 0.02.
LFTS including lipase within normal limits except albumin 3.
VBG was significant for pH 7.25, pCO2 56, pO2 102, HCO3 26.
Serum tox was negative.
Blood cultures were drawn.
ECG showed SR with PR prolongation (230 ms), NA/NI, early repol
in I, II and lateral leads. No acute STEMI or ST/T changes
concerning for ischemia.
VS on transfer:
HR 69, 135/79, pOx 100 % on 500x18, PEEP 5, FiO2 100.
Levophed @ 0.2
On arrival to the ICU, patient was comfortably intubated,
non-responsive.
.
Review of systems: unable to obtain given patient intubated
Past Medical History:
- cirrhosis secondary to Hepatitis C complicated by metabolic
and hepatic encephalopathy, unknown if history of varices or SBP
- seizure disorder
- s/p left hip operation (unknown type) and septic hip
- s/p left shoulder operation (unknown type)
- Alcoholism (abstinent for four years)
- History of IVDU (?heroin)
- Chronic kidney disease (unknown stage)
- Hypertension
- Anxiety/Depression/Bipolar
- History of C. diff colitis
- History of aspiration pneumonia
- unknown cardiac history per family members
Social History:
Unable to obtain on admission.
Family History:
Unable to obtain on admission.
Physical Exam:
ADMISSION EXAM
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Poor dentition,
Endotracheal tube, NG tube
Lymphatic: Cervical WNL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, petechiae on right medial lower
extremity
Skin: Warm
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Sedated, Tone: Not assessed, withdrawals all four extremities to
pain and grimaces, CN grossly intact
.
Discharge Exam:
AVSS
AOX3
Dullness at left base otherwise good airmovement with wheezes,
rales or rhonchi
Pertinent Results:
Admission Labs:
[**2121-1-12**] 01:20PM WBC-12.0* RBC-4.08* HGB-12.5* HCT-37.2*
MCV-91 MCH-30.5 MCHC-33.4 RDW-14.0
[**2121-1-12**] 01:20PM NEUTS-88.1* LYMPHS-7.7* MONOS-4.0 EOS-0.1
BASOS-0.1
[**2121-1-12**] 01:00PM ALT(SGPT)-23 AST(SGOT)-26 ALK PHOS-95 TOT
BILI-0.6
[**2121-1-12**] 01:12PM LACTATE-2.5*
[**2121-1-12**] 01:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2121-1-12**] 01:00PM PT-14.8* PTT-49.5* INR(PT)-1.4*
[**2121-1-12**] 01:00PM ALBUMIN-3.0*
[**2121-1-12**] 01:00PM cTropnT-0.02*
[**2121-1-12**] 01:00PM LIPASE-7
[**2121-1-12**] 01:00PM ALT(SGPT)-23 AST(SGOT)-26 ALK PHOS-95 TOT
BILI-0.6
.
CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST
IMPRESSION:
1. Left femoral deformity, displacement and hardware of
indeterminate
chronicity, with intermediate density in the joint space.
Correlation with
clinical history and prior imaging, if available, would be
helpful. Acute
trauma and infection cannot be excluded.
2. Evidence for portal hypertension, including splenomegaly and
recanalized
paraumbilical veins, likely secondary to cirrhosis.
3. Bilateral pulmonary opacities, concerning for aspiration.
4. Trace perihepatic ascites.
.
MR [**Name13 (STitle) 430**]:
1. Bright DWI and FLAIR signal in the bilateral globus pallidus
with no
evidence of corresponding bright signal on ADC may represent a
sub-acute
hypoxic injury or other metabolic/toxic process.
2. Ethmoid and left mastoid air cells fluid. Correlate
clinically.
3. Unremarkable MRA of the head.
.
Discharge Labs:
[**2121-1-17**] 06:00AM BLOOD WBC-5.6 RBC-4.03* Hgb-12.0* Hct-35.4*
MCV-88 MCH-29.8 MCHC-33.9 RDW-14.6 Plt Ct-143*
[**2121-1-17**] 06:00AM BLOOD Plt Ct-143*
[**2121-1-17**] 06:00AM BLOOD Glucose-108* UreaN-7 Creat-0.8 Na-141
K-3.2* (repleted) Cl-106 HCO3-27 AnGap-11
Brief Hospital Course:
60M history of IVDU/alcoholism, cirrhosis secondary to Hepatitis
C, CKD, seizure disorder, asthma, hypertension, anxiety that was
found down apneic with acute encephalopathy, hypercarbic
respiratory with resultant sepsis likely from pulmonary source
and ? basal ganglia ischmemia in setting of hypotension.
# Acute Metabolic Encephalopathy: The initial differential was
broad including drug overdose in setting of prior substance
abuse history and positive toxicology screen with opiates and
benzos, toxic-metabolic namely hypercarbia/hypoxemia from poor
respiratory drive, primary neurogenic such as post-ictal state
in setting of prior seizure history or basal ganglia stroke
given head CT findings, septic encephalopathy among others.
Likely sequence of events would be process such as pneumonia or
drug overdose leading to respiratory failure with subsequent
sepsis and hypoperfusion resulting in combined picture of
primary neurogenic and septic encephalopathy with contribution
of hypercarbia. MR [**First Name (Titles) **] [**Last Name (Titles) 92557**] for etiology. Patient was
placed on propofol on admission to ICU with grossly intact
cranial nerves and moving all extremities when sedation weaned.
Pt was subsequently extubated without complication and his
mental status returned to baseline over the course of three
days. Unclear what role likely overdose and/or aspiration
pneumonia plated [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **].
.
# Hypotension: Pt presented with hypotension. He was found down
for an uncertain amount of time. Etiology potentially
multifactorial secondary to overdose, hypovolemia from poor PO
intake, and/or potentially septic shock from aspiration
pneumonia. There was initial concern for cardiogenic shock from
STEMI at OSH, but ECG, troponins, bedside ECHO in ER not
suggestive of acute event making cardiogenic shock less likely.
No evidence of distributive shock from process such as
pancreatitis. The patients SBP improved with fluids. Blood
cultures were no growth to date. Following extubation and
transfer to the floor, the patients SBPs improved to baseline.
.
# Hypercarbic, hypoxemic respiratory failure secondary to likely
overdose and subsequent Aspiration PNA (MRSA): Pt presented with
low respiratory rate with pin-point pupils concerning for
toxidrome from opiates/benzo; however, he was not responsive to
narcan. Differential included a benzo overdose; however,
girlfriend does not favor as [**Name (NI) 269**] controls medications given
issues in past. His A-a gradient initially was 80.9 suggesting
that in addition to frank hypoventilation given clinical
history, there was likely some concurrent parenchymal process
such as V/Q mismatch (A-a gradient approximately 81). Initial
gas showing primary respiratory acidosis. CT torso with
contrast was performed but not optimized to look for PE. Per
[**Doctor Last Name 3012**] score, he is in low risk group (1.3 % risk) given relative
immobility. CT does suggest aspiration event. Overall, favor
toxidrome with subsequent aspiration event. Pt was initially
treated with Vanc/cefepime. Sputum culture with rare MRSA.
Repeat CXR (PA/Lateral) confirmed retrocardiac infiltrate. This
was later transitioned to Bactrim/Flagyl. Pt was breathing
comfortably on room air on discharge.
.
CHRONIC ISSUES:
# Basal ganglia infarcts: Head CT showing basal ganglia lesions,
which could be concerning for infarcts. MR revealed a sub-acute
hypoxic injury or other metabolic/toxic process.
- Recommend Neurology follow-up as outpatient.
.
# ?Hip pathology: Patient with left femoral deformity,
displacement and hardware of indeterminate age - per family, had
hip operation several years ago.
- Outpatient f/u
.
# History of drug abuse/alcoholism
Toxicology screen positive for benzo and opiates. Uncertain if
these represent home medications. Outpatient follow-up.
# [**Last Name (un) **]: Pt presented with Cr of 1.9, improved to 0.8 with IVF on
discharge.
.
# Cirrhosis secondary to Hepatitis C (Admit MELD 12): Per
report, pt with hx of hepatic encephalopathy in past. Unknown if
varices or ascites/SBP in past. CT showing evidence of portal
hypertension including splenomegaly and trace perihepatic
ascites. No frank evidence of decompensated liver disease. f/u
as outpatient.
# Seizure disorder: No seizure activity in house. Continue
Keppra.
.
TRANSITIONAL ISSUES:
# Incidental findings
1. Bright DWI and FLAIR signal in the bilateral globus pallidus
with no
evidence of corresponding bright signal on ADC may represent a
sub-acute
hypoxic injury or other metabolic/toxic process.
2. Left femoral deformity, displacement and hardware of
indeterminate
chronicity, with intermediate density in the joint space.
Correlation with
clinical history and prior imaging, if available, would be
helpful. Acute
trauma and infection cannot be excluded.
# Transitional issues
- repeat CXR in [**3-14**] weeks to evaluate for resolution of
pulmonary process
.
# PCP [**Last Name (NamePattern4) **]: Direct verbal signout was provided to current
PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 92558**], on [**2120-1-18**]. The PCP expressed that the pt
had recently been dismissed from his practice, but that the pt
could follow-up with him within the next 30 days for aspiration
pneumonia follow-up. Of note, the pt was also recently dismissed
from his Neurologist for unclear reasons. Thus it was explained
to the patient that he must establish new care with a PCP
following his appointment with Dr. [**Last Name (STitle) 92558**] at which time he
should be referred to a new Neurologist and have his records
transferred.
.
# Home Services: The patient was discharged home to the [**Company 3596**]
with home services for cardiopulmonary evaluation give his
resolving aspirtion pneumonia
Medications on Admission:
- Keppra 1000 mg PO BID
- Folic acid 1 mg PO qAM
- Celexa 40 mg PO qAM
- Multivitamin
- Trazodone 150 mg PO qHS
- Klonopin 1 mg PO BID
- Gapapentin 300 mg PO TID
- Ferrous sulfate 325 mg PO BID
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
Disp:*15 Tablet(s)* Refills:*0*
4. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*10 Tablet(s)* Refills:*0*
5. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
7. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: [**4-17**]
MLs PO Q6H (every 6 hours) as needed for cough: For 2 weeks. .
Disp:*qs bottle* Refills:*0*
8. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
Discharge Disposition:
Home With Service
Facility:
Comfort Home care
Discharge Diagnosis:
Primary Diagnosis
- Overdose
- Acute Hypercarbic Respiratory Failure
- Aspiration Pneumonia
.
Secondary Diagnoses
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 the [**Hospital1 18**] after being found down where you
live. You were brought to the ICU and intubated. After a few
days your were brought out to the medicine floor and treated for
a pneumonia.
.
Please continue to take all of your medications as prescribed.
You have been started on two new antibiotics for pneumonia.
.
Please keep all of your medical appointments.
Followup Instructions:
Primary Care Follow-Up:
As you know you have been discharged from Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 92559**]
practice at [**Telephone/Fax (1) 84402**]. You are able to see Dr. [**Last Name (STitle) 9303**] for
pneumonia follow-up for the next 30 days before finding a new
primary care physician.
.
Please establish care with a new Neurologist after meeting with
your new PCP.
|
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icd9cm
|
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[
[]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,593
| 142,646
|
9097
|
Discharge summary
|
report
|
Admission Date: [**2164-8-22**] Discharge Date: [**2164-9-4**]
Date of Birth: [**2129-1-8**] Sex: M
Service: MEDICINE
Allergies:
Ceclor / Cefuroxime / Prevacid / Red Dye / Proton Pump
Inhibitors / Aspartame / Phenylalanine / Cephalosporins
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Poor oral intake, elevated LFTs.
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
35 year old male with h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 849**]-Gastaut Syndrome transferred
from [**Hospital3 **] for evaluation of fever, transaminitis,
and gallstones. He was admitted to [**Hospital1 2436**] initially because
he had not been feeling well and had not been taking PO for 2
days; he was therefore unable to take his Depakote. On
admission, he was febrile with mild leukopenia, transaminitis,
hyperbilirubinemia, and elevated PSA;
At [**Hospital1 2436**], UTI was initially suspected but urine culture was
negative. He had a history of prostatitis and given the PSA was
presumed to have prostatitis again; he was therefore treated
with Unasyn x13 days.
RUQ ultrasound showed gallstones without dilation of the ducts.
HIDA scan was negative for common bile duct obstruction or
cholecystitis. For the transaminitis, GI was consulted and
thought this was most likely due to Zantac vs. Depakote. AST
and ALT decreased during the hospitalization, but alk phos
increased.
The Depakote was therefore stopped and the patient was started
on Keppra 500mg PO BID (IV form not available at [**Hospital1 2436**]),
and Zonegran 600mg PO daily. (Prior to admission, he had been
taking Zonegran alternating 700/800 mg PO daily, and Depakote
1250mg PO BID). However, it is not clear that he was able to
take the Zonegran as he was frequently refusing PO; he did not
receive
this medication [**2164-8-22**] per med sheets. He had 2 witnessed
seizures [**2164-8-22**], treated with ativan. EEG showed "slowing with
sharp waves bilaterally, without evidence of epileptiform
activity.
During his hospitalization, he received hydration for his acute
renal failure and creatinine decreased from 1.4 to 1.0.
He was transferred here for further evaluation of his
transaminitis and management of seizures.
Past Medical History:
[**Location (un) 849**]-Gastaut Syndrome. He was first noted to have staring
spells at age 3, and was treated with phenobarbital at [**Hospital1 2025**],
which helped. At age 17, he had a significant change in his
seizures, having frequent spells of head drop, arm drop, and
laughing. He had frequent staring spells, and 20-30 drop
attacks daily. He was hospitalized at [**Hospital1 2025**] for LTM, and
underwent several medications but over the course of the year
hhis seizures became intractable. He received much of his care
at [**Hospital3 1810**] [**Location (un) 86**]. At age 25 he had a vagal nerve
stimulator placed. Prior medications have included Depakote,
Felbamate, Lamictal, Trileptal, Neurontin, Lorazepam.
Birth Hx: Mom had vaginal bleeding and decreased fetal movements
in the 3rd trimester. Birth was normal.
Development: Delayed. First words at 4 years; walked at 4
years.
After that regressed and became non-verbal.
Hypertrophic Cardiomyopathy
GERD
Multiple hospitalizations for aspiration pneumonia
Moderate hearing loss
s/p bilateral ear tubes, tonsillectomy, adenoidectomy
Pureed diet, honey thick liquid diet
Social History:
Lives at a group home. Parents are legal guardians.
Family History:
Father - parkinson's disease; Sister - mild MR, ovarian
cysts, [**Name (NI) **] palsy. +family history of DM, hyperlipidemia, CAD,
colon polyps, breast CA, vaginal CA
Sister has learning disability. There is no other
history of seizures, mental retardation or early child death in
the family.
Physical Exam:
Tmax/Tc: 96.6/96, BP 100s-119/60s-70s, HR 70s-90s, RR 18, O2 sat
98%RA
Gen: Awake, alert, not in distress, lying in bed. Wearing
diaper.
Skin: Jaundiced, without scleral icterus.
Heent: Macrocephalic with low set ears. Wearing thick glasses.
No conjunctival injection.
Neck: Supple, no meningismus. No cervical bruit.
Resp: Clear to auscultation bilaterally
CV: Regular rate and rhythm. 3/6 SEM loudest at LSB.
Abd: Bowel sounds normoactive, abdomen soft, non-tender, and
non-distended. Abdominal scar suggests prior G-tube.
Extrem: Warm and well-perfused. No arthralgia. ROM full.
Neuro:
MS - Awake, alert. Does not speak. Does not follow commands.
Cranial Nerves ?????? does not track to light or faces, but closes
eyes to light. Pupils 4mm, sluggishly reactive. Does not turn
to sound. Face symmetric.
Motor - Moves all extremities equally. Does not follow commands
for individual muscle testing. Bilateral wrist contractures
with
spontaneous clonus.
Reflexes - Patella DTRs 3+ bilaterally. 2 beats ankle clonus on
the right; no ankle clonus on the left. Spontaneous clonus at
the wrists bilaterally.
Sensation - Withdraws to tickle in both arms and legs.
Coordination - Unable to test; does not reach for objects.
Gait - Not tested.
Pertinent Results:
Labs at [**Hospital1 2436**]:
[**2164-8-9**]:
CBC: WBC 11.9, Hct 42, Plt 90
Chem: BUN 33, Cr 1.4 (baseline BUN 14, Cr 0.9)
LFTs: AST 245, ALT 307, Bilirubin 3.6, Ammonia 46,
Coags: INR 1.3, PT 15.3, PTT 44.9
VPA: 29
PSA: 5.5
UA: Nitrites positive, WBC [**11-2**]
Urine culture: Negative.
RUQ ultrasound: Gallstones without dilation of the ducts.
[**2164-8-22**]:
CBC: WBC 4.8, Hb 11.0, Hct 33, Plt 373
Chem: Na 138, K 4.0, Cl 108, HCO3 24, BUN 4, Cr 0.8, Ca 9.0
LFTs: AST 83, ALT 139, Alk Phos 83, Bili 3.1, Albumin 2.1
Labs at [**Hospital1 18**]:
[**2164-8-22**] 11:30PM BLOOD WBC-4.8 RBC-3.44* Hgb-10.7* Hct-33.8*
MCV-98 MCH-31.1 MCHC-31.7 RDW-15.8* Plt Ct-409#
[**2164-8-22**] 11:30PM BLOOD Neuts-49.2* Lymphs-39.3 Monos-7.2 Eos-3.2
Baso-1.1
[**2164-8-23**] 12:55PM BLOOD PT-13.7* PTT-26.0 INR(PT)-1.2*
[**2164-8-22**] 11:30PM BLOOD Glucose-88 UreaN-4* Creat-1.0 Na-137
K-4.3 Cl-108 HCO3-25 AnGap-8
[**2164-8-22**] 11:30PM BLOOD TotProt-6.4 Albumin-2.8* Globuln-3.6
Calcium-8.9 Phos-3.9 Mg-2.0
[**2164-8-22**] 11:30PM BLOOD ALT-139* AST-104* AlkPhos-697* Amylase-46
TotBili-4.0* DirBili-2.9* IndBili-1.1
[**2164-8-22**] 11:30PM BLOOD Ammonia-98*
[**2164-8-22**] 11:30PM BLOOD TSH-9.6*
[**2164-8-23**] 04:20AM BLOOD Free T4-1.2
[**2164-8-23**] 04:20AM BLOOD Valproa-LESS THAN
[**2164-8-22**] 11:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2164-8-22**] CXR: In comparison with the study of [**2160-12-23**], there again
are relatively low lung volumes. The vagal nerve stimulator is
again seen overlying the left lung. No evidence of acute
pneumonia, vascular congestion, or pleural effusion.
[**2164-8-23**] RUQ Abdominal Ultrasound: Cholelithiasis with no sign
of cholecystitis.
Brief Hospital Course:
A/P: 35yo M w/hx of [**Location (un) 849**]-Gastaut Syndrome who presents as a
tranfer from [**Hospital3 **] for elevated LFTs.
.
# Choledocholithiasis: Patient had progressive elevation of
LFTs in cholestatic pattern. Initially at the OSH, this was
suspected to be medication-related and his Depakote was
discontinued. At [**Hospital1 18**], all his other medications (Zonegram and
fexofenadine) were discontinued per Liver consult
recommendations except for the initiation of Keppra by Neurology
with adequate control of his seizure activity. Hepatitis
serologies were all negative. He had mild leukocytosis and low
grade fevers initially at [**Hospital1 18**], which resolved quickly without
antibiotics, making initial cholangitis less likely. He never
had any RUQ pain on exam, though his response is limited. He
then had an ERCP that showed multiple stones and underwent
sphinicterotomy. His bilirubin peaked to 11.1 on [**8-30**], which
slowly decreased afterwards. He was on ciprofloxacin and flagyl
for 5 days per ERCP for cholangitis prophylaxis.
.
# A fib with RVR: Following ERCP procedure for gallstones in the
biliary tree, patient was transferred to the ICU floor for
atrial fibrillation with RVR and on diltiazem drip and
hemodynamically stable. Atrial fibrillation occurred in the
setting of extubation and ERCP, which may have been stressors.
No underlying cardiac or pulmonary disease. No known history of
Afib in the past. A TTE showed hyperdynamic LV systolic function
and normal diastolic function without significant valvular
regurgitation seen. No structural abnormalities were identified
that could have accounted for this new arrhythmia. He appeared
dry and volume depleted on exam, which could have contributed to
Afib. Diltiazem gtt was continued during his stay in ICU with
only brief discontinuation when his heart rate was below 100.
Patient was never hemodynamically unstable requiring
cardioversion.
.
# Transaminitis, increased alk phos/total bili: s/p ERCP with
sphincterotomy on [**8-28**] showing an impacted stone in the major
papilla and with successful removal of over 10 gallstones.
Hepatic cholestasis may also be secondary to depakote or
fexofenadine medication. LFT slowly trended down during his
hospital stay. At the end of his ICU stay, his AST/ALT were
within normal range.
.
# Bacteremia: Patient was found to have MRSA bacteremia on [**8-29**],
vancomycin was started.
.
# MRSA Pneumonia: On transfer to ICU, patient had frequent O2
desats to high 80s, in the setting of sleeping, having increased
O2 requirement. CXR on [**8-29**] showed Complete left hemithorax
opacification likely representing left lung collapse and left
pleural effusion; and subsequent chest CT showed that instead of
collapse, his left lung was filled with consolidation. He was
started on cefepime in addition to vancomycin for this
pneumonia. Although his code status was DNR/DNI, upon discussion
with his mother who was his health care proxy, he was intubated
for the purpose of bronchoscopy. BAL grew out MRSA. Although the
plan was to extubate after bronchoscopy, he couldn't be weaned
off the ventilator safely so he remained on the ventilator until
[**9-3**] when the HCP decided to withdraw all intensive care, and
transitioned his care to comfort measures only. He was extubated
on [**9-3**], and transferred to a private room on the medicine
floor. He expeired on the afternoon of [**2164-9-4**].
.
# Sepsis: Patient met the criteria for sepsis. He was on
broad-spectrum antibiotics for MRSA that grew out of his blood
cultures and sputum cultures. He was aggressively resuscitated
with IVF boluses to maintain his goal MAP of 65 and UOP
>30cc/hr.
.
# Acute renal failure: Patient was noted to be in acute renal
failure on [**9-2**], creatinine bumped from 0.7 to 2.4. The
etiologies was most likely ATN due to hypotension in the setting
of sepsis.
.
# Coagulopathy: Patient had rising coags which peaked on [**9-2**]
with PT 21.1, PTT 38.9 and INR 2.0. No evidence of DIC was
noted. This likely represented his worsening liver failure in
the setting of worsening sepsis.
.
# [**Location (un) 849**]-Gastaut Syndrome: Patient was followed by Neurology at
baseline. Once patient was started and titrated up on Keppra,
his seizure activity returned to baseline per Neurology, who
compared EEG readings with the OSH.
.
# Hypoxia: Patient required intubation, but after discussion of
course and complication with family in the ICU, HCP/family
decided to make DNR/DNI on CMO. He was electively extubated [**9-3**]
and discharged to the medical floor overnight. He was given IV
morphine, scopolamine. Palliative care attending saw patient,
and and clergy staff visited with family. Patient's family
members were able to be with him at his bedside for 4 hours
prior to his death on [**9-3**] at 5:15pm. Autopsy declined by HCP
[**Name (NI) **] [**Name (NI) 31385**] (phone communication with me)
.
# FEN: Patient was on tube feeds for nutritional support during
his stay in ICU, and these were then discontinued.
.
# PPx: SC Heparin, bowel regimen
# Code: DNR/DNI, confirmed with HCP
# Communication: [**Name (NI) **] [**Name (NI) 31385**] (HCP) [**Telephone/Fax (1) 31386**]
Medications on Admission:
NEW MEDICATIONS FROM [**Hospital1 **]:
Unasyn 3g IV q8h
Keppra 500mg PO/IV BID; d/c summary and medication sheets report
he received Keppra IV when not taking PO, although verbal report
was that Keppra was not available IV at [**Hospital1 2436**].
Ativan 0.5mg q1h PRN seizure
Lactobacillus 1 tab PO TID
Colace 100mg PO BID
Senna 1 tab qhs PRN constipation
Dulcolax 10mg PO daily PRN constipation
Arixtra 2.5mg SC q12h, hold if platelets <100 or with renal
insufficiency.
Desenex powder
1/2NS at 75cc/hr when pt refuses PO for >8 hours
HOME MEDICATIONS CHANGED AT [**Hospital1 **]:
Zonegran 300mg PO BID (changed from home dose of 700mg daily
alternating with 800mg daily every other day)
HOME MEDICATIONS CONTINUED AT [**Hospital1 **]:
Calcium carbonate 1250mg (500mg elemental) PO BID
Loratadine 10mg PO daily
Folic acid 1mg PO daily
Miconazole 2% powder QID to groin area PRN redness/itching
Balmex
HOME MEDICATIONS DISCONTINUED AT [**Hospital1 **]:
Depakote 1250mg PO BID
Zantac 150mg PO BID
Multivitamin 1 tab PO daily
Uroquid Acid #2 (Methenamine [**Last Name (un) **]-sod biphosphonate 500mg-500mg
tab) 1 tab PO BID, 2 hours apart from calcium.
Milk of magnesia
Tylenol 650mg PO q4h PRN pain
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"51.85",
"33.23",
"96.72",
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icd9pcs
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[
[
[]
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402, 408
|
13389, 13398
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5110, 6837
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3529, 3824
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330, 364
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3458, 3513
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,802
| 149,747
|
46250
|
Discharge summary
|
report
|
Admission Date: [**2198-1-6**] Discharge Date: [**2198-1-18**]
Date of Birth: [**2153-10-27**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
thyrotoxicosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 20179**] is a 44F with PMH Graves' disease for the past 7
years, previously on PTU and propranolol, non-adherent on
medications for ?years, who is transferred from [**Hospital3 **]
for management of atrial fibrillation and continuing
thyrotoxicosis. She initially presented to her PCP [**Last Name (NamePattern4) **] [**1-5**] for
SOB, dry cough. She noted that she developed SOB two days prior
to that on Weds night. At the [**Location (un) 620**] ED, she was noted to have
HR in 150s and was given metoprolol with little effect, and
placed on dilt gtt. Endocrinology was curbsided, and they
recommended PTU 100mg TID, propranolol 10mg TID. Her initial
thyroid studies showed TSH < 0.014, with free T4 >7.77 and free
T3 pending. Despite propranolol 10mg q8hr and PTU 100mg q8hr,
she required dilt gtt to keep HR controlled. Her HR improved,
but her BP was borderline at low 90s to 100s sytolic. Per notes,
thought she would require uptitration of PTU to 200mg q8hr, but
preferred to transfer for endocrinology input. She had atrial
fibrillation, attributed to thyrotoxicosis. Additionally she was
hypoxic requiring 3LNC thought to be [**1-25**] pulmonary edema. She
was not diuresed there given BP's in 90s-100s systolic.
On arrival to the ICU, her VS are T 98.6, HR 90, BP 100/75, RR
25, O2 95% 3L NC. She feels much improved, but continues to
have SOB. Did have 2 episodes of nausea/vomiting today. She
denies chest pain, pressure, or palpitations. She sleeps on 1
pillow at home, and denies orthopnea, PND. She said she has
always had swelling of her RLE, but has noticed over the last
both have swelling. She denies any recent weight loss or gain.
She denies fever, chills, or sweats. She denies tremors.
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, or weakness. Denies 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:
[**Doctor Last Name 98318**] disease for 7 years - non compliant on medications
Social History:
Lives at home with boyfriend. [**Name (NI) 1403**] at Shaw's.
- Tobacco: [**12-25**] ppd x24 yrs
- Alcohol: denies
- Illicits: denies
Family History:
Aunt with goiter, mother with HTN
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.6 BP: 100/75 P: 90 R:25 O2:93% 3L NC
General: Alert, oriented, no acute distress
HEENT: Prominent exopthalmos, lid lag present, sclera anicteric,
MMM, oropharynx clear
Neck: supple, JVD present, ?low thyroid (difficult to palpate),
non-tender
Lungs: Decreased breath sounds in bilateral bases, no wheezes,
rales, ronchi
CV: tachycardic with regular 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, 1+ pitting edema of
bilateral legs, increased circumference of R calf compared to L.
No tremor
Pertinent Results:
LABS:
Outside labs:
[**2198-1-5**]
142/104/12
----------<105
4.2/23/0.6
.
Ca 9.1 Mg 2.3 Phos 4.4
Alb 3.5
TP 6.6
AP 130
ALT 32
AST 19
.
INR 1.3
UHCG negative
ESR 6
WBC 7.6 Hgb 12.5 Hct 38.5
BNP 1143
.
On admission:
[**2198-1-6**] 08:11PM BLOOD WBC-10.4 RBC-4.67 Hgb-13.0 Hct-38.2
MCV-82 MCH-27.8 MCHC-34.0 RDW-12.6 Plt Ct-[**Numeric Identifier **]/14/12 08:11PM
BLOOD Neuts-67.3 Lymphs-24.5 Monos-7.3 Eos-0.6 Baso-0.4
[**2198-1-6**] 08:11PM BLOOD PT-15.5* PTT-32.2 INR(PT)-1.5*
[**2198-1-6**] 08:11PM BLOOD Glucose-151* UreaN-21* Creat-0.7 Na-133
K-4.2 Cl-103 HCO3-20* AnGap-14
[**2198-1-6**] 08:11PM BLOOD ALT-22 AST-20 LD(LDH)-137 AlkPhos-92
TotBili-0.9
[**2198-1-6**] 08:11PM BLOOD Albumin-3.9 Calcium-9.3 Phos-4.1 Mg-2.0
[**2198-1-6**] 08:11PM BLOOD TSH-<0.02*
[**2198-1-6**] 08:11PM BLOOD T4-21.5* T3-349* calcTBG-0.36*
TUptake-2.78* T4Index-59.8* Free T4-6.7*
.
[**2198-1-9**] 06:30AM BLOOD WBC-6.4 RBC-4.07* Hgb-11.4* Hct-33.3*
MCV-82 MCH-28.0 MCHC-34.1 RDW-13.1 Plt Ct-139*
[**2198-1-8**] 04:30AM BLOOD WBC-6.6 RBC-4.17* Hgb-11.5* Hct-34.0*
MCV-82 MCH-27.6 MCHC-33.8 RDW-12.6 Plt Ct-142*
[**2198-1-7**] 06:11AM BLOOD WBC-9.4 RBC-4.33 Hgb-11.9* Hct-35.0*
MCV-81* MCH-27.5 MCHC-34.0 RDW-12.9 Plt Ct-150
[**2198-1-6**] 08:11PM BLOOD WBC-10.4 RBC-4.67 Hgb-13.0 Hct-38.2
MCV-82 MCH-27.8 MCHC-34.0 RDW-12.6 Plt Ct-179
[**2198-1-6**] 08:11PM BLOOD Neuts-67.3 Lymphs-24.5 Monos-7.3 Eos-0.6
Baso-0.4
[**2198-1-9**] 06:30AM BLOOD PT-14.1* PTT-30.1 INR(PT)-1.3*
[**2198-1-8**] 04:30AM BLOOD PT-14.7* PTT-29.2 INR(PT)-1.4*
[**2198-1-6**] 08:11PM BLOOD PT-15.5* PTT-32.2 INR(PT)-1.5*
[**2198-1-9**] 06:30AM BLOOD Glucose-111* UreaN-16 Creat-0.5 Na-139
K-3.7 Cl-106 HCO3-25 AnGap-12
[**2198-1-8**] 03:15PM BLOOD Glucose-140* UreaN-16 Creat-0.5 Na-139
K-4.1 Cl-108 HCO3-24 AnGap-11
[**2198-1-8**] 04:30AM BLOOD Glucose-112* UreaN-16 Creat-0.5 Na-139
K-3.5 Cl-108 HCO3-25 AnGap-10
[**2198-1-7**] 06:11AM BLOOD Glucose-108* UreaN-18 Creat-0.6 Na-137
K-3.6 Cl-104 HCO3-23 AnGap-14
[**2198-1-6**] 08:11PM BLOOD Glucose-151* UreaN-21* Creat-0.7 Na-133
K-4.2 Cl-103 HCO3-20* AnGap-14
[**2198-1-8**] 04:30AM BLOOD ALT-18 AST-15 LD(LDH)-119 AlkPhos-81
TotBili-0.7
[**2198-1-6**] 08:11PM BLOOD ALT-22 AST-20 LD(LDH)-137 AlkPhos-92
TotBili-0.9
[**2198-1-6**] 08:11PM BLOOD TSH-<0.02*
[**2198-1-6**] 08:11PM BLOOD T4-21.5* T3-349* calcTBG-0.36*
TUptake-2.78* T4Index-59.8* Free T4-6.7*
.
EKG [**2198-1-6**]:
Atrial fibrillation. No previous tracing available for
comparison
.
CXR [**2198-1-6**]:
FINDINGS: Cardiac silhouette is enlarged, and accompanied by
upper zone
vascular re-distribution. Bibasilar patchy and linear opacities
are present, accompanied by small bilateral pleural effusions.
The etiology of the basilar opacities is uncertain, particularly
in absence of older studies for comparison. Differential
diagnosis includes aspiration, pneumonia, atelectasis, and
dependent edema.
.
LENI [**1-7**];
IMPRESSION: No evidence of deep venous thrombosis in the right
lower
extremity.
.
EKG [**1-9**]:
Atrial fibrillation with rapid ventricular response. Delayed
precordial
R wave transition. Borderline low limb lead voltage. Compared to
the previous tracing of [**2198-1-6**] no diagnostic interim change
.
ECHO [**2198-1-10**]:
The left atrium is mildly dilated. The left atrium is elongated.
The estimated right atrial pressure is at least 15 mmHg. Left
ventricular wall thicknesses and cavity size are normal. Overall
left ventricular systolic function is severely depressed (LVEF=
25-30 %) due to akinesis of the inferior wall, septum and
moderate hypokinesis of the remaining segments. The right
ventricular cavity is mildly dilated with borderline normal free
wall function. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. The mitral valve leaflets do not fully
coapt. Moderate to severe (3+) mitral regurgitation is seen. The
left ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. Moderate to
severe [3+] tricuspid regurgitation is seen. There is
moderate-severe pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Moderate-severe global and regional left ventricular
dysfunction. At least moderate-severe functional mitral
regurgitation. Moderate-severe pulmonary artery systolic
hypertension.
[**2198-1-17**] 06:40AM BLOOD WBC-5.9 RBC-4.76 Hgb-12.9 Hct-39.4 MCV-83
MCH-27.2 MCHC-32.8 RDW-12.9 Plt Ct-175
[**2198-1-16**] 06:35AM BLOOD WBC-5.0 RBC-4.31 Hgb-12.0 Hct-35.9*
MCV-84 MCH-27.8 MCHC-33.3 RDW-13.0 Plt Ct-143*
[**2198-1-15**] 06:30AM BLOOD WBC-4.9 RBC-4.36 Hgb-12.0 Hct-36.4 MCV-83
MCH-27.4 MCHC-32.8 RDW-13.1 Plt Ct-148*
[**2198-1-14**] 06:06AM BLOOD WBC-4.1 RBC-4.27 Hgb-11.8* Hct-35.5*
MCV-83 MCH-27.7 MCHC-33.3 RDW-13.0 Plt Ct-124*
[**2198-1-13**] 07:20AM BLOOD WBC-5.0 RBC-4.07* Hgb-11.4* Hct-34.0*
MCV-84 MCH-28.0 MCHC-33.5 RDW-13.0 Plt Ct-140*
[**2198-1-12**] 06:45AM BLOOD WBC-4.8 RBC-4.15* Hgb-11.5* Hct-35.1*
MCV-85 MCH-27.7 MCHC-32.8 RDW-12.9 Plt Ct-153
[**2198-1-11**] 07:30AM BLOOD WBC-6.2 RBC-4.35 Hgb-11.9* Hct-36.2
MCV-83 MCH-27.4 MCHC-32.9 RDW-13.2 Plt Ct-162
[**2198-1-10**] 06:40AM BLOOD WBC-5.3 RBC-4.08* Hgb-11.3* Hct-34.2*
MCV-84 MCH-27.7 MCHC-33.1 RDW-13.0 Plt Ct-144*
[**2198-1-9**] 06:30AM BLOOD WBC-6.4 RBC-4.07* Hgb-11.4* Hct-33.3*
MCV-82 MCH-28.0 MCHC-34.1 RDW-13.1 Plt Ct-139*
[**2198-1-8**] 04:30AM BLOOD WBC-6.6 RBC-4.17* Hgb-11.5* Hct-34.0*
MCV-82 MCH-27.6 MCHC-33.8 RDW-12.6 Plt Ct-142*
[**2198-1-7**] 06:11AM BLOOD WBC-9.4 RBC-4.33 Hgb-11.9* Hct-35.0*
MCV-81* MCH-27.5 MCHC-34.0 RDW-12.9 Plt Ct-150
[**2198-1-6**] 08:11PM BLOOD WBC-10.4 RBC-4.67 Hgb-13.0 Hct-38.2
MCV-82 MCH-27.8 MCHC-34.0 RDW-12.6 Plt Ct-179
[**2198-1-6**] 08:11PM BLOOD Neuts-67.3 Lymphs-24.5 Monos-7.3 Eos-0.6
Baso-0.4
[**2198-1-18**] 06:40AM BLOOD PT-25.1* PTT-40.9* INR(PT)-2.4*
[**2198-1-17**] 11:15AM BLOOD PT-20.7* PTT-39.1* INR(PT)-2.0*
[**2198-1-17**] 06:40AM BLOOD Plt Ct-175
[**2198-1-16**] 06:35AM BLOOD Plt Ct-143*
[**2198-1-16**] 06:35AM BLOOD PT-20.6* PTT-38.2* INR(PT)-2.0*
[**2198-1-15**] 06:30AM BLOOD Plt Ct-148*
[**2198-1-15**] 06:30AM BLOOD PT-25.1* PTT-43.2* INR(PT)-2.4*
[**2198-1-14**] 06:06AM BLOOD Plt Ct-124*
[**2198-1-14**] 06:06AM BLOOD PT-36.5* PTT-40.7* INR(PT)-3.6*
[**2198-1-13**] 07:20AM BLOOD Plt Ct-140*
[**2198-1-13**] 07:20AM BLOOD PT-29.4* PTT-67.1* INR(PT)-2.8*
[**2198-1-12**] 10:46PM BLOOD PTT-69.7*
[**2198-1-12**] 12:45PM BLOOD PTT-52.9*
[**2198-1-12**] 06:45AM BLOOD Plt Ct-153
[**2198-1-12**] 06:45AM BLOOD PT-16.5* PTT-62.3* INR(PT)-1.6*
[**2198-1-12**] 12:30AM BLOOD PTT-116.2*
[**2198-1-11**] 07:30AM BLOOD Plt Ct-162
[**2198-1-10**] 06:40AM BLOOD Plt Ct-144*
[**2198-1-9**] 06:30AM BLOOD Plt Ct-139*
[**2198-1-9**] 06:30AM BLOOD PT-14.1* PTT-30.1 INR(PT)-1.3*
[**2198-1-8**] 04:30AM BLOOD Plt Ct-142*
[**2198-1-8**] 04:30AM BLOOD PT-14.7* PTT-29.2 INR(PT)-1.4*
[**2198-1-7**] 06:11AM BLOOD PT-15.5* PTT-30.1 INR(PT)-1.5*
[**2198-1-7**] 06:11AM BLOOD Plt Ct-150
[**2198-1-7**] 06:11AM BLOOD [**Name (NI) 8255**] TO PTT-UNABLE TO
INR(PT)-UNABLE TO
[**2198-1-6**] 08:11PM BLOOD Plt Ct-179
[**2198-1-6**] 08:11PM BLOOD PT-15.5* PTT-32.2 INR(PT)-1.5*
[**2198-1-18**] 06:40AM BLOOD Na-138 K-4.4 Cl-105
[**2198-1-17**] 06:40AM BLOOD Glucose-99 UreaN-13 Creat-0.5 Na-139
K-4.2 Cl-105 HCO3-24 AnGap-14
[**2198-1-16**] 06:35AM BLOOD Glucose-103* UreaN-16 Creat-0.6 Na-139
K-4.1 Cl-107 HCO3-25 AnGap-11
[**2198-1-15**] 06:30AM BLOOD Glucose-97 UreaN-15 Creat-0.6 Na-140
K-4.2 Cl-106 HCO3-26 AnGap-12
[**2198-1-14**] 06:06AM BLOOD Glucose-96 UreaN-12 Creat-0.6 Na-140
K-3.6 Cl-106 HCO3-26 AnGap-12
[**2198-1-13**] 07:20AM BLOOD Glucose-102* UreaN-12 Creat-0.6 Na-138
K-3.6 Cl-106 HCO3-25 AnGap-11
[**2198-1-12**] 06:45AM BLOOD Glucose-116* UreaN-13 Creat-0.6 Na-140
K-4.0 Cl-106 HCO3-25 AnGap-13
[**2198-1-10**] 06:40AM BLOOD Glucose-117* UreaN-16 Creat-0.6 Na-141
K-3.9 Cl-107 HCO3-26 AnGap-12
[**2198-1-9**] 06:30AM BLOOD Glucose-111* UreaN-16 Creat-0.5 Na-139
K-3.7 Cl-106 HCO3-25 AnGap-12
[**2198-1-8**] 03:15PM BLOOD Glucose-140* UreaN-16 Creat-0.5 Na-139
K-4.1 Cl-108 HCO3-24 AnGap-11
[**2198-1-8**] 04:30AM BLOOD Glucose-112* UreaN-16 Creat-0.5 Na-139
K-3.5 Cl-108 HCO3-25 AnGap-10
[**2198-1-7**] 06:11AM BLOOD Glucose-108* UreaN-18 Creat-0.6 Na-137
K-3.6 Cl-104 HCO3-23 AnGap-14
[**2198-1-6**] 08:11PM BLOOD Glucose-151* UreaN-21* Creat-0.7 Na-133
K-4.2 Cl-103 HCO3-20* AnGap-14
[**2198-1-8**] 04:30AM BLOOD ALT-18 AST-15 LD(LDH)-119 AlkPhos-81
TotBili-0.7
[**2198-1-6**] 08:11PM BLOOD ALT-22 AST-20 LD(LDH)-137 AlkPhos-92
TotBili-0.9
[**2198-1-18**] 06:40AM BLOOD TSH-<0.02*
[**2198-1-11**] 07:30AM BLOOD TSH-<0.02*
[**2198-1-6**] 08:11PM BLOOD TSH-<0.02*
[**2198-1-18**] 06:40AM BLOOD T4-17.6* T3-317* Free T4-4.0*
[**2198-1-11**] 07:30AM BLOOD T4-23.2* T3-444* Free T4-7.0*
[**2198-1-6**] 08:11PM BLOOD T4-21.5* T3-349* calcTBG-0.36*
TUptake-2.78* T4Index-59.8* Free T4-6.7*
Brief Hospital Course:
Ms. [**Known lastname 20179**] is a 44F with PMH Graves' disease for the past 7
years, previously on PTU and propranolol, non-adherent on
medications, who is transferred from [**Hospital3 **] for
management of atrial fibrillation and continuing thyrotoxicosis.
.
# Thyrotoxicosis: On admission had 2 out of 4 of cardinal
symptoms of thyrotoxicosis: atrial fibrillation and GI upset
(vomiting). No sign of CNS effects, no fever; no sign of overt
or impending thyroid storm. OSH labs and [**Hospital1 18**] labs consistent
with thyrotoxicosis-- TSH less than 0.014, free T4 7.77, free T3
drawn admission. Had been started on PTU 100mg TID, propranolol
10mg TID, and dilt drip at OSH (stopped the afternoon of
transfer). She was restarted on PTU and propranolol on
admission at the same doses, however endocrine was consulted the
following morning and recommended [**Name (NI) 98319**] PTU and instead
starting methimazole uptitrated to 20mg [**Hospital1 **]. Thyroid studies
were resent, consistent with findings from [**Location (un) 620**]. Atrial
fibrillation was managed with propranolol and diltiazem
initially, see below, then converted to Toprol. Diltiazem, and
digoxin. Per endocrinology, there was no need for iodine or
steroids during admission. She should have an eye examination
and follow up with endocrinology to consider ablative therapy
(follow up arranged-see below). Pt's final hyperthyroid regimen
is methimazole 40mg daily. She will be following up with Dr.
[**Last Name (STitle) 13059**]. Repeat TFTs were performed day of discharge and the
endocrine team was satisfied the the current regimen.
# Atrial fibrillation: New afib with RVR to 150s. Was
resistant to tx initially with metoprolol and IV dilt doses at
OSH, however had slowed somewhat with diltiazem gtt, stopped
this prior to transfer. Has some degree of hemodynamic
compromise with decreased blood pressures in the 90-100s range.
She was continued on propranolol and started on PO diltiazem for
rate control, and her blood pressures held steady, never
dropping below SBP 90s. Echo was obtained and showed severe
heart failure and mitral regurgitation. Cardiology was
consulted, and recommended multiple medication changes. Pt was
started on metoprolol and diltiazem. Despite high doses of
metoprolol and addition of digoxin, but was unable to be
titrated off diltiazem. Therefore, her final regimen is Toprol
XL 150mg [**Hospital1 **], diltiazem XR 120mg, digoxin 0.125mg daily. She was
started initially on aspirin, but given ECHO findings of
systolic heart failure, cardiology recommended that pt start on
coumdin. This was started and pt was therapeutic at the time of
discharge. Discharge coumadin dose was 2.5mg with an INR of 2.4.
Please see above for INR trends. Pt was initially given 3mg of
coumadin on [**1-12**]. She became supratherapeutic on [**1-14**] and
coumadin dose was held then decreased to 2mg on [**1-15**]. This was
increase to 2.5mg as pt's INR was 2.0 x2 checks. She was
instructed to have a repeat INR check on [**2198-1-22**] at PCP's office
for further titration prn. She will also be following up with
Dr. [**Last Name (STitle) **] on [**2198-2-8**] for further care. She was not discharged
with aspirin therapy.
.
# acute systolic CHF/orthopnea-Pt presented with significant LE
edema as well as orthopnea. Tachycardia and poor adherence to
thyroid medications likely has resulted in tachycardia induced
cardiomyopathy or hyperthyroid cardiomyopathy. ECHO was
performed showing an EF 25-30%, unknown prior EF as no echo on
file. Cardiac enzymes were negative at OSH. CXR showed bibasilar
atelectasis vs infection vs pneumonitis, some vascular
congestion. However clinically, pt did not have PNA. She did
have clinical CHF. In addition, she did have RLE >LLE swelling,
raising concern for PE; but LENI negative for DVT. Pt was given
aggressive IV diuresis that was started in the ICU and pt's
orthopnea quickly resolved and LE edema markedly improved. Pt
received a few days of 20mg IV lasix [**Hospital1 **] that was converted into
40mg PO lasix with continued good effect. I/Os and daily weights
were monitored. Weight on discharge was 137lbs. Pt's final
medication regimen is Toprol xl 150mg [**Hospital1 **], diltiazem XR 120mg
daily, digoxin 0.125mg, lisinopril 2.5mg daily, lasix 40mg
daily. Would uptitrate ACEI prn. Pt was educated on a low salt
diet as well as the importance of monitoring daily weights. She
was instructed to call her PCP/cardiologist if she develops
symptoms of dehydration or volume overload in order to titrate
her lasix therapy.
.
# Lower extremity edema: per her history, is long-standing,
however pt had noticed R calf > L calf for the past few months.
No calf pain/tenderness. LENI negative for DVT. Likely due to
CHF and hyperthyroidism. See above
.
# Elevated INR/coagulopathy- Not on any anticoagulant
medications prior to admission. INR was 1.3 at OSH and 1.5->1.4
at [**Hospital1 18**]. No clear reason for elevation-- thyroid disease can
cause coagulation abnormalities, however hyperthyroidism usually
causes hypercoagulability. Was on lovenox at OSH, but this
should not effect PT/INR. However, pt was started on
anticoagulation as above and not clearly will have an elevated
INR.
.
#anemia-normocytic-trend/monitor. Appeared stable. Likely due to
chronic disease/acute illness. Pt should have consideration of
outpatient iron studies and colonoscopy prn. HCT 39.4 on day of
discharge.
.
#thrombocytopenia-likely due to acute illness. Resolved. plt 175
on day of DC.
.
# FEN: no caffeine, low salt
# Prophylaxis: therapeutic INR. coumadin
# Access: peripherals .
# Code: Full
HCP-pt reports her sister [**Name (NI) 553**] [**Name (NI) **] [**Telephone/Fax (1) 98320**]
Medications on Admission:
none
Discharge Medications:
1. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. methimazole 10 mg Tablet Sig: Four (4) Tablet PO once a day:
40mg daily.
Disp:*120 Tablet(s)* Refills:*2*
3. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO twice a day: 150mg
twice a day.
Disp:*180 Tablet Extended Release 24 hr(s)* Refills:*2*
6. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
7. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
Disp:*30 Capsule, Extended Release(s)* Refills:*2*
8. Outpatient [**Name (NI) **] Work
PT/INR. Please go to Dr.[**Name (NI) 6854**] office on Monday [**2198-1-22**] to have
an INR checked. Please send results to
Name: [**Last Name (LF) **],[**First Name3 (LF) **] C.
Location: [**Hospital1 **] HEALTHCARE-[**Location (un) 8596**]
Address: [**Location (un) 8597**], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 8598**]
Fax: [**Telephone/Fax (1) 98321**]
Discharge Disposition:
Home
Discharge Diagnosis:
-thyrotoxicosis
-[**Doctor Last Name 933**] disease
-atrial fibrillation with RVR
-acute systolic heart failure and mitral valve
insufficiency/regurgitation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with thyrotoxicosis due to not taking your
medications for Grave's disease. For this, you were initially
monitored in the ICU and were followed by the endocrinology
team. Your PTU was STOPPED and you were STARTED on methimazole
by the endocrinology team.
In addition, you had atrial fibrillation with a fast heart rate.
For this, you were started on metoprolol, digoxin and diltiazem
with good effect. In addition, you were found to have heart
failure (likely due to your fast heart rate) and were started on
new medications for this (see below). You should weight yourself
daily and follow a low salt diet.
.
You were started on a blood thinner (coumadin) due to your heart
failure and irregular heart rate in order to decrease the risk
of stroke. You will need to have your INR monitored by your PCP.
[**Name10 (NameIs) 357**] go to Dr.[**Name (NI) 6854**] office on Monday [**1-22**] for INR check.
.
It is of extreme importance that you continue to take your
medications properly for your thyroid and heart diseases as not
doing so could further damage your heart and/or lead to eventual
death.
.
Medication changes:
1.start metoprolol-for heart
2.start methimazole-for thyroid
3.start lisinopril-for heart
4.start coumadin-blood thinner
5.start diltiazem-for heart
6.start digoxin-for heart rate
7.start lasix-for heart and to prevent extra fluid accumulation
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 98322**], MD
Specialty: INTERNAL MEDICINE
When: Wednesday [**1-24**] at 11:45am
Location: [**Hospital1 **] HEALTHCARE-[**Location (un) 8596**]
Address: [**Location (un) 8597**], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 8598**]
.
Department: ENDOCRINOLOGY
When: WEDNESDAY [**2198-2-7**] at 2:30 PM
With: [**First Name11 (Name Pattern1) 312**] [**Last Name (NamePattern4) 3015**], M.D. [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIOLOGY
When: THURSDAY [**2198-2-8**] at 9:30AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD ([**Telephone/Fax (1) 8937**]
Location: [**Hospital1 **]- [**Location (un) 620**]
Address: [**Street Address(2) 3001**], [**Location (un) 620**], MA
|
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icd9cm
|
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icd9pcs
|
[
[
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|
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|
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,855
| 168,096
|
25663
|
Discharge summary
|
report
|
Admission Date: [**2122-7-17**] Discharge Date: [**2122-7-26**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
Headache, nausea
Major Surgical or Invasive Procedure:
placement of IVC filter.
History of Present Illness:
This is an 83 yo RH woman with history of DVTs on coumadin,
breast cancer, HTN, hypercholesterolemia, who was transferred
from OSH with an intracerebral hemorrhage. The history is per
patient and her daughters.
.
The patient had sudden onset of a horrible headache 48 hrs ago
prior to arrival at [**Hospital1 18**], frontal and bitemporal, constant,
aching, not associated with any fever, neck pain, weakness or
numbness. The headache persisted. The following day the patient
was very nauseated, with multiple bouts of bilious emesis. On
the day of presentation she did not recognize her daughter, left
the freezer door open, and thus her family brought her to
[**Hospital3 10310**] hospital.
.
BP at OSH was 176/64, and a head CT showed a 5x4cm hemorrhage in
the right parietal lobe with two hypodensities in the left
frontal lobe. INR 2.04 and she was given 2 u FFP, 10mg vit K,
and transferred to [**Hospital1 18**]. Here INR was 1.8, got 3 more units of
FFP and INR went down to 1.3. SBP was in the 180's and thus
labetolol gtt was started -> bp down to 140's. Repeat head CT
showed stable right parietal bleed (per neurosurgery attending
Dr. [**Last Name (STitle) **]. She was loaded with dilantin 1 gram as well for
shaking in her arm.
.
Patient denies any fever, chills, preceeding weakness, numbness,
visual changes, prior history of stroke or seizures, recent
illnesses. No h/o fall or trauma.
Past Medical History:
1. HTN
2. Hypercholesterolemia
3. DVTs (multiple) on coumadin, INR difficult to control per
daughters, recent INR was in the range of 4.
4. Breast cancer [**2114**] s/p lumpectomy, XRT and tamoxifen. No
chemotherapy. No recurrence known.
5. Left hip replacement.
6. Recent history of elevated WBCs.
Social History:
-very active woman
-Lives in an apt in a family members house, independent in all
ADLS
-widowed, 5 kids.
-Formerly worked as a PT assistant.
-No tob/etoh/drugs.
Family History:
-brother with lymphoma, many family members with CAD.
-son and daughter with [**Name (NI) 4330**], PE
Physical Exam:
AT ADMISSION:
VITALS: 99.4, 64, 178/44, 18, 100% on 2LNS
GEN: elderly woman in NAD, sitting upright in a stretcher with
eyes closed intermittantly
SKIN: no rash
HEENT: NC/AT, anicteric sclera, dry mm
NECK: supple, no carotid bruits, no LAD
CHEST: normal respiratory pattern, CTA bilat. No axillary LAD
CV: regular rate and rhythm without murmurs
ABD: soft, nontender, nondistended, +BS, no HSM
EXTREM: no edema, warm and well perfused. A line in right arm.
NEURO:
Mental status:
Patient is alert, awake, pleasant affect and slightly
disinhibited behavior.
Oriented to person, place, time and president.
Fair attention - names MOYB quickly, pauses at [**Month (only) **], and
continues to name the rest of the months. Tells a coherent
story.
Language is fluent with good comprehension, repitition, naming
of body parts, no dysarthria.
No apraxia (brushes hair), no neglect (names all in the room).
Able to calculate, no left/right mismatch.
Registration [**2-5**] objects. Recalls [**2-5**] objects after 3 minutes.
.
Cranial Nerves:
I: deferred
II: Visual fields: left homonomous hemianopsia. Fundoscopic
exam: discs flat, fundi clear, no hemorrhages or exudates.
Pupils:3->2 mm, consensual constriction to light.
III, IV, VI: EOMS full, gaze conjugate. + nystagmus that
fatigues (s/p dilantin load), no ptosis.
V: facial sensation intact over V1/2/3 to light touch and pin
prick.
VII: symmetric face
VIII: hearing NOT intact to finger rubs
IX, X: Symmetric elevation of palate
[**Doctor First Name 81**]: SCM and trapezius [**4-9**] bilaterally
XII: tongue midline without atrophy or fasciulations.
.
Sensory:
Normal touch, vibration, pinprick. No extinction to double
simultaneous stimulation.
.
Motor:
Some wasting of small hand muscles, mild increased tone in legs.
No fasciculations or drift. No adventitious movements. No
asterixis.
Strength:
Delt Tri [**Hospital1 **] WE WF FE FF IP QD Ham DF PF Toe
LEFT:5 5 5 5 5 5 5 4 5 4 5 5 5
.
Reflexes: No grasp, glabellar, snout, palmomental. No Jaw jerk.
[**Hospital1 **] BR Tri Pat Ach Toes
RT: 3 3 3 4 0 up
LEFT: 3 3 3 4 0 up
.
Coordination:
Normal finger-to-nose, RAMs.
.
Gait: not tested given on labetolol gtt.
.
EXAM UPON TRANSFER FROM ICU TO FLOOR:
VITALS: 101.6, 74-86,109-153/37-57, 18, 100% on 2LNS
GEN: elderly woman in NAD, sleeping, arousable, needs prompting
to stay awake
SKIN: no rash
HEENT: NC/AT, anicteric sclera, moinst mmm
NECK: supple, no carotid bruits, no LAD
CHEST: normal respiratory pattern, CTA bilat. No axillary LAD
CV: regular rate and rhythm without murmurs
ABD: soft, nontender, nondistended, +BS, no HSM
EXTREM: edema 1+ bilaterlly, pitting, warm and well perfused.
NEURO:
Mental status:
Patient is drowsy, needs continues prompting, perseverating,
answers most questions "yes, yes"
Oriented to person, place (after orientation), time (only after
re-orientation)
[**Last Name (un) 64011**] attention: needs continues prompting;
Language is fluent with good comprehension, repitition, naming
of body parts (but calls L-arm the R-arm), no dysarthria.
Some neglect (not able to point/count all people in the room;
might be related to poor attention.
Registration [**2-5**] items (date/month/year). Recalls [**2-5**] pieces of
information in 5 minutes.
.
Cranial Nerves:
I: deferred
II: Visual fields: dense left homonomous hemianopsia.
Pupils:3->2 mm, consenual constriction to light.
III, IV, VI: EOMS full, gaze conjugate. no ptosis.
V: facial sensation intact over V1/2/3 to light touch and cold
VII: symmetric face
VIII: hearing intact to finger rubs
IX, X: Symmetric elevation of palate
[**Doctor First Name 81**]: SCM and trapezius [**4-9**] bilaterally
XII: tongue midline without atrophy or fasciulations.
.
Sensory:
Exam unreliable as she answers almost every question with yes:
touch, vibration, pinprick normal. Extinction to double
simultaneous stimulation.
.
Motor:
Some wasting of small hand muscles, mild increased tone in legs.
No fasciculations or drift. Resting tremor in R-hand.
Strength:
Delt Tri [**Hospital1 **] WE WF FE FF IP QD Ham DF PF Toe
LEFT:5 5 5 5 5 5 5 4 5 4 5 5 5
.
Reflexes: + grasp.
[**Hospital1 **] BR Tri Pat Ach Toes
RT: 1 1 1 1 0 up
LEFT: 1 1 1 1 0 up
.
Coordination:
Normal finger-to-nose, RAMs, HTS.
.
Gait: not tested; patient drowsy
Pertinent Results:
LABS/Radiology:
Na 143, K 3.7, Cl 107, bicarb 26, bun 19, cr 0.8, gluc 109
CBC: 20/36/168, mcv 92
Diff: 39N, 2 bands, 55L, 4 monos, 0 eos, 1+ aniso, poiklo,
macrocy, microcy, ovalocy, tear-drop.
INR 1.8->1.3 now
UA: mod blood, 30 prot, 50 ket, [**5-15**] r, [**2-7**] wbc, occ bact, 0 epi
CK 83, MB ND, Trop <0.01
.
CXR: 1. Right hilar fullness, which may indicate
lymphadenopathy.
2. Increased interstitial markings bilaterally, which may
represent mild pulmonary edema, atypical pneumonia, or less
likely, bilateral lymphangitic spread of tumor.
.
[**7-17**] NCHCT at 3pm: 1. Large intraparenchymal hemorrhage arising
from
right temporoparietal, occipital regions. No definite evidence
of
intracranial metastasis on this non-contrast examination.
2. Extension of hemorrhage into lateral ventricles and
subarachnoid space.
.
[**7-17**] NCHCT at 9pm: There has been no significant change in the
extent
of the large right temporoparietal and occipital lobe
intraparenchymal hemorrhage. This measures approximately 3.9 x
4.7 cm, which is essentially unchanged. Intraventricular
hemorrhage is again noted, as are small foci of blood along the
falx. No hydrocephalus or significant shift of midline
structures is seen.
.
[**7-23**] NCHCT: There has been no appreciable change in size or
surrounding edema of the large right temporoparietal
intraparenchymal hemorrhage, with extension into the right
lateral ventricle. Blood layering in the left occipital [**Doctor Last Name 534**] has
been resorbed. Again seen are several tiny foci of hemorrhage
adjacent to the falx, unchanged from prior studies. There is
subarachnoid blood and isolated sulcus at the extreme left
vertex, new from the prior study. There is no hydrocephalus or
shift of normally midline structures.
.
[**7-18**]: MRI: This is a limited study with motion degraded T1
sagittal images obtained. The area of hemorrhage is identified
in the right posterior temporoparietal region as seen on the CT
of [**2122-7-17**].
.
EEG: [**7-18**]: This is an abnormal portable EEG due to the presence
of slow and disorganized background rhythm with generalized
bursts of delta frequency slowing. These findings suggest a mild
encephalopathy.
Brief Hospital Course:
This is an 83 yo woman with history of breast cancer, HTN, and
high cholesterol, and DVTs on Coumadin who presents with
headache x 48 hours and emesis. The patient was admitted to the
neuro ICU with an intracranial hemorrhage. After 3 days she was
transferred to the floor.
.
1. Neurological:
Intracranial hemorrhage: The neurological exam at admission was
significant for a left homonomous hemianopsia and mild left leg
weakness in an upper motor neuron pattern. No papilledema was
seen on fundi exam. CT showed an intracerebral hemorrhage in
the right parietal lobe with some surrounding edema. There is a
question of two other hyperdensities in bilateral frontal lobes
as well. Repeat head CT 6 hrs later is stable, without signs of
enlargement, hydrocephalus, or shift. There was a question of
whether the intracranial bleed was into a mass lesion. MRI of
the head with and without gadolinium did not demonstrate a mass,
but follow-up MRI in [**5-13**] weeks was recommended to re-evaluate
once hemorrhage has partially resorbed. Given the breakthrough
of the hemorrhage into the ventricular system, the patient was
monitored closely for signs of hydrocephalus.
Neurosurgery was consulted and recommended no operative
management. They recommended beginning a mannitol drip, for a
few days only, and to start the patient on dilantin for seizure
prophylaxis. Patient had been started on phenytoin for seizure
prophylaxis, at a dose of 100 mg tid. Patient was sub
therapeutic in dilantin level and did not have any seizures
during this time. She also developed a rash to dilantin.
Therefore, dilantin was discontinued.
An EEG showed no epileptiform discharges but was remarkable for
mild encephalopathy.
Patient's left homonymous hemianopsia remained stable and the
encephalopathy, noticeable by inattentiveness and sleepiness,
slowly improved.
.
2. Cardiovascular: While in the ICU, patient's elevated blood
pressure was managed with labetalol gtt (goal <140). She was
then weaned off the drip and started on atenolol 100 mg. She
ruled out for MI. No events were noted per telemetry. Her
blood pressure goal was <140 SBP.
.
3. Hematology:
a) The patient was on Coumadin for DVT. The supra therapeutic
INR was decreased by multiple units of FFP and Vit-K. In the
setting of history of hypercoagulability, and a new RLE DVT, an
IVC filter was placed by vascular surgery, as Coumadin is
contraindicated at this point. Given a positive family history
for DVT and PE, a hypercoagulable workup should be considered.
b) The patient was noted to have an increased WBC. She was seen
by Hematology/Oncology for rule out CLL. Peripheral blood flow
cytometry study revealed involvement by a CD5 positive, CD23
positive, CD20 (dim) B-cell lymphoproliferative disorder,
immuonphenotypically consistent with chronic lymphocytic
leukemia. There was no recommendation for treatment at the
present time, however, WBC count will be followed as an
outpatient.
.
4. Pulmonary: Chest XR on admission demonstrated hilar fullness
which was concerning for mass. A CT-chest showed no evidence for
pulmonary or hilar masses.
.
5. ID: The patient was febrile during the acute phase, and was
found to have an elevated white count and a urinalysis
suggesting a UTI. The patient had a foley catheter in place for
the first 5 days of her hospital stay. The patient was treated
with levofloxacin 500 mg QD. Also, due to the possibility of
line infection, her left subclavian central line which was
placed at the time of admission, was removed and the tip was
sent for culture. Access was maintained through a peripheral IV
in her right arm.
.
6. Renal: The patient was noted to have a renal cyst on
Chest-CT. The patient is known to have this cyst for 4 years
which has not changed in size. Primary care doctor will repeat a
MR abdomen with contrast in a few months.
.
7. FEN: Patient was evaluated by Speech and Swallow after the
acute phase, and her diet was advanced accordingly. She
tolerated a cardiac diet.
.
8. Disposition: PT/OT consult obtained, recommended short term
rehabilitation. Placed at [**Hospital3 **] center.
.
9. FULL CODE. HCP = [**Name (NI) **] [**Name (NI) 1968**] (daughter) [**Telephone/Fax (1) 64012**].
Medications on Admission:
MEDS: (doses not known)
lasix
atenolol
zocor
coumadin 7 or 8 mg each night (goal [**1-8**]).
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Atenolol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily):
please adjust dose to keep SBP<150.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
6. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
8. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
1. Intracranial hemorrhage, right temporoparietal lobe
2. urinary tract infection
3. chronic lymphocytic leukemia
4. renal cyst
5. hypertension
6. deep venous thrombosis lower extremity
Discharge Condition:
good
Discharge Instructions:
Follow up MRI HEAD with gad in [**4-11**] weeks.
Please continue to take all medications as prescribed.
Follow up with your PCP after discharge from rehab.
Please have your electrolytes checked at rehab (K and Mg).
Followup Instructions:
1. Please f/u at the stroke clinic (dr. [**Last Name (STitle) **]/dr. [**Last Name (STitle) 1693**]).
Please call [**Telephone/Fax (1) 1694**] to update your demographics, schedule
the appointment and to receive directions.
2. Please call [**Telephone/Fax (1) 327**] for MRI/MRA brain with contrast
appointment and make sure it is before the visit with neurology.
3. Please follow up with your primary care physician after
discharge from rehab. You will also need a MRI abdomen with
gadolinium to look at the kidney as this could not be scheduled
while you were in the hospital.
Completed by:[**2122-7-28**]
|
[
"V10.3",
"599.0",
"453.40",
"593.2",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"38.93",
"88.65"
] |
icd9pcs
|
[
[
[]
]
] |
13998, 14083
|
8880, 13105
|
280, 307
|
14313, 14320
|
6662, 8857
|
14583, 15198
|
2258, 2361
|
13248, 13975
|
14104, 14292
|
13131, 13225
|
14344, 14560
|
2376, 2841
|
224, 242
|
335, 1740
|
5631, 6643
|
5052, 5615
|
1762, 2063
|
2079, 2242
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,286
| 113,177
|
35003+57962
|
Discharge summary
|
report+addendum
|
Admission Date: [**2100-9-15**] Discharge Date: [**2100-10-6**]
Date of Birth: [**2050-2-13**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Fall, shortness of breath
Major Surgical or Invasive Procedure:
Tracheostomy [**9-25**]
Change of tracheostomy [**9-30**]
IR-placement of R thoracic pigtail catheter [**10-4**]
History of Present Illness:
50yo M suffering a fall from ~10ft, landing on his back.
Initially brought to [**Hospital3 59514**] Hospital, imaging revealing
multiple BL rib fxs, and transferred to [**Hospital1 18**] by ambulance for
further eval and mgmt.
Past Medical History:
DM2
HTN
psoriasis
s/p repair of R hand injury
Social History:
married, lives in [**State 4260**]. Currently in MA working as window
repairer.
Family History:
unavailable
Physical Exam:
O: T:100.3 BP: 180/93 HR:117 RR 36 O2Sats 100% NRB
Gen: in distress; pain
HEENT: Pupils:3.5-2.5 bilat, EOMs intact, small tongue lac, TMs
clear
Neck: Supple.
Lungs: good effort, tender to palp over ribs bilaterally,
limited auscultation but BL BS present, no crepitus.
Cardiac: tachy. S1/S2.
Abd: Soft, obese, NT, BS+
Ext: Warm and well perfused. R hip tenderness.
Rectal: good tone, no gross blood
Neuro: GCS 15
Orientation: Oriented to person, place, and date.
Motor:
D B T FE FF IP Q AT [**Last Name (un) 938**] G
R 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch intact.
Reflexes: B T Br Pa Ac
Right 2+
Left 2+
Toes downgoing bilaterally
Pertinent Results:
[**2100-10-3**] 02:22AM BLOOD WBC-7.3 RBC-2.74* Hgb-8.1* Hct-25.2*
MCV-92 MCH-29.6 MCHC-32.2 RDW-14.8 Plt Ct-272
[**2100-10-2**] 03:51AM BLOOD PT-15.6* PTT-25.4 INR(PT)-1.4*
[**2100-10-3**] 02:22AM BLOOD Glucose-146* UreaN-36* Creat-1.0 Na-139
K-4.8 Cl-107 HCO3-26 AnGap-11
[**2100-10-3**] 02:22AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.5
[**2100-9-30**] 02:05AM BLOOD Type-ART pO2-87 pCO2-54* pH-7.42
calTCO2-36* Base XS-8
Brief Hospital Course:
50yo M transfer to [**Hospital1 18**] as a trauma basic. Evaluation in the
trauma bay revealed a GCS of 15, HD stable, mildly labored
breathing but maintaining saturation on supplemental oxygen.
Imaging from OSH as well as here included CT Head (negative), CT
C-Spine (no acute injury), and CT Torso (rib fx R [**2-23**] and rib
fx L 1,[**2-20**]; R scapular fracture; possible R adrenal hemorrhage;
and transverse process fx T9, L1 and L3).
The patient was admitted to the TSICU under the Trauma Surgery
service. Neurosurgical consult indicated no operative
management for the transverse process fractures. Respiratory
status declined over the first hospital day leading to
endotracheal intubation on HD 2. This remained his major issue
as ventilator status failed to improve. He developed a MSSA PNA
(dx'd by BAL on HD 4), which was treated with a 7-day course of
Nafcillin. His failure to wean led to an open tracheotomy
performed on HD 11, with placement of a #8 Portex. The trach
tube caused local irritation, presumably due to being too short
in relation to his body habitus, and was therefore changed at
the bedside on HD 16 to a #8 [**Last Name (un) 295**]. The vent wean continued
but a few days later regressed. CXRs showed a R pleural
effusion, which was drained by an IR-placed pigtail cathether
(1500cc of serosanguinous fluid on the first day) on HD 20.
Sedation during endotracheal intubation was weaned off shortly
after tracheotomy. Analgesia and anxiolytics are currently
morphine and ativan. Patient is interactive and appropriate
with episodes of mild agitation. There were no cardiovascular
issues throughout his stay; antihypertensives were eventually
begun when he became hypertensive. Tube feeds were begun
shortly after intubation via a nasogastric tube. PEG was not an
option given his body habitus, and thus a Dobhoff was placed at
the bedside. Renal function was stable. Gentle diuresis with a
lasix drip was employed to facilitate the ventilator wean.
Hyperkalemia at the time of admission was treated successfully
with calcium, insulin, and bicarbonate; no further electrolyte
abnormalities ensued. Glycemic control became problem[**Name (NI) 115**] after
reaching goal tube feeding; the patient's home doses of oral
antiglycemics were added to a progressively more-agressive
insulin sliding scale. Besides the MSSA PNA, the patient's
sputum also grew out Enterobacter on HD 12. Because the patient
had no fever, no leukocytosis, and no sputum, and because the
colony counts were <100,000, no antibiotics were given. No
hematologic concerns arose; no transfusions were needed
throughout. Prophylaxis included Heparin SQ and pneumoboots, as
well as pepcid until tube feeds reached goal. Access included
an arterial line and central venous catheter placed on HD 1.
The right subclavian was changed on HD 11.
At the time of discharge, patient is awake and alert, tolerating
a tube feed diet via Dobhoff, on oral medications, ventilated
via trach, afebrile, with stable vital signs.
Medications on Admission:
actos 30mg daily, cozaar 15mg daily, amlodipine/benzapril
10-20mg daily, glyburide 5mg daily
Discharge Medications:
1. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2
times a day).
Disp:*qs qs* Refills:*2*
2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTUES (every Tuesday).
3. Metoprolol Tartrate 50 mg Tablet Sig: 0.75 Tablet PO TID (3
times a day): hold for SBP < 100 or HR < 60.
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
5. Oxycodone 5 mg/5 mL Solution Sig: Ten (10) mL PO Q4H (every 4
hours) as needed for pain.
6. Glyburide 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
7. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours).
8. Metoclopramide 5 mg/mL Solution Sig: Two (2) mL Injection Q6H
(every 6 hours).
9. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) mL
Mucous membrane twice a day.
10. Colace 50 mg/5 mL Liquid Sig: Ten (10) mL PO twice a day.
11. Acetaminophen 500 mg/5 mL Liquid Sig: Five (5) mL PO every
four (4) hours as needed for pain.
12. Losartan 25 mg Tablet Sig: One (1) Tablet PO once a day:
hold for SBP < 100.
13. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
14. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) puff
Inhalation twice a day.
15. Combivent 18-103 mcg/Actuation Aerosol Sig: Six (6) puff
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
16. Senna 8.8 mg/5 mL Syrup Sig: Five (5) mL PO twice a day as
needed for constipation.
17. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-16**]
gtt Ophthalmic every four (4) hours as needed.
18. Hydrocortisone 2.5 % Cream Sig: One (1) application Topical
twice a day.
19. Morphine 2 mg/mL Syringe Sig: [**12-16**] mL Injection Q1H (every
hour) as needed for Pain.
20. Lorazepam 2 mg/mL Syringe Sig: [**12-16**] mL Injection every four
(4) hours as needed for agitation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehab
Discharge Diagnosis:
L1, L3-8, R3-11 rib fx with right-sided flail
Right scapula hair-line fracture
Right transverse process fracture T9, L1, and L3
respiratory failure
Right pleural effusion
morbid obesity
Diabetes mellitus, type 2
Hypertension
psoriasis
Discharge Condition:
Stable
Discharge Instructions:
Please [**Name8 (MD) 138**] MD or come to ER for: fever or chills; nausea,
vomiting, diarrhea, constipation, abdominal distension,
abdominal pain, intolerance of tube feeds; shortness of breath,
secretions from trach, dislodgment of trach, clogging of trach;
redness, drainage, or swelling at trach site.
Continue tube feeds via nasogastric Dobhoff tube. Continue
foley to gravity. Wean vent as tolerated.
Followup Instructions:
Please follow-up with a trauma surgeon in [**State 4260**], near where you
are being discharged to. You may call the office of Dr. [**Last Name (STitle) **],
Trauma Surgery at [**Hospital1 18**], at [**Telephone/Fax (1) 6429**] for any concerns or
questions.
Name: [**Known lastname 447**],[**Known firstname 856**] Unit No: [**Numeric Identifier 12852**]
Admission Date: [**2100-9-15**] Discharge Date: [**2100-10-6**]
Date of Birth: [**2050-2-13**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9036**]
Addendum:
Pt developed low-grade fever to 101.3 on evening prior to
admission. HD stable, WBC yesterday 11 which is unchanged.
Reviewed with staff, as well as med-flight transport crew. Given
that patient is going to acute-care facility for long-term care,
will proceed with discharge plans today.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 12853**] Rehab
[**First Name11 (Name Pattern1) 1332**] [**Last Name (NamePattern1) 9039**] MD [**MD Number(2) 9040**]
Completed by:[**2100-10-6**]
|
[
"696.1",
"112.0",
"250.02",
"518.81",
"807.4",
"041.4",
"401.9",
"278.01",
"807.07",
"805.4",
"746.9",
"805.2",
"482.41",
"811.00",
"E849.8",
"599.0",
"E881.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.72",
"38.91",
"34.04",
"97.23",
"96.6",
"38.93",
"31.1",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8964, 9178
|
2196, 5231
|
340, 455
|
7534, 7543
|
1754, 2173
|
8000, 8941
|
894, 907
|
5374, 7184
|
7276, 7513
|
5257, 5351
|
7567, 7977
|
922, 1735
|
275, 302
|
483, 711
|
733, 780
|
796, 878
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,855
| 158,902
|
25664
|
Discharge summary
|
report
|
Admission Date: [**2122-9-3**] Discharge Date: [**2122-9-8**]
Service: NEUROLOGY
Allergies:
Dilantin
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Left sided weakness and numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is an 83 year old right handed woman s/p a recent R parietal
hemorrhage ([**7-10**]) in the setting of coumadin therapy, and
residual L sided weakness, who presents with new large R frontal
and intraventricular hemorrhage. She was eating breakfast on
[**9-3**], when she suddenly developed slurred speech, L arm and leg
weakness as well as numbness. No complaints of headache. She was
taken to an OSH where her initial GCS was 14. She became
progressively more somnolent and then vomited, at which time she
was intubated. She was premedicated with lidocaine, fentanyl,
succ, etomidate, propofol and vecuronium for intubation. She is
allergic to dilantin, and was given ativan for seizure
prophylaxis, although no hx of seizure.
ROS negative for recent illness. During her hospitalization from
[**7-17**] to [**7-26**] she also had a UTI that was treated. She was d/c'ed
from [**Hospital1 18**] on [**7-26**] to rehab with notable L homonymous
hemianopsia.
Past Medical History:
1. HTN
2. Hypercholesterolemia
3. DVTs (multiple) on coumadin, INR difficult to control per
daughters, recent INR was in the range of 4.
4. Breast cancer [**2114**] s/p lumpectomy, XRT and tamoxifen. No
chemotherapy. No recurrence known.
5. Left hip replacement.
6. Recent diagnosis of CML after w/u of elevated WBC
Social History:
Patient is a very active woman who lives with a family member
but has been largely independent with most ADLs. Widow, has five
children. No known tobacco, EtOH, or illicit drug use.
Family History:
Brother - lymphoma. Son, daughter - DVTs, PE. Multiple family
members with CAD.
Physical Exam:
Physical exam on admission:
BP 210/66 HR 55 RR 16
Intubated, sedated with propofol. No evidence of head trauma.
Heart - RRR no m/r/g
Lungs - diminshed breath sounds at bases bilaterally
Abd - soft, NT/ND
Ext - warm and well perfused.
Neuro:
Not responsive to loud voice or sternal rub. R Pupil 2 mm, L
pupil 3 mm, both minimally reactive. R gaze preference, but EOMI
to dolls maneuver. +sluggish corneals bilaterally.
Minimal grimace to nasal tickle. No gag or cough. To nailbed
pressure,
withdraws RUE, extensor posturing of LUE, triple flexion in LE
bilaterally. Upgoing toes bilaterally. No spontaneous mvmts.
Pertinent Results:
[**9-3**]
CBC 27.8>38.3<175 42N 56L (smudge cells present) 2M
Na 142 K 4.5 Cl 106 CO2 22 BUN 15 Cr 0.8 Glu 146
Ca 8.3 Mg 1.6 Ph 2.8
PT 13.0 PTT 21.4 INR 1.1
[**9-8**]
U/A mod blood, +nitrite, tr protein, mod leukocytes, 11-20 WBCs
[**9-3**] Head CT - 1. New large right frontal lobe intraparenchymal
hematoma with associated intraventricular hemorrhage and slight
shift of midline structures leftward. 2. Small bilateral
subarachnoid hemorrhage in the frontal lobe regions. 3. Old
hematoma site in the right parietal lobe.
[**9-4**] Head CT - Unchanged right frontal lobe hematoma. There is
extensive adjacent vasogenic edema, with extension of acute
blood into the ventricular system, especially at the ipsilateral
lateral ventricle. Increased acute blood is also seen extending
into the subarachnoid spaces at the cerebral sulci bilaterally.
Prominence of the lateral ventricles and temporal horns persist,
and acute blood is again noted within the third and fourth
ventricles.
[**9-8**] CXR - Right lower lobe progressive consolidation,
concerning for an evolving site of pneumonia. Persistent left
retrocardiac opacity, which may be due to atelectasis or
additional site of pneumonia. Small bilateral pleural effusions.
Brief Hospital Course:
Patient is an 83 year old woman with large R frontal
intraparenchymal hemorrhage with diffuse intraventricular
extension and also subarachnoid hemorrhage.
Neuro - The patient's R frontal hemorrhage (a second hemorrhage
within 2 months), is most likely related to amyloid angiopathy.
She was evaluated by Neurosurgery in the ED; no surgical
intervention was recommended. Hyperventilated, received Mannitol
from [**9-3**] - 10/. Mild increase in edema and increased
subarachnoid hemorrhage on [**9-4**] head CT. Seizure prophylaxis
with Depakote was initiated (Dilantin allergy). Sedation with
Propofol was stopped on [**9-4**], but the patient remained minimally
responsive throughout the hospitalization.
CV - Goal SBP 130-150 initially maintained with nipride drip in
the ED; transitioned to a Labetalol drip upon admission.
Resp - Intubated, ventilated to goal pCO2 25-30. [**9-8**] CXR
revealed right lower lobe pneumonia.
FEN/GI - Initially NPO, received Famotidine. NGT feeds started
on [**9-6**].
ID - Febrile to 102 on [**9-8**]. In addition to pneumonia on CXR,
U/A c/w likely UTI.
Heme - HCT was 38.3 on admission, decreased to 25.9 on [**9-8**].
Blood loss possibly due to increasing intracranial hemorrhage,
GI losses, marrow infiltration related to CML, among other
etiologies.
Code status changed to DNR on [**9-4**]. Given the patient's poor
prognosis related to her large hemorrhage, once fever developed
on [**9-8**], and there was new evidence of likely pneumonia and UTI,
the family decided to transition to comfort measures only. The
patient was extubated, a morphine drip was initiated and
titrated for comfort. Additional medications, interventions, and
workup of anemia/infection were stopped. The patient died on
[**9-8**] after cardiorespiratory arrest, several hours after
extubation.
Medications on Admission:
Atenolol
Discharge Disposition:
Expired
Discharge Diagnosis:
R frontal intraparenchymal hemorrhage.
Discharge Condition:
Deceased.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2122-9-9**]
|
[
"486",
"V12.51",
"438.20",
"401.9",
"431",
"599.0",
"427.5",
"205.10",
"277.3",
"518.84",
"V43.64",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
5672, 5681
|
3794, 5613
|
247, 253
|
5763, 5894
|
2530, 3771
|
1798, 1879
|
5702, 5742
|
5639, 5649
|
1894, 1908
|
175, 209
|
281, 1242
|
1922, 2511
|
1264, 1582
|
1598, 1782
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,397
| 161,281
|
32566
|
Discharge summary
|
report
|
Admission Date: [**2115-11-11**] Discharge Date: [**2115-11-19**]
Service: CARDIOTHORACIC
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Transfer for cardiac catherization s/p NSTEMI found at OSH.
Major Surgical or Invasive Procedure:
Cardiac catherization [**2115-11-11**]
Coronary artery bypass graft x3 (Left internal mammary artery >
left anterior descending, saphenous vein graft > obtuse
marginal, saphenous vein graft > posterior descending artery)
[**2115-11-14**]
History of Present Illness:
Ms. [**Known lastname 75924**] is an 86 y.o. woman with hx of arthritis and
hypercholesterolemia, admitted at [**Hospital 1474**] Hospital on Saturday,
[**2115-11-9**] with c/o chest pain. The day prior to admission, the
patient had substernal, pressure-like chest pain that was
intermittent and radiated to both arms. Her arms felt
"lead-like." She denied any other associated symptoms,
including nausea, vomiting, diaphoresis, or shortness of breath.
She took aspirin in the morning and the night prior to
admission. Her chest pain progressively got worse during the
night. She thought she was having a heart attack or stroke and
told her daughter she needed to go to the hospital. Presented to
OSH and transferred for further cardiac evaluation
Past Medical History:
Arthritis
Hypercholesterolemia
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Lives in apartment attached to daughters home
Family History:
There is no family history of premature coronary artery disease
or sudden death. Her sister had a stroke around the age of
50-60. Her brother had a stent placed in his 60's. Her mother
had a stroke at 72. Her maternal aunt had a stroke in her 60's.
Physical Exam:
PHYSICAL EXAMINATION:
VS: T 98.6 147/66 74 20 97% RA; admit weight 57.9 kg
Gen: Elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple, no JVD appreciated.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. II/VI SEM heard at RUSB. No thrills, lifts.
No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Soft inspiratory
crackles at right lung base.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e. No femoral bruits.
Skin: No ulcers, scars, or xanthomas. Bilateral lower extremity
varicose veins.
.
Pulses:
Right: DP 2+ PT 1+
Left: DP 2+ PT 1+
Pertinent Results:
[**2115-11-19**] 07:20AM BLOOD WBC-8.0 RBC-4.39 Hgb-12.6 Hct-37.6 MCV-86
MCH-28.7 MCHC-33.5 RDW-14.6 Plt Ct-357#
[**2115-11-14**] 01:32PM BLOOD Neuts-66.2 Lymphs-27.0 Monos-5.2 Eos-1.4
Baso-0.2
[**2115-11-19**] 07:20AM BLOOD Plt Ct-357#
[**2115-11-14**] 02:51PM BLOOD PT-13.9* PTT-42.0* INR(PT)-1.2*
[**2115-11-11**] 04:01PM BLOOD Plt Ct-290
[**2115-11-11**] 04:01PM BLOOD PT-13.6* PTT-36.0* INR(PT)-1.2*
[**2115-11-14**] 01:32PM BLOOD Fibrino-299
[**2115-11-19**] 07:20AM BLOOD Glucose-109* UreaN-12 Creat-0.8 Na-140
K-4.0 Cl-100 HCO3-29 AnGap-15
[**2115-11-11**] 04:01PM BLOOD Glucose-103 UreaN-16 Creat-0.8 Na-132*
K-3.8 Cl-99 HCO3-27 AnGap-10
[**2115-11-14**] 06:15AM BLOOD CK(CPK)-157*
[**2115-11-14**] 06:15AM BLOOD CK-MB-6 cTropnT-2.76*
[**2115-11-19**] 07:20AM BLOOD Mg-2.0
[**2115-11-12**] 06:15AM BLOOD Triglyc-108 HDL-55 CHOL/HD-3.7
LDLcalc-127
[**2115-11-15**] 03:20PM BLOOD freeCa-1.14
[**2115-11-14**] 09:45AM BLOOD freeCa-1.14
RADIOLOGY Final Report
CHEST (PA & LAT) [**2115-11-18**] 9:21 AM
CHEST (PA & LAT)
Reason: ? effusion
[**Hospital 93**] MEDICAL CONDITION:
87 year old woman s/p CABG.
REASON FOR THIS EXAMINATION:
? effusion
HISTORY: 87-year-old female status post CABG.
PA AND LATERAL CHEST RADIOGRAPHS: Comparison is made with the
chest radiograph of [**2115-11-15**]. The sternotomy wires are unchanged
in position. There has been interval increase in left pleural
effusion and associated atelectasis. Small pleural effusion is
also noted on the right, slightly improved from the prior exam.
The upper halves of the lungs are clear. Mild cardiomegaly is
unchanged. No pneumothorax is noted.
IMPRESSION: Increase in left pleural effusion.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 95**] [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: TUE [**2115-11-19**] 9:30 AM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 75925**] (Complete)
Done [**2115-11-14**] at 11:56:12 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2028-11-9**]
Age (years): 87 F Hgt (in): 62
BP (mm Hg): 114/67 Wgt (lb): 130
HR (bpm): 56 BSA (m2): 1.59 m2
Indication: Intraoperative TEE for CABG procedure
ICD-9 Codes: 745.5, 786.51, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2115-11-14**] at 11:56 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW1-: Machine: siemens
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 40% >= 55%
Aorta - Annulus: 1.9 cm <= 3.0 cm
Aorta - Sinus Level: *4.1 cm <= 3.6 cm
Aortic Valve - Valve Area: *2.0 cm2 >= 3.0 cm2
Mitral Valve - MVA (P [**1-15**] T): 2.0 cm2
Findings
LEFT ATRIUM: Mild spontaneous echo contrast in the LAA.
Depressed LAA emptying velocity (<0.2m/s) Cannot exclude LAA
thrombus.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Left-to-right shunt
across the interatrial septum at rest. Small secundum ASD.
LEFT VENTRICLE: Mildly depressed LVEF.
RIGHT VENTRICLE: Mild global RV free wall hypokinesis.
AORTA: Moderately dilated aortic sinus. Simple atheroma in
descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild
AS (AoVA 1.2-1.9cm2). Mild to moderate ([**1-15**]+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Prebypass
1. Mild spontaneous echo contrast is present in the left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). A left atrial appendage thrombus cannot be
excluded.
2. A left-to-right shunt across the interatrial septum is seen
at rest. A small secundum atrial septal defect is present.
Overall left ventricular systolic function is mildly depressed
(LVEF= 40%).
3. There is mild global right ventricular free wall hypokinesis.
4.The aortic root is moderately dilated at the sinus level.
5.There are simple atheroma in the descending thoracic aorta.
6.The aortic valve leaflets (3) are mildly thickened. There is
mild aortic valve stenosis (area 1.2-1.9cm2). Mild to moderate
([**1-15**]+) aortic regurgitation is seen. The [**Location (un) 109**] was 1.0 when the
cardiac output was 2.3. On giving Dobutamine the cardiac output
increased to 4.0 and the [**Location (un) 109**] by planimetry and continuity
equation was 2.0.
7.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. There is a trivial/physiologic
pericardial effusion.
Post Bypass
1. Patient is being AV paced and receiving an infusion of
epinephrine.
2. Biventricular sysstolic function is unchanged.
3. Small secundum ASD still present.
4. Aorta intact post decannulation.
5. Mild mitral regurgitation persists.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician
Sinus rhythm. Occasional ventricular premature beats. Borderline
left
axis deviation. Non-specific ST-T wave changes. Compared to
tracing
of [**2115-11-11**] ventricular premature beats are new. Otherwise, no
other
significant diagnostic change.
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
65 0 90 458/466 0 -36 -20
RADIOLOGY Final Report
CAROTID SERIES COMPLETE [**2115-11-12**] 9:08 AM
CAROTID SERIES COMPLETE
Reason: evaluate for stenosis
[**Hospital 93**] MEDICAL CONDITION:
87 year old woman with NSTEMI s/p cath that showed 3VD. Pre-op
workup for possible CABG.
REASON FOR THIS EXAMINATION:
evaluate for stenosis
CAROTID SERIES COMPLETE.
REASON: Preop CABG.
FINDINGS: Duplex evaluation was performed of both carotid
arteries. Moderate plaque was identified on the left.
On the right, peak systolic velocities are 89, 70, 187 in the
ICA, CCA, ECA respectively. The ICA to CCA ratio is 1.3. This is
consistent with less than 40% stenosis.
On the left, peak systolic velocities are 124, 90, 331 in the
ICA, CCA, ECA respectively. The ICA to CCA ratio is 1.4. This is
consistent with a 40-59% stenosis, although this will fall to
the lower end of the range.
There is antegrade flow in both vertebral arteries.
IMPRESSION: Moderate left-sided plaque with a 40-59% carotid
stenosis although this will fall to the lower end of the range.
On the right, there is less than 40% carotid stenosis.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: WED [**2115-11-13**] 1:05 PM
[**2115-11-13**] 9:31 pm URINE Source: CVS.
**FINAL REPORT [**2115-11-15**]**
URINE CULTURE (Final [**2115-11-15**]): <10,000 organisms/ml.
Brief Hospital Course:
Ms. [**Known lastname 75924**] is an 86 y.o. F with h/o arthritis and
hypercholesterolemia, admitted to OSH for [**Hospital 39700**] transferred to
[**Hospital1 **] for catherization that showed 3VD, referred to cardiac
surgery for evaluation. She underwent preoperative workup and
[**11-15**] went to the operating room for coronary artery bypass
graft. See operative report for further details. She was
transferred to the CVICU in stable condition on epinephrine,
propofol and nitroglycerin drips. Extubated later that afternoon
and drips weaned over the next couple of days. Transferred to
the floor on POD #3 to begin increasing her activity level. She
had short episode of atrial fibrillation treated with beta
blockers and converted to normal sinus rhythm. Physical
followed patient during entire post-op course for strength and
mobility. She continued to make steady process and was
discharged home with VNA services on post-op day five.
Medications on Admission:
ASA 325 mg daily
Atorvastatin 80 mg daily
Isosorbide mononitrate 60 mg daily
Clopidogrel 75 mg daily (loaded [**11-9**])
Pantoprazole 40 mg daily
Metoprolol 12.5 mg [**Hospital1 **]
Magnesium oxide prn
Indomethacin prn
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. 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*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily): total
of 75mg dose .
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Bayada Nurses Inc
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Post operative atrial fibrillation
NSTEMI
Hypercholesterolemia
Arthritis
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule all appointments
Dr [**Last Name (STitle) **] 4 weeks [**Telephone/Fax (1) 170**]
Dr [**First Name (STitle) **] 1-2 weeks [**Telephone/Fax (1) 3183**]
Dr. [**Last Name (STitle) 7047**] in [**2-16**] weeks
Completed by:[**2115-11-19**]
|
[
"414.01",
"410.71",
"E878.2",
"427.31",
"272.0",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"36.12",
"39.61",
"88.72",
"99.04",
"88.53",
"88.55",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
12802, 12850
|
10552, 11503
|
297, 537
|
13000, 13007
|
2647, 3701
|
13518, 13779
|
1561, 1815
|
11772, 12779
|
9282, 9371
|
12871, 12979
|
11529, 11749
|
13031, 13495
|
1830, 1830
|
1852, 2628
|
198, 259
|
9400, 10529
|
565, 1320
|
1342, 1374
|
1390, 1545
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,565
| 110,298
|
5150
|
Discharge summary
|
report
|
Admission Date: [**2142-6-14**] Discharge Date: [**2142-6-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Mechanical ventilation
History of Present Illness:
85 year-old female with CHF (right sided), pulmonary HTN, atrial
fib, rheumatic heart disease s/p mechanical MVR, severe TR, HTN,
who presents from [**Hospital1 **] with lethargy and AMS. Recent history
is remarkable for being discharged from [**Hospital1 18**] on [**2142-6-4**] after
presenting with abdominal pain, being found to have SBO and
undergoing lysis of adhesions and left inguinal hernia repair,
with a course complicated by pneumonia for which she received
vanc/zosyn and eventually required trach/PEG for difficulty
weaning off ventilator (was unsuccessfully extubated during
hospital stay).
.
She was doing well at [**Hospital1 **] until the morning of admission
when she was noted to be more lethargic and to have AMS. At
baseline, she is alert and oriented x 3 but was less responsive.
She was brought to [**Hospital1 18**] ED for further evaluation.
.
In the ED, initial vs were: [**Age over 90 **]F->100.4 103 95/60->75/55 100% on
trach mask. She had a RUQ U/S which was negative and a CXR which
showed a RLL pneumonia, and she was given levo/flagly for
possible c. diff, and vancomycin/ceftriaxone for
healthcare-associated pna. Her mental status was waxing and
[**Doctor Last Name 688**] but she was not felt to need an LP. Her SBP rose to 95
after infusion of 3L NS. Given her transient hypotension and
concern for sepsis, she was admitted to the MICU for further
management.
.
On the floor, she was able to answer simple questions. Her
passy-muir valve had been removed but per report, even while it
was in place in the ED, she was nonverbal. She denied chest
pain, headache, shortness of breath, and pain in general.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
Cerebellar infarcts
Pancreatic cyst
Diabetes
Mitral valve disease s/p MVR with mechanical valve
Severe tricuspid regurgitation (3+)
Aortic regurgitation (1+)
History of rheumatic fever
Chronic atrial fibrillation
Congestive heart failure
Iron deficiency anemia
Hypertension
Seizure disorder
CCY
Left inguinal hernia
Social History:
No alcohol. No cigarette smoking.
Physical Exam:
Vitals: T: 97 BP: 93/48 P: 100 R: 13 O2: 100%trach mask
General: Alert but waxing and [**Doctor Last Name 688**] ability to follow simple
commands, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: decreased BS worse on right than left
CV: irregular rate and rhythm, normal S1 + S2, [**3-2**] sys murmur
Abdomen: soft, non-tender, + distended, midline scar in lower
abdomen c/d/i
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2142-6-14**] 06:15PM GLUCOSE-121* UREA N-38* CREAT-1.0 SODIUM-148*
POTASSIUM-4.1 CHLORIDE-114* TOTAL CO2-24 ANION GAP-14
[**2142-6-14**] 06:15PM CALCIUM-8.9 PHOSPHATE-4.0 MAGNESIUM-1.9
[**2142-6-14**] 06:15PM WBC-9.6# RBC-3.28*# HGB-9.4*# HCT-29.3*
MCV-89 MCH-28.5 MCHC-32.0 RDW-18.2*
[**2142-6-14**] 06:15PM PLT COUNT-238
[**2142-6-14**] 02:28PM HCT-28.8*#
[**2142-6-14**] 06:30AM GLUCOSE-121* UREA N-40* CREAT-1.0 SODIUM-145
POTASSIUM-5.7* CHLORIDE-113* TOTAL CO2-23 ANION GAP-15
[**2142-6-14**] 06:30AM ALT(SGPT)-80* AST(SGOT)-126* ALK PHOS-413*
TOT BILI-0.4
[**2142-6-14**] 06:30AM CALCIUM-7.8* PHOSPHATE-4.5 MAGNESIUM-2.0
[**2142-6-14**] 06:30AM WBC-6.2 RBC-2.47* HGB-7.2* HCT-22.6* MCV-91
MCH-29.1 MCHC-31.8 RDW-19.2*
[**2142-6-14**] 06:30AM PLT COUNT-270
[**2142-6-14**] 06:30AM PLT COUNT-270
[**2142-6-14**] 06:30AM PT-33.3* PTT-33.8 INR(PT)-3.5*
[**2142-6-14**] 04:39AM TYPE-ART O2-100 PO2-158* PCO2-53* PH-7.32*
TOTAL CO2-29 BASE XS-0 AADO2-520 REQ O2-85 INTUBATED-NOT INTUBA
[**2142-6-14**] 04:39AM LACTATE-0.8
[**2142-6-14**] 04:39AM O2 SAT-100
[**2142-6-14**] 01:35AM AMMONIA-50*
[**2142-6-13**] 10:25PM LACTATE-0.9
[**2142-6-13**] 10:10PM GLUCOSE-120* UREA N-48* CREAT-1.1 SODIUM-147*
POTASSIUM-5.0 CHLORIDE-111* TOTAL CO2-30 ANION GAP-11
[**2142-6-13**] 10:10PM ALT(SGPT)-81* AST(SGOT)-125* ALK PHOS-430*
TOT BILI-0.3
[**2142-6-13**] 10:10PM LIPASE-51
[**2142-6-13**] 10:10PM LIPASE-51
[**2142-6-13**] 10:10PM CALCIUM-8.7 PHOSPHATE-4.7*# MAGNESIUM-2.2
[**2142-6-13**] 10:10PM VIT B12-592
[**2142-6-13**] 10:10PM TSH-1.7
[**2142-6-13**] 10:10PM WBC-7.7 RBC-2.96* HGB-8.6* HCT-26.4* MCV-89
MCH-28.9 MCHC-32.5 RDW-19.3*
[**2142-6-13**] 10:10PM WBC-7.7 RBC-2.96* HGB-8.6* HCT-26.4* MCV-89
MCH-28.9 MCHC-32.5 RDW-19.3*
[**2142-6-13**] 10:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2142-6-13**] 10:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2142-6-13**] 10:10PM URINE RBC-0-2 WBC-[**3-29**] BACTERIA-FEW YEAST-MOD
EPI-0-2
**FINAL REPORT [**2142-6-19**]**
GRAM STAIN (Final [**2142-6-16**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2142-6-19**]):
OROPHARYNGEAL FLORA ABSENT.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. SPARSE
GROWTH.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. RARE
GROWTH.
SECOND COLONY TYPE.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STENOTROPHOMONAS (XANTHOMONAS)
MALTOPHILIA
| STENOTROPHOMONAS
(XANTHOMONAS) MALTOPH
| |
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
--------------------
CT CHEST W/O CONTRAST Study Date of [**2142-6-14**] 11:47 AM
IMPRESSION:
1. Severe multi-chamber cardiomegaly. Pulmonary hypertension.
2. Suspected tracheobronchomalacia.
3. Bibasilar extensive consolidations accompanied by volume loss
that might be considered for a combination of atelectasis and
pneumonia. Small bilateral pleural effusions.
4. Upper lung opacities that might represent infection versus
pulmonary dema. Pulmonary hemorrhage cannot be excluded but
should be correlated with clinical findings.
5. Extreme kyphosis due to the presence of multiple thoracic
fractures is described in detail within the text.
ECHO [**2142-6-14**]
The left atrium is markedly dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is
10-20mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). The
right ventricular cavity is moderately dilated with normal free
wall contractility. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Mild
(1+) aortic regurgitation is seen. A bileaflet mitral valve
prosthesis is present. The prosthetic mitral valve disks appears
slightly thickened, but open normally. The mean gradient (9
mmHg) is higher than expected for this type of prosthesis.
Trivial mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] Severe [4+] tricuspid
regurgitation is seen. Given estimated RA pressures, pulmonary
artery systolic hypertension is estimated as severe. There is no
pericardial effusion.
IMPRESSION: Dilated right ventricle. Normal global and regional
left ventricular systolic function. Mild aortic regurgitation.
Bileaflet mitral valve prosthesis with higher-than-normal
gradients. Severe tricuspid regurgitation. Probably severe
pulmonary hypertension.
Brief Hospital Course:
85 year-old female with CHF (right sided), pulmonary HTN, atrial
fib, rheumatic heart disease s/p mechanical MVR, severe TR, HTN,
who presents with AMS and question sepsis.
# Pneumonia/respiratory failure: She was admitted with altered
mental status and met SIRS criteria with fever and tachycardia,
with infiltrates later seen on chest CT. She was treated for
healthcare-associated pneumonia with vancomycin and ceftazidime.
Cultures eventually grew stenotrophomonas sensitive to bactrim
but this was thought to repesent colonization rather than
infection. She is to complete a seven day course of antibiotics
with last doses on [**6-21**], and a PICC was placed to facilitate
this. She continued to require intermittent respiratory support
with mechanical ventilation, particularly overnight when there
was concern for tiring. During the day time, she was typically
placed on trach collar. She was also diuresed intermittently
because her chest x-ray demonstrated some pulmonary edema and
pleural effusions. However, at times her systolic blood
pressure fell to the 80s with diuresis. Her lasix dose will
need continued adjustment to optimize her volume status.
# Altered mental status: She was lethargic and minimally
arousable at presentation but had an arterial blood glass that
demonstrated a normal pH. Her altered mental status was thought
to be secondary to infection and improved with treatment of
pneumonia. TSH, B12, and RPR were negative.
# Atrial fibrillation: She was previously on metoprolol but was
started on digoxin during [**Month (only) 547**]-[**2142-5-25**] hospitalization after
cardiology consultation. Digoxin level at presentation was
normal at 1.7. However, because her ventricular rate was high in
the 120s at times, she was started on metoprolol. Her warfarin
was initially held in the setting of antibiotics and an INR>3
but restarted.
# Mitral valve replacement: Mechanical valve per report and
history of rheumatic heart disease. She was continued on
warfarin as described above.
# Communication: Son is [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 21092**], [**First Name4 (NamePattern1) **] [**Known lastname **] is
daugther [**Telephone/Fax (1) 21093**].
Medications on Admission:
Digoxin 0.125 mg daily
Colace, Senna
MVI
Insulin SS
Coumadin 5 mg po qd
Bactrim 800-160 q12 hr
Discharge Medications:
1. Pneumococcal 23-ValPS Vaccine 25 mcg/0.5 mL Injectable Sig:
One (1) ML Injection ASDIR (AS DIRECTED).
2. Digoxin 50 mcg/mL Solution Sig: 0.125 mg PO DAILY (Daily):
PEG TUBE.
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): PEG TUBE.
4. Therapeutic Multivitamin Liquid Sig: One (1) Tablet PO
DAILY (Daily): PEG TUBE.
5. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) MG
PO BID (2 times a day): PEG TUBE.
6. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed for bm: PEG TUBE.
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: PEG TUBE.
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day): PEG TUBE.
9. Ceftazidime 1 gram Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours) for 2 days: LAST DOSE 5/28.
10. Vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
MG Intravenous Q 12H (Every 12 Hours) for 2 days: LAST DOSE
[**6-21**].
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: PEG
TUBE.
12. Insulin Lispro 100 unit/mL Solution Sig: PER INSULIN SLIDING
SCALE Subcutaneous ASDIR (AS DIRECTED): PER INSULIN SLIDING
SCALE (NO CHANGES MADE DURING ADMISSION).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Ventilator associated pneumonia
Respiratory failure
Right ventricular failure
Atrial fibrillation
Secondary:
Mitral valve replacement
Discharge Condition:
Good
Discharge Instructions:
You were admitted because of a change in your mental status. We
diagnosed you with pneumonia and treated you with antibiotics.
We also helped remove some fluid from your lungs.
Please take all of your medications as prescribed. Please keep
all of your follow-up appointments. Continue your antibiotics
until [**6-21**].
Please call your doctor or return to the hospital if you
experience fevers, chills, sweats, chest pain, shortness of
breath or anything else of concern.
Followup Instructions:
Please contact your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] an
appointment within the next one week.
Completed by:[**2142-6-19**]
|
[
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"349.82",
"250.00",
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"997.31",
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"V58.61",
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"345.90"
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11918, 11984
|
8324, 9509
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291, 315
|
12172, 12178
|
3322, 8301
|
12704, 12868
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10692, 11895
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10572, 10669
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12202, 12681
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2792, 3303
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2006, 2386
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230, 253
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343, 1987
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9524, 10546
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2408, 2726
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2742, 2777
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,709
| 163,252
|
45869
|
Discharge summary
|
report
|
Admission Date: [**2112-7-17**] Discharge Date: [**2112-7-26**]
Date of Birth: [**2029-3-16**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Lethargy, AMS
Major Surgical or Invasive Procedure:
RIJ placement
Endotracheal intubation
History of Present Illness:
83yoM with h/o RCC s/p nephrectomy [**2085**] (with dural infiltration
s/p decompression laminectomy at C2-3; s/p upper C-spine
irradiation), CAD s/p MI, CRI baseline Cr 1.2-1.6, AAA s/p EVAR
[**7-/2111**], and recent R hip replacement.
Pt was admitted to [**Hospital6 **] after a fall and had a R
total hip replacement on [**6-17**]. Per family, was in their ICU
for "breathing not well and low oxygen level" but was not
intubated. He was treated with IV ABx for PNA but details
unknown. He was given 6u PRBC's for post-op bleeding. He had
some "fibrillation" which the family was told was normal
post-op. Called out to Cards floor. Spent total 10d in the
hospital, d/c [**6-28**] to [**Hospital1 599**] [**Location (un) 55**] rehab.
In the rehab, was given Lasix for volume overload and Oxycodone
for pain control; both of which the pt's family feel were given
but not monitored much. Overall, he was doing well, working with
PT, and improving. Then, he had a fall 3d prior to arrival onto
his L hip (contralateral to operation), for which he went to his
Orthopedist 2d prior and the family states had X-rays and
everything was called as OK.
He was found to be lethargic at the nursing home on day of
admission, and per family he is more confused, very weak, and
not acting himself. Medics noted him to be moving all
extremities, without focal weakness and gave him 250 cc NS en
route. The family denies any f/c/sweats, n/v/abd
pain/diarrhea/constipation, CP, palpitations, SOB, urinary sxs,
CVA sxs, tingling/numbness.
In the ED initial VS: 98.5 103 90/49 18 92%. He had a CT
head which showed no acute hemorrhage but with small hypodensity
in R putamen new from [**2108**], and possibly small interval lacunar
infarct. He was guaic negative. CXR's had to be done a couple
times due to poor imaging, but eventually showed opacity at lung
bases, L>R called as PNA vs atelectasis.
He was febrile in the ED at 2pm to 102, so got 1g of Tylenol.
His systolics were 80-90's through the ED so given 2L IVF's with
improvement to 110; but then dropped to 70's and so got 3rd and
4th L's of NS and RIJ placed, started on Levophed, on small dose
before transfer 0.03 mcg/kg/min with improvement in SBP to 120's
by transfer to MICU. Total in ED = 5L NS, also got Zosyn IV, 1g
IV Vancomycin. VS before admission: 102.2, 78, 120/77, 22, 95%
3L ROS as above. Otherwise, negative all other systems per
family.
Past Medical History:
- RCC s/p nephrectomy [**2085**] with dural infiltration s/p
decompression laminectomy at C2-3 in [**10/2107**]; s/p upper cervical
spine irradiation completed in [**11/2107**] -> being followed by [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 724**]
- CAD s/p MI ~20 yrs ago and not currently active, family denies
CABG or caths
- CRI, with baseline Cr 1.2-1.6
- Complex infrarenal aortic aneurysm, s/p EVAR in [**7-/2111**]
- Left hip dhs [**4-/2106**], complicated by failure of fixation,
converted to a left bipolar arthroplasty on [**5-/2106**], then
revision arthroplasty of the left hip and removal of a left
femur blade plate [**9-14**]
- R hip surgery in [**6-/2112**] for displaced R femoral neck fracture
- H/o falls and gait disturbance
- MRSA bacteremia [**2112-7-17**]
Social History:
Patient was living in [**Location (un) 55**] before the R hip replacement
with wife of 60 years, but was discharged to [**Location (un) 55**] [**Hospital1 599**]
after. 1 ppd x60 yrs and was smoking up until 4 wks ago, drinks
1-2 drinks of vodka (1 oz) daily, no illicits. 4 children, many
grandchildren, 2 great grandchildren
Family History:
Reviewed and non-contributory
Physical Exam:
ADMISSION
101.8 112/59 76 21 97%3L NC
Elderly gentleman laying in bed, awakens to voice, answers
questions. He looks lethargic and ill, but not frankly toxic and
not in distress. EOMI, pupils 3->2, sclera normal. Mouth with
very dry appearing tongue and chapped lips. RIJ in place,
difficult to assess JVP but not grossly distended.
Poor to fair air movement with light sounding paninspiratory
"dry" sounding crackles at the bases, very light
RRR without AS type murmur overlying S1, but with present S2.
Abd soft NT ND, benign
Bilateral hips are normal appearing no erythema, warmth,
swelling, TTP
Upper LUE with large ecchymoses on medial aspect. BLE with 1-2+
pitting edema to mid shin. Extremities are all warm, well
perfused, no mottling. Bilateral DP's and radials difficult to
palpate. L heel with an unstageable ulcer with a black eschar
overlying, and surrounding area of erthythema.
CN 2-12 grossly intact, able to move extremities, following
commands, oriented to [**Hospital1 **], person, and that he had a R hip
surgery, but not date
FEX ON DISCHARGE
T 98.2 BP 112/64 HR 60 RR 18 100%2LNC
GENERAL: Elderly gentleman lying comfortably in bed. NAD AAOx3
HEENT: EOMI, anicteric, MMM, oropharnyx clear
NECK: Supple, no JVD or LAD
HEART: II/VI systolic ejection murmur heard diffusely across
precordium
RESPIRATORY: Non labored, speaking in full sentences with 2LNC.
Soft crackles over bases bilaterally
GI: NT/ND. Normoactive BS. No HSM or masses noted.
EXTREMITIES: +1 pitting edema rt leg up to knee. Left heel ulcer
unchanged: 1x2 cm closed lesion with eschar with surrounding
erythema. Dressed. Rt hip without pain with passive flexion to
90 degress with internal and external rotation.
NEURO: CNII-XII intact. No gross sensory or motor losses,
although patient requires assist out of bed to chair.
Pertinent Results:
See WebOMR
Brief Hospital Course:
1. MRSA BACTERMIA/SEPTIC SHOCK: In MICU, pt continued IVF's and
pressors were eventually able to be weaned. He was started on
Vanc/Zosyn/Levaquin intially but transitioned to vancomycin
alone after multiple blood cultures showed MRSA. Source of
infection was sought, but could not be definitevely determined.
Right hip aspiration yielded small amount of fluid which was not
infected by either gram stain or culture. MRI of left foot did
not show osteomyelitis. CT of abdomen revealed AAA graft in good
condition. Patient could not tolerate TEE to evaluate for
endocarditis. Patient was continued on vancomycin for planned 6
week treatment. Patient was discharged afebrile >72 hours with
blood cultures NGTD from both [**7-21**] and [**7-22**]. He is to follow up
in ID, orthopedic, and vascular clinic.
2. ACUTE ON CHRONIC RENAL FAILURE: Cr 2.2 on admission was above
baseline 1.6-1.7. Improved to 1.7 by MICU callout with IVF's and
patient was discharged with Cr of 1.6. Diuresis was reinstated
upon return of baseline kidney function.
3. HEEL ULCER/CELLULITIS: This was evaluated by infectious
disease, podiatry, and vascular surgery. MRI was performed and
did not show evidence of osteomylelitis. It is not felt that
this was the cause of his bacteremia. Arterial duplex showed
evidence of PVD and vascular surgery felt that he may benefit
from revascularization. Angiography has been scheduled for a
week after discharge, but it remains unclear if the patient and
family want to pursue this.
4. ATRIAL FIBRILLATION: Patient was noted to be in atrial
fibrillation with RVR on [**7-20**]. He responed well to his oral
metoprolol tartrate dose of 25mg. The following day he was
increased to 37.5 mg metoprolol tartrate [**Hospital1 **] and his rate
remained well controlled. He spontaneously reverted back to NSR
on [**7-25**] per telemetry. He was discharged on metoprolol succinate
100 daily and amiodarone 200 daily. Prophylaxis was originally
[**Date Range **] 325 daily. Coumadin 2.5 mg daily was started prior to
discharge. He is to follow up with his cardiologist.
5. ANEMIA OF INFLAMMATION: His Hct on admission was 25-30, but
drifted down during his stay. This is likely due to frequent
phlebotomy and poor production due to inflammation and CKD. He
was offered transfusion but declined. His hematocrit was 22 on
the day of discharge.
6. NSTEMI: In the unit, he had non-specific ST segment changes
that were likely rate related compared to prior EKG. His
troponin rose from 0.07 to peak 0.18 then downtrended with
negative MB fraction. Echo was done to evaluate for valvular
infection and for LV function which was suboptimal due to
habitus. Suspect demand ischemia in setting of sepsis. Patient
is to follow up with his his cardiologist.
CHRONIC PROBLEMS
1. Infrarenal AAA s/p EVAR repair 8/[**2110**]. Stable. Graft noted to
be stable on multiple radiographic studies.
2. Movement disorder NOS: Per OMR, patient with movement
disorder NOS. He was restarted on his home dosing of
carbidopa-levodopa on admission to the floor.
3. Mood disorder: Patient was continued on his home cymbalta
20mg.
4. BPH: Patient was restarted on his home finasteride and
tamsulosin once blood pressures stabilized.
OUTSTANDING STUDIES
-Blood Cx final reports for [**7-21**] [**7-22**] and [**7-25**]
-Final report for LRE US [**7-26**]. Preliminary read negative for DVT
-Prealbumin
TRANSITIONAL ISSUES
-[**Month (only) 116**] consider ACEI or [**Last Name (un) **] in this patient
-Will need monitoring of INR
-Will need follow up of HCT
-Will follow up with vascular surgery to evaluate for PAD
Medications on Admission:
- Amiodarone 200 mg daily
- [**Last Name (un) **] 325 mg [**Hospital1 **] (?)
- Carbidopa-Levodopa 25-100 -> 3 "half" tablets PO bid
- Cymbalta 20 mg daily
- Finasteride 5 mg daily
- Lipitor 20 mg daily
- Metoprolol 25 mg [**Hospital1 **]
- Pantoprazole 40 mg daily
- Potasssium Cl 20 mEq daily
- Spiriva 18 mcg handihaler
- Tamsulosin 0.4 mg daily
- Tylenol prn
- Bisacodyl prn
- Fleet enema
- Milk of Magnesia prn
- Oxycodone 5mg prn pain
- Multivitamin daily
- Tums 500 mg tid
- Lasix 60 mg PO MWF
- Trazadone 25 mg PO hs
- Colace 200 mg daily
- Senokot 8.6 mg 2 tabs daily
- Duonebs 0.5 mg / 3 mg q4 prn
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. amiodarone 200 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. carbidopa-levodopa 25-100 mg Tablet Sig: 1.5 (one and a half)
Tablets PO BID (2 times a day).
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
8. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
11. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
12. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) cap Inhalation once a day.
13. potassium chloride 20 mEq Packet Sig: One (1) packet PO once
a day.
14. multivitamin Tablet Sig: One (1) Tablet PO once a day.
15. [**Hospital1 **] 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
16. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain. Tablet(s)
18. Lasix 20 mg Tablet Sig: Three (3) Tablet PO 3 times a week:
Monday, Wednesday, Friday.
19. trazodone 50 mg Tablet Sig: 0.5 (one half) Tablet PO at
bedtime as needed for insomnia.
20. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) treatment Inhalation every 4-6 hours
as needed for shortness of breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Primary:
- MRSA bacteremia and septic shock
- NSTEMI
- Anemia of inflammation
- LLE heel ulcer and cellulitis
- Peripheral vascular disease
- Atrial fibrillation with RVR
- Acute on chronic renal failure
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital because your family the staff
at your rehabilitation facility were concerned you were becoming
more lethargic. We found out that you had a serious infection in
your blood caused by MRSA. This infection was likely coming from
the ulcer on your left foot, but we can't be 100% sure. We took
fluid from your right hip, which didn't look infected, and also
scanned your AAA repair graft, which looked good as well. We
tried to get an ultrasound of your heart to evaluate if your had
an infection of your heart valves, but we couldn't get a good
picture. As a result, we will treat you with 6 weeks of IV
antibiotics. Additionally, we will have you follow up with the
vascular surgeons to make sure you have enough blood flow to
your left heel to fight the infection.
Also, while you were here we noticed you have an abnormal heart
rhythm called atrial fibrillation. We can control the rate of
your heart with medicines, but you do have an increased risk of
stroke. We started you on a blood thinning medication called
coumadin to help prevent a stroke. You will need to get your
blood levels (INR) checked frequently while on coumadin. You
should follow up with your cardiologist to follow this heart
rhythm. Finally, on the day of your discharge, we noted that
your blood count was below the value recommended for someone
with heart disease. We offered you a blood transfusion, which
you declinced knowing the risks and benefits of a transfusion.
Please note the following changes to your medications:
START Vancomycin 1 g every day intravenously through [**9-5**].
START Coumadin 2.5 mg daily and then as instructed by your
doctor
[**First Name (Titles) **] [**Last Name (Titles) 9766**] to 81mg daily
INCREASE Metoprolol to 100mg daily
No other changes were made to your medications. Please attend
the following appointments we have made for you. It has been a
pleasure taking care of you.
Followup Instructions:
Name: [**Last Name (LF) 1147**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 822**]
Phone: [**0-0-**]
Appointment: Tuesday [**2112-8-2**] 11:30am
Name: [**Last Name (LF) 7111**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: PRO SPORTS ORTHOPEDICS, INC.
Address: [**Street Address(2) **], [**Apartment Address(1) 4473**], [**Location (un) **],[**Numeric Identifier 1415**]
Phone: [**Telephone/Fax (1) 32114**]
Appointment: Friday [**2112-8-5**] 11:15am
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2112-8-17**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: VASCULAR SURGERY
When: TUESDAY [**2112-8-30**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: RADIOLOGY
When: TUESDAY [**2112-8-30**] at 1 PM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
[
"300.00",
"600.00",
"428.31",
"682.7",
"427.31",
"403.90",
"V10.52",
"707.20",
"253.6",
"995.92",
"428.0",
"443.9",
"707.07",
"V43.64",
"038.12",
"785.52",
"781.0",
"263.0",
"584.9",
"781.2",
"285.21",
"280.9",
"414.01",
"410.71",
"585.3",
"296.90",
"348.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"88.72",
"83.95"
] |
icd9pcs
|
[
[
[]
]
] |
12124, 12218
|
5898, 9497
|
316, 356
|
12466, 12513
|
5863, 5875
|
14627, 16174
|
3976, 4007
|
10156, 12101
|
12239, 12445
|
9523, 10133
|
12644, 14183
|
4022, 5844
|
14212, 14604
|
263, 278
|
384, 2792
|
12528, 12620
|
2814, 3615
|
3631, 3960
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,763
| 161,293
|
10392+56139
|
Discharge summary
|
report+addendum
|
Admission Date: [**2152-7-14**] Discharge Date: [**2152-7-17**]
Date of Birth: [**2108-4-25**] Sex: F
Service: SURGERY
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
[**2152-7-17**]: Colonoscopy
History of Present Illness:
This is a 44 year-old women with longstanding IDDM complicated
by ESRD s/p transplant in [**2147**] as well as a more recent
diagnosis of severe diffuse mesenteric ischemia who presented to
the ER last night with BRBPR. In addition she was admitted
[**6-28**]/to [**6-30**] with hematochezia. She was treated
conservatively with hydration and IV antibiotics for presumed
ischemic colitis and discharged home OFF antibiotics. She had
felt well up until the day prior to admission. No abdominal pain
or cramping. She did have some non-bloody diarrhea which has
resolved. She denies light headedness or syncope
Past Medical History:
-LRRT [**1-19**], 2 episodes acute rejection
-CAD s/p MI, EF 20%
-htn
-DM1
-[**4-24**] percutaneous balloon expandable stenting of the left
common iliac artery, percutaneous balloon angioplasty of the
right SFA and above-the-knee popliteal followed by stenting for
flow-limiting dissection of the distal SFA. Percutaneous balloon
angioplasty of theorigin of the right anterior tibialis.
-Mesenteric ischemia with superior mesenteric artery stenosis.
-squamous cell CA, right arm, left leg: removed
-BRBPR [**2152-7-14**], transfused. Colonoscopy: friable polyps and
ulcerated area. Bx'd
Social History:
married, currently not working. Lives in 2 level house. Has had
AllCare VNA in past.
Family History:
N/C
Physical Exam:
VS: 97.5, 93, 116/75, 20, 100%RA
Gen: NAD, A+Ox3
Skin: no rash, non-icteric
Card: RRR
Lungs: CTA bilaterally
Abd: Soft, non-tender, non-distended no rebound, guarding
Rectal exam: clotted blood at anus
Extr: no edema
Pertinent Results:
[**2152-7-13**] 09:40PM WBC-9.5 RBC-4.62 Hgb-12.2 Hct-38.7 MCV-84
MCH-26.3* MCHC-31.4 RDW-14.7 Plt Ct-395
[**2152-7-14**] 01:45AM WBC-9.1 RBC-3.03*# Hgb-8.1*# Hct-25.5*# MCV-84
MCH-26.6* MCHC-31.6 RDW-15.2 Plt Ct-331
[**2152-7-13**] PT-13.8* PTT-25.0 INR(PT)-1.2*
[**2152-7-13**] Glucose-591* UreaN-32* Creat-1.5* Na-133 K-5.3* Cl-98
HCO3-24 AnGap-16
[**2152-7-17**] Glucose-169* UreaN-18 Creat-1.2* Na-138 K-4.1 Cl-105
HCO3-24 AnGap-13
[**2152-7-13**] ALT-32 AST-27 CK(CPK)-22* AlkPhos-120* TotBili-0.2
[**2152-7-17**] tacroFK-7.6
[**2152-7-17**] 05:32AM BLOOD WBC-5.4 RBC-4.53 Hgb-12.6 Hct-37.9 MCV-84
MCH-27.9 MCHC-33.3 RDW-15.6* Plt Ct-271
[**2152-7-17**] 05:32AM BLOOD Glucose-169* UreaN-18 Creat-1.2* Na-138
K-4.1 Cl-105 HCO3-24 AnGap-13
[**2152-7-17**] 05:32AM BLOOD Calcium-9.2 Phos-3.5 Mg-1.5*
Brief Hospital Course:
44 y/o female admitted with BRBPR and Hct drop from 38.7% to
25.5%. She was admitted to the SICU and received four units of
packed cells, with subsequent resonse to 40%. Over the next few
days her Hct remained stable with no further bleeding noted, Hct
at discharge was 37.9%.
GI was consulted and a colonoscopy was performed after an bowel
prep with IV hydration to prevent dehydration given ischemic
bowel. She tolerated the prep and underwent the colonoscopy on
[**7-17**].
Results as follows:
Presumed pseudopolyps scattered throughout the descending and
transverse colon (biopsy)
Severe circumferential ulceration beginning at 90cm (biopsy)
Otherwise normal colonoscopy to 90 cm
Recommendations: Follow up biopsies
Resume ASA/Plavix and consider right hemicolectomy as below
Additional notes: The patient likely bled from the ulcerated
area at 90cm and this is likely ischemic in nature. We elected
not to continue the exam because of the severity of the
inflammation and risk of perforation. Although the smaller left
sided pseudopolyps could have bled, these are less likely to
account for the magnitude of her HCT drop. Would restart
ASA/Plavix while awaiting biopsies. The risk of rebleeding is
exceedingly high but, so is the risk of infarction.
Post colonoscopy, vital signs were stable and she felt well
without any abdominal pain. Findings were communicated to the
surgeon. Aspirin and plavix were resumed and she was discharged
home with instruction to hydrate well and call with any
bleeding, abdominal pain or dizziness/lightheadedness.
Podiatry saw her to evaluate a right heel ulcer. This appeared
to be healing well.
She was discharged home in stable condition with a follow up
appointment arranged on [**7-20**] with Dr. [**Last Name (STitle) 816**].
Medications on Admission:
pravachol 10', FK [**1-18**], Pred 5, Plavix 75, ASA 325', Lantus
16qam, RISS, Protonix
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
4. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
5. Insulin Glargine 100 unit/mL Solution Sig: Sixteen (16) units
Subcutaneous once a day: Continue sliding scale insulin per home
routine.
6. Pravachol 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. Bactrim 80-400 mg Tablet Sig: One (1) Tablet PO once a day.
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
LGI bleeding
intestinal friable polyps, ulceration
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Please monitor for rectal bleeding or evidence of bleeding such
as nosebleeds or easy bruising as you are restarting the Aspirin
and Plavix.
Continue labwork per transplant clinic recommendations
Followup Instructions:
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2152-7-20**] 9:00
VASCULAR LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2152-8-2**] 11:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2152-8-2**]
12:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2152-7-17**] Name: [**Known lastname 6056**],[**Known firstname **] Unit No: [**Numeric Identifier 6057**]
Admission Date: [**2152-7-14**] Discharge Date: [**2152-7-17**]
Date of Birth: [**2108-4-25**] Sex: F
Service: SURGERY
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 48**]
Addendum:
CHF, chronic
Anemia secondary to lower GI bleeding
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**] MD, [**MD Number(3) 52**]
Completed by:[**2152-8-11**]
|
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"V58.66",
"403.91",
"557.1",
"412",
"707.14",
"V15.82",
"428.0",
"250.61",
"583.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"99.04",
"45.25"
] |
icd9pcs
|
[
[
[]
]
] |
6844, 7004
|
2783, 4559
|
299, 330
|
5553, 5560
|
1955, 2760
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5905, 6821
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1698, 1703
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4698, 5429
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5479, 5532
|
4585, 4675
|
5584, 5882
|
1718, 1936
|
232, 261
|
358, 968
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990, 1579
|
1595, 1682
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,043
| 102,173
|
14225+14226
|
Discharge summary
|
report+report
|
Admission Date: [**2176-7-5**] Discharge Date: [**2176-7-7**]
Service: SURGERY
Allergies:
Amoxicillin / Penicillins / Coumadin / Oxycodone / Megestrol
Acetate / Remeron / Ritalin
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Free air on CXR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 87 y/o male with extensive past medical history who
was recently discharged after admission for possible
meningitis/altered mental status. During that admission the
patient was found to be a significant aspiration risk and a
G-tube was placed by interventional radiology. He was discharged
to [**Hospital **] rehab in good condition off all antibiotics on [**7-4**].
He
presents today after a routine CXR was performed at [**Hospital **] rehab
which demonstrated free intra-abdominal air beneath the right
hemidiaphragm. The patient was subsequently transfered to [**Hospital1 18**]
for evaluation. At the time of presentation he was in no acute
distress, without complaints of pain, nausea/vomiting,
fever/chills. He had a suprapubic catheter which was
functioning
appropriately as well as a flexi-seal rectal tube which was
collecting appropriate volumes of stool.
Past Medical History:
-DM II, on insulin
-prostate CA s/p XRT [**2156**]
-chronic urinary incontinence, s/p TURP [**10-6**]
-history of UTIs, including prior MRSA, klebsiella, proteus,
pseuduomonas
-s/p bladder rupture and repair x2, [**2-8**], [**6-8**]
-atrial fibrillation, not anticoagulated due to h/o bleeding
-hyperthyroidism
-depression
-hypertension
-moderate aortic stenosis on TTE [**5-/2176**]
-peripheral vascular disease
-h/o CVA [**2172**]
-severe chronic axonal neuropathy, radiculopathy and plexopathy
(due to XRT) per Dr. [**Last Name (STitle) **], with right foot drop for many
years
-L3 compression fracture
-cataract s/p bilateral laser surgery, also with "macular edema"
s/p dexamethasone injection
-hard of hearing
-left thyroid nodule, benign
Social History:
Smoked 2 ppd tobacco x24 years. Quit in [**2137**]. Denies EtOH.
Former WWII vet. Former Fire Fighter. Wife is HCP. Daughter is
RN, son is engineer.
Family History:
No illnesses, strokes, DM or early heart attacks run in the
family.
Physical Exam:
On Admission
GEN: NAD
HEENT: AT/NC, EOMI, neck supple, trachea midline
CV: Irregular, no m/g/r
RESP: CTAB
ABD: soft, non-tender, non-distended, no rebound, no guarding,
no
external evidence of injury, no gross masses, midline
infra-umbilical incision well healed. L midline; G-tube secured,
no surrounding erythema or discharge. Suprapubic catheter,
secured, no discharge/erythema. Rectal tube in place
EXT: no C/C/E
TLD: R PICC
Pertinent Results:
[**2176-7-4**] 05:55AM BLOOD WBC-5.8 RBC-2.50* Hgb-7.5* Hct-23.8*
MCV-95 MCH-29.8 MCHC-31.3 RDW-17.1* Plt Ct-396
[**2176-7-4**] 05:55AM BLOOD Plt Ct-396
[**2176-7-4**] 05:55AM BLOOD Glucose-116* UreaN-31* Creat-1.7* Na-147*
K-4.3 Cl-118* HCO3-23 AnGap-10
[**2176-7-4**] 05:55AM BLOOD Calcium-8.0* Phos-2.5* Mg-2.2
Radiology Report CHEST (PA & LAT) Study Date of [**2176-7-5**] 2:22 PM
FINDINGS: Comparison made to 5/28/200, and to fluoroscopy from
GJ tube
placement [**2176-7-3**].
Free intraperitoneal air under both hemidiaphragms is not
unexpected following recent G-tube placement. Cardiomediastinal
contours are unchanged. The lungs are grossly clear and well
expanded. Right PICC terminates in the mid SVC. There is no
pleural effusion or pneumothorax.
Radiology Report CHEST (PA & LAT) Study Date of [**2176-7-6**] 2:22 PM
FINDINGS: There is a moderate amount of free air seen under the
right
hemidiaphragm extending across the midline. The amount on the
right is
similar compared to prior. The amount on the left is slightly
less. _____
tube is again seen over the left upper quadrant. There is patchy
atelectasis in the left lower lung. The right subclavian PICC
line is unchanged.
Brief Hospital Course:
Pt admitted to observation due to free air seen on CXR s/p PEG
placement. Abdominal exam benign during hospital course. Free
air stable on serial CXR. Tube feeds via g-tube resumed and
advanced and tolerated well. Pt discharged back to rehab
facility [**2172-7-5**].
Medications on Admission:
1. Phenytoin 125 mg/5 mL Suspension Sig: One (1) PO TID (3
times a day).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
7. Insulin Glargine 100 unit/mL Cartridge Sig: Six (6) Units
Subcutaneous at bedtime.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Phenytoin 125 mg/5 mL Suspension Sig: One [**Age over 90 **]y Five
(125) mg PO TID (3 times a day).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
4. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for fungus.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. Colace 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO twice a
day as needed for constipation.
7. Lantus 100 unit/mL Solution Sig: Six (6) Units Subcutaneous
at bedtime.
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units SC Injection TID (3 times a day).
10. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Free air on CXR s/p G-tube placement
Discharge Condition:
Good
Discharge Instructions:
Please call your surgeon if you develop chest pain, shortness of
breath, fever greater than 101.5, severe abdominal pain or
distention, persistent nausea or vomiting, inability to eat or
drink, or any other symptoms which are concerning to you.
Activity: No heavy lifting of items [**11-14**] pounds until the
follow up appointment with your doctor.
Medications: Resume your home medications. You should take a
stool softener, Colace 100 mg twice daily as needed for
constipation. Pain medication may make you drowsy. No driving
while taking pain medicine.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7025**], MD Phone:[**Telephone/Fax (1) 5285**]
Date/Time:[**2176-8-8**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2176-8-9**] 11:00
Please call the office of Dr.[**Last Name (STitle) **] at ([**Telephone/Fax (1) 9000**] to schedule
a follow-up appointment.
Admission Date: [**2176-7-8**] Discharge Date: [**2176-7-10**]
Service: MEDICINE
Allergies:
Amoxicillin / Penicillins / Coumadin / Oxycodone / Megestrol
Acetate / Remeron / Ritalin
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Hematuria
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 42290**] is an 87 year old male with a history of bladder
ruptures x 2, s/p intraperitoneal bladder rupture managed by
operative repair on [**2176-6-4**] with insertion of suprapubic tube and
foley catheter sent from [**Hospital 100**] Rehab for bleeding from 3-way
catether and suprapubic catheter. He also complains of some
suprapubic pain. Of note, patient has a PICC line, and he had
TPA x3 for PICC line in the recent past.
In the ED, initial VS: T 97.9 HR 68 BP 160/94 RR 18 O2 100%
RA. Had Afib with RVR between 80-140s, but then got evening
lopressor --> now HR 80-90. Labs including blood cultures/urine
culturese were sent. Ceftazidine x 1 gm IV was given in ED for
possible cysitits as well as 1 L NS. Also given lopressor 5 mg
IV x 1 and metoprolol 25 mg po daily. Urology consulted in the
ED, who recommended the following: make sure suprapubic catheter
flushes, and if so, run CBI through suprapubic catheter, capping
off 3-way catheter and allow NS to drain to gravity. Continue
suprapubic irrigation at 2 drips per second. This is goal for
avoiding clotting and not for clearing of hematuria. Patient
has bladder capacity 20 cc per urology.
The patient is being admitted to the MICU for q 1 hour bladder
checks and CBI for tenuous bladder. He can only complain of his
penis and anus hurting.
Review of systems: Unable to obtain as pt unable to cooperative
Past Medical History:
-DM II, on insulin
-prostate CA s/p XRT [**2156**]
-chronic urinary incontinence, s/p TURP [**10-6**]
-history of UTIs, including prior MRSA, klebsiella, proteus,
pseuduomonas
-s/p bladder rupture and repair x2, [**2-8**], [**6-8**]
-atrial fibrillation, not anticoagulated due to h/o bleeding
-hyperthyroidism
-depression
-hypertension
-moderate aortic stenosis on TTE [**5-/2176**]
-peripheral vascular disease
-h/o CVA [**2172**]
-severe chronic axonal neuropathy, radiculopathy and plexopathy
(due to XRT) per Dr. [**Last Name (STitle) **], with right foot drop for many
years
-L3 compression fracture
-cataract s/p bilateral laser surgery, also with "macular edema"
s/p dexamethasone injection
-hard of hearing
-left thyroid nodule, benign
Social History:
Smoked 2 ppd tobacco x24 years. Quit in [**2137**]. Denies EtOH.
Former WWII vet. Former Fire Fighter. Wife is HCP. Daughter is
RN, son is engineer.
Family History:
No illnesses, strokes, DM or early heart attacks run in the
family.
Physical Exam:
VITAL SIGNS: 97.1 107 154/83 25 100% RA
GEN: chronic appearing elderly male lying in bed
HEENT: EOMI, anicteric, MM dry, no cervical LAD
CHEST: CTAB no w/r/r
CV: irreg irreg, no m/r/g
ABD: NDNT, soft, NABS
EXT: no c/c/e
NEURO: difficult time answering questions, A&O x 1 (name only),
tremor worsened with FTN testing
DERM: sacral decub stage II
GU: scrotum dusky, foley in place but with anterior well-healed
tear; suprapubic tube with surrounding draining
Pertinent Results:
Admission:
[**2176-7-7**] 04:32AM WBC-7.0# RBC-2.65*# HGB-8.2*# HCT-24.9*#
MCV-94 MCH-30.8 MCHC-32.9 RDW-16.6*
[**2176-7-7**] 04:32AM PLT COUNT-428#
[**2176-7-7**] 04:32AM CALCIUM-8.2* PHOSPHATE-2.5* MAGNESIUM-2.3
[**2176-7-7**] 04:32AM GLUCOSE-76 UREA N-25* CREAT-1.4* SODIUM-141
POTASSIUM-3.7 CHLORIDE-112* TOTAL CO2-24 ANION GAP-9
[**2176-7-7**] 10:30PM PT-14.0* PTT-26.5 INR(PT)-1.2*
[**2176-7-7**] 10:30PM WBC-8.1 RBC-2.75* HGB-8.2* HCT-26.3* MCV-96
MCH-29.9 MCHC-31.2 RDW-16.5*
[**2176-7-7**] 10:30PM NEUTS-68.1 LYMPHS-20.7 MONOS-5.1 EOS-5.6*
BASOS-0.4
[**2176-7-7**] 10:30PM GLUCOSE-136* UREA N-26* CREAT-1.4* SODIUM-140
POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-20* ANION GAP-14
[**2176-7-7**] 11:00PM URINE RBC->50 WBC-[**4-4**] BACTERIA-RARE YEAST-NONE
EPI-1
[**2176-7-7**] 11:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN->300
GLUCOSE-100 KETONE-40 BILIRUBIN-LG UROBILNGN-4* PH-8.5* LEUK-LG
[**2176-7-7**] 11:22PM LACTATE-1.4
[**2176-7-8**] 03:58AM PHENYTOIN-4.0*
Admission:
CTU: No sign of bladder rupture is noted. No free fluid is noted
in the pelvis and no sign of extravasation of administered
contrast is noted. Stable reflux of the administered contrast
into the left distal ureter is
unchanged since [**2175-3-3**]. Hyperdense filling defect within
the bladder.
Brief Hospital Course:
1. Hematuria: evaluated and followed by urology who felt this
cause of this was tPA used to clear his PICC line on a
background of radiation cysitis. CTU was without acute change.
Hematocrit initially stable, but on HD2 required 1 u prbc
transfusion. He was started on CBI and attained clear urine on
[**2176-7-9**]. CBI was discontinued at this time. He did complain of
suprapubic discomfort at admission and had received a dose of
antibiotics prior to admission. This was discontinued in the
ICU and his urine culture demonstrated no growth. Urology
recommended the use of either detrol or ditropan as necessary to
control bladder spasms.
**** Note: DO NOT USE ANY HEPARIN BASED PRODUCTS OR TPA IN THIS
PATIENT. This can cause gross hematuria in his Foley. His
bladder is only 20 cc capacity. If PICC clotted, would consider
resiting it.
2. Anemia: has baseline anemia of chronic disease and iron
deficiency anemia at 25-27. He required 1u prbc transfusion on
[**2176-7-9**] and received a second on [**2176-7-10**].
3. Diarrhea: profuse, watery diarrhea C. difficle positive,
started metronidazole 500 mg q8h on [**2175-7-11**]. He has a sacral
decubitus ulcer and had a rectal bag to collect the stool. He
has a posterior anal fissure, seen by surgery on anoscopy and
should not have a rectal tube. Tub soaks as able for symptom
control.
4. Atrial fibrillation with RVR: continued on metoprolol, did
not require additional IV.
5. Renal failure: creatinine stable at 1.5 while in the
hospital.
6. DM: continued on outpatient regimen and asa 81 mg daily. AM
[**7-9**] he had low BG and his lantus was reduced to 4 mg daily.
7. Seizures: history of nonconvulsive status. He came in on
phenytoid 125 mg tid with a low dilantin level. He was given
additional 400 mg dilantin on [**2176-7-8**] with only mild improvement
in his level. He was given additional 500 mg IV load on [**2176-7-9**]
with improvement in his level to 10.2. Phenytoin level is to be
checked at rehab. If level is not between 15-20, will need to
ask neurologist for titration at rehab.
8. Anal Fissure: Surgery consulted. Anoscopy demonstrated
fissure. The anal area was kept clean and dry. No rectal tube
should be used with fissure.
9. Disposition: Full Code.
Medications on Admission:
Phenytoin 125 mg TID via G tube
Metoprolol Tartrate 50 mg [**Hospital1 **] via G tube
Acetaminophen 650 mg q4 hours via G tube
Clotrimazole 1% cream 1 application topical [**Hospital1 **] prn fungal
Senna 8.6 mg qhs via G tube
Colace 100 mg [**Hospital1 **] prn constipation via G tube
Lantus 6 units SQ qhs
Aspirin 81 mg po daily
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Phenytoin 125 mg/5 mL Suspension Sig: One [**Age over 90 **]y Five
(125) mg PO TID (3 times a day).
3. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day) as needed for fungal rash.
4. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: Three
[**Age over 90 **]y Five (325) mg PO DAILY (Daily).
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours for 14 days.
6. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q4H (every 4 hours): NTE 4 g/24 hours.
7. Lantus 100 unit/mL Cartridge Sig: Four (4) units Subcutaneous
at bedtime.
8. Humalog Insulin Sliding Scale
Please check FS qidachs and follow insulin sliding scale as
attached
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis:
1. Hematuria
2. C. difficile
Secondary Diagnosis:
1. Anal fissure
2. Seizures
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted with hematuria. You were treated with
continuous bladder irrigation. You were also found to have an
anal fissure on anoscopy. The surgeons recommended that your
stools remain soft and to keep your anal region clean. You were
given blood transfusions while you were in the hospital.
Please continue to take your medications as prescribed. Please
keep all your medical appointments.
Your baby aspirin was stopped in the setting of hematuria.
Your lantus was decreased to 4 units at bedtime as you were
hypoglycemic in the hospital.
You were started on iron for iron deficiency.
You were started on Metronidazole 500 mg po/GTube three times a
day for c. difficile infection
If you have any of the following symptoms, please call your
doctor or got to the nearest ER: fever>101, chest pain,
shortness of breath, abdominal pain, gross blood in your urine,
bright red blood per rectum, or any other concerning symptoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7025**], MD Phone:[**Telephone/Fax (1) 5285**]
Date/Time:[**2176-8-8**] 10:00 (Neurology)
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2176-8-9**] 11:00 (Renal)
Completed by:[**2176-7-18**]
|
[
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"V12.04",
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"355.9",
"V44.1",
"909.2",
"276.2",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.48",
"49.21"
] |
icd9pcs
|
[
[
[]
]
] |
15199, 15265
|
11735, 13993
|
7451, 7459
|
15407, 15417
|
10415, 11712
|
16404, 16754
|
9850, 9919
|
14374, 15176
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15286, 15286
|
14019, 14351
|
15441, 16381
|
9934, 10396
|
8851, 8897
|
7402, 7413
|
7487, 8832
|
15356, 15386
|
15305, 15335
|
8919, 9667
|
9683, 9834
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,197
| 140,946
|
9676
|
Discharge summary
|
report
|
Admission Date: [**2102-6-29**] Discharge Date: [**2102-7-4**]
Date of Birth: [**2049-12-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Blood Transfusion.
Colonoscopy
History of Present Illness:
52 yo female with h/o breast ca s/p mastectomy and
AC+tamoxifen, h/o diverticulosis, who presents with BRBPR for
approximately 24 hours. On the evening on the second, the
patient had significant diarrhea after having had a lactose meal
earlier in the day, and noted some blood at the end of her BM.
The following morning, on [**6-29**], the patient had loose, water
stool which had about [**12-30**] cup blood and a large clot. Later that
AM, around 11, she had another BM which was mostly blood and
clots as well. At 3 PM, and 3:30, she had 2 more BMs which were
mostly bloody, and some clots. She could not fully quantify the
amount at that time. She decided to drive home, but felt
lightheaded and had blurry vision, so she called EMS to bring
her to the ED. She denies any abdominal pain, but she does
report some slight burning in her lower abdomen. She states that
she has not been constipated recently, denies any nausea or
vomiting up until this afternoon. She felt nauseous on the way
to the ED, then in the ED, vomited prior to NGL. She denies any
hematemesis. She reports that in the last few weeks, she noted
very slight pink tinge on the toilet paper after a BM, but has
never had significant bleeding such as this before.
In the ED, vitals were 98.3 115 16/56 20 100% 4L . Prior to NGL
attempt, the patient vomited significant amount of food, but no
hematemsis. She was HD stable throughout her ED course. 2 large
bore IVs were started and she was started on 1 unit pRBC prior
to transfer. GI was consulted in the ED and recommended nuc med
scan.
Past Medical History:
Breast Cancer; local, s/p left mastectomy, AC+ tamoxifen x 5
yrs; now on leupron and femara
HTN
Melanoma s/p resection
Social History:
She is single and not currently in a relationship. She works as
a computer programmer. No tobacco, Etoh, drug use. Works out
with personal trainer once a week.
Family History:
Cousin with lung cancer. Brother melanoma. Mother colon cancer
age 61.
Physical Exam:
VS: 97.6 126/73 97 17 99% RA
GEN: WDWN female, NAD, appears comfortable, slightly pale
HEENT: NCAT, PERRL, MMM
CV: RRR, no murmurs appreciated
LUNGS: CTA bilaterally
ABD: soft, obese, NT. normal BS.
EXT: trace pedal edema; good capillary refill
NEURO: A/O x 3; moves all extremities without difficulty
RECTAL: deferred; had signficant blood with BMs
Pertinent Results:
[**2102-7-4**] 06:10AM BLOOD WBC-8.7 RBC-4.55 Hgb-13.9 Hct-40.6 MCV-89
MCH-30.4 MCHC-34.1 RDW-14.5 Plt Ct-303
[**2102-7-3**] 03:10PM BLOOD Hct-45.2
[**2102-7-3**] 06:00AM BLOOD Glucose-84 UreaN-7 Creat-0.8 Na-145 K-4.3
Cl-107 HCO3-32 AnGap-10
[**2102-7-2**] 03:17AM BLOOD Glucose-87 UreaN-7 Creat-0.8 Na-142 K-3.5
Cl-106 HCO3-28 AnGap-12
[**2102-6-29**] 05:00PM BLOOD cTropnT-<0.01
[**2102-6-29**] 05:00PM BLOOD CK(CPK)-55
[**2102-7-2**] 03:17AM BLOOD Calcium-9.4 Phos-4.5 Mg-2.0
IMAGING
-------
1) CHEST (PORTABLE AP) ([**2102-6-29**])
FINDINGS: The lungs are clear without consolidation or edema.
The
mediastinum is unremarkable. The cardiac silhouette is within
normal limits
for size. No effusion, pneumothorax, or free air under the
diaphragm is
identified. The visualized osseous structures are unremarkable.
IMPRESSION: No acute pulmonary process.
2) GI Bleeding Scan ([**2102-6-29**])
RADIOPHARMACEUTICAL DATA:
14.7 mCi Tc-[**Age over 90 **]m RBC ([**2102-6-29**]);
INTERPRETATION: Following intravenous injection of autologous
red blood cells labeled with Tc-99m, blood flow and dynamic
images of the abdomen for 90 minutes were obtained. A left
lateral view of the pelvis was also obtained.
Blood flow images show dynamic radiotracer activity within the
vascular
structures. Dynamic blood pool images show no abnormal tracer
accumulation.
IMPRESSION: No evidence of active GI bleeding during the time of
study.
COLONOSCOPY
Endoscopist(s): [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**], M.D. (attending)
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (fellow)
Date: Monday, [**2102-7-3**]
Ref. Phys.: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], , MD Patient: [**Known firstname **] [**Known lastname 174**]
Assisting Nurse(s)/
Other Personnel: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Instrument: pcf180al Birth Date: [**2049-12-22**] (52 years)
ASA Class: P2 ID#: [**Numeric Identifier 32714**]
Medications: fentanyl 175 micrograms
Midazolam 4.5 mg IV
Indications: GI Bleeding
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated her
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered
conscious sedation. Supplemental oxygen was used. The patient
was placed in the left lateral decubitus position and the
colonoscope was introduced through the rectum and advanced under
direct visualization until the terminal ileum was reached. The
cecal sling folds were seen. The appendiceal orifice and
ileo-cecal valve were identified. Careful visualization of the
colon was performed as the colonoscope was withdrawn. The
colonoscope was retroflexed within the rectum. The procedure was
not difficult. The quality of the preparation was fair.
Visualization of the ascending colon and sigmoid colon was poor.
The patient tolerated the procedure well. The digital exam was
abnormal. Hemorhoids. There were no complications.
Findings:
Contents: Red blood and clotted blood was seen in the sigmoid
colon, descending colon, transverse colon and ascending colon.
The clotted blood was flushed, but no bleeding source could be
located.
Protruding Lesions Small non-bleeding grade 1 internal &
external hemorrhoids were noted.
Excavated Lesions Several diverticula with medium openings were
seen in the sigmoid colon and ascending colon.Diverticulosis
appeared to be of mild severity. No single bleeding diverticulum
was found.
Impression: Diverticulosis of the sigmoid colon and ascending
colon
Grade 1 internal & external hemorrhoids
Blood in the sigmoid colon, descending colon, transverse colon
and ascending colon
Otherwise normal colonoscopy to terminal ileum
Recommendations: Repeat HCT on arrival to the floor.
Continue to monitor serial HCTs overnight.
If she has additional bleeding, the best step would be
angiography. We suspect a right-sided diverticular bleed, but a
sigmoid diverticular bleed is possible as well.
Please follow-up with either Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] [**Telephone/Fax (1) 682**], or in
[**Location (un) **] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2987**] [**Telephone/Fax (1) 2986**] in [**2-28**] weeks.
Additional notes: The procedure was performed by the GI fellow
and attending.
Brief Hospital Course:
##. Hematochezia: Pt was admitted for a 2 day history of
hematochezia with lightheadedness. Upon admission to the ER pt
was noted to be anemic secondary to blood loss and was
transferred to the ICU where she received 5 units of packed red
blood cells. Whilst in the ICU a tagged RBC was performed and
showed no active bleeding. Prior to discharge day pt was
transferred to the floor where a colonoscopy revealed showed
extensive diverticular disease extending up into the ascending
colon with fresh blood. On the day of discharge pt showed a
stabe Hct x 72hours and was able to tolerate a PO diet with
gross rebleeding.
##. HTN: During hospitalization pt was continued on her home
regimen of blood pressure medications and remained normotensive.
##. H/o breast cancer: During hospitalization pt was continued
on her home regimen of Femara.
Medications on Admission:
LETROZOLE 2.5 mg daily
LEUPROLIDE 7.5 mg Syringe every 11 weeks x 1 dose
MOEXIPRIL 7.5 mg daily
ASPIRIN 81 mg daily
CALCIUM 1000 mg daily
MULTIVITAMIN 1 tablet daily
Discharge Medications:
1. Letrozole 2.5 mg Tablet Sig: One (1) Tablet PO qdaily ().
2. Leuprolide 7.5 mg Syringe Sig: One (1) Intramuscular every
11weeks.
3. Moexipril 7.5 mg Tablet Sig: [**12-28**] - 1 Tablet PO once a day.
4. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
5. Calcium 500 mg Tablet Sig: Two (2) Tablet PO once a day.
6. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Lower GI bleed, presume diverticular source
Discharge Condition:
Stable, Afebrile
Discharge Instructions:
You were admitted to the hospital for bleeding from your lower
digestive system. When in the hospital your blood count was low
so you needed a blood transfusion. Before you were discharged
from the hospital your blood count remained at a normal, steady
level and you were able to eat solid food without more bleeding.
If you notice bloody bowel movements again please return to the
emergency department.
Followup Instructions:
1. Please set up an appointment to see your Primary Care
Physician within the next few weeks.
2.Provider: [**Doctor Last Name 24141**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2102-7-25**] 8:30
3. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4285**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 22**]
Date/Time:[**2102-12-5**] 9:30
4. Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2102-12-5**] 9:30
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"285.1",
"493.90",
"562.12",
"174.9",
"V16.0",
"455.3",
"V10.82",
"455.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8673, 8679
|
7202, 8047
|
320, 352
|
8770, 8789
|
2739, 7179
|
9243, 9872
|
2281, 2353
|
8264, 8650
|
8700, 8749
|
8073, 8241
|
8813, 9220
|
2368, 2720
|
275, 282
|
381, 1945
|
1967, 2088
|
2104, 2265
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,500
| 101,872
|
40767
|
Discharge summary
|
report
|
Admission Date: [**2164-6-5**] Discharge Date: [**2164-6-22**]
Date of Birth: [**2092-5-15**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Fatigue, fever, and lethargy
Major Surgical or Invasive Procedure:
ICD pacemaker lead extraction with attempt at vegetation removal
via femoral access
History of Present Illness:
The patient is a 72 yo woman with h/o CAD s/p CABG in [**2157**], sick
sinus syndrome s/p PM/ICD placement in [**2163**], and dilated
cardiomyopathy with EF of 35%, who presented to [**Hospital3 **]
Hospital on [**6-3**] with fever and lethargy. The patient was
reportedly feeling unwell for approximately one month prior to
admission. On the day of admission, she was at a family [**Holiday **]
dinner and was noted to be lethargic, weak, and pale. EMS was
thus called, and she was brought to [**Hospital3 **] Hospital for
further evaluation.
.
At the OSH, the patient was initially febrile to 102 and her K+
in the ED was 7.6. She was in respiratory distress and was
placed on BiPAP and was noted to have a LLL infiltrate on CXR.
Blood cultures subsequently grew GPCs in clusters in [**5-14**]
bottles, and a TTE demonstrated a vegetation on her AICD lead.
She was started on Vancomycin and Ampicillin. The decision was
made to transfer her to [**Hospital1 18**] for lead extraction.
.
Review of systems is positive for headache and mild shortness of
breath. Otherwise, she denies any prior history of stroke, TIA,
deep venous thrombosis, pulmonary embolism, bleeding at the time
of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies chills or rigors. She denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia
2. CARDIAC HISTORY:
-CABG: 3-vessel CABG in [**2157**] at the [**Hospital1 756**]
-PERCUTANEOUS CORONARY INTERVENTIONS: [**2157**] and [**2163**]
-PACING/ICD: Placed in [**2163-5-12**] for NSVT and sick sinus
syndrome
3. OTHER PAST MEDICAL HISTORY:
Dilated cardiomyopathy with an EF of 35% (TTE in [**2163**])
CRI with ARF in [**2163**] requiring 2 sessions of HD (baseline Cr
1.2)
Retinopathy
Hypothyroidism
Cataract disease
Gout
Rubeosis iritis
Carotid stenosis
Insomnia
Cholelithiasis
Anemia
Syncope
Social History:
The patient lives with her husband. She previously smoked
tobacco and quit 10 years ago. She does not drink EtOH
regularly (1 drink/year on their anniversary)
Family History:
Her mother passed away in her 50s from a CVA and renal failure.
Her father died from cardiac disease at a relatively young age
(not specified). Sister passed away of cancer and one brother
had "kidney problems".
Physical Exam:
On admission:
VS: T=99.6, BP=104/55, HR=65, RR=20, O2 sat=96% on 2L
GENERAL: elderly female, hard of hearing, in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVD.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, tachycardic, normal S1, S2. II/VI holosystolic,
blowing murmur heard best in 5th LICS mid-clavicular line. No
thrills, lifts. No S3 or S4. No ICD pocket tenderness.
LUNGS: No chest wall deformities, mild kyphosis. Resp were
unlabored, no accessory muscle use. Crackles to mid lungs
bilaterally, R>L.
ABDOMEN: Soft, NT/ND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: DP pulses dopplerable bilaterally
On discharge:
Pertinent Results:
On admission:
[**2164-6-5**] 05:25PM BLOOD WBC-16.4* RBC-3.11* Hgb-8.7* Hct-28.5*
MCV-92 MCH-28.1 MCHC-30.6* RDW-20.0* Plt Ct-247
[**2164-6-5**] 05:25PM BLOOD Neuts-87.2* Lymphs-7.8* Monos-4.5 Eos-0.3
Baso-0.2
[**2164-6-5**] 05:25PM BLOOD PT-30.8* PTT-30.1 INR(PT)-3.0*
[**2164-6-5**] 05:25PM BLOOD Glucose-204* UreaN-40* Creat-1.5* Na-137
K-4.7 Cl-101 HCO3-26 AnGap-15
[**2164-6-5**] 05:25PM BLOOD ALT-15 AST-52* LD(LDH)-235 AlkPhos-33*
TotBili-0.4
[**2164-6-5**] 05:25PM BLOOD Albumin-2.9* Calcium-8.8 Phos-2.7 Mg-2.1
[**2164-6-5**] 05:25PM BLOOD %HbA1c-7.7* eAG-174*
Hct and WBCs
[**2164-6-6**] 04:15AM BLOOD WBC-13.9* Hct-27.4*
[**2164-6-7**] 05:34PM BLOOD WBC-12.6* Hct-25.0*
[**2164-6-8**] 03:06PM BLOOD WBC-16.5* Hct-28.0*
[**2164-6-9**] 03:32PM BLOOD WBC-11.6* Hct-26.3*
[**2164-6-10**] 06:11AM BLOOD WBC-9.8 Hct-26.2*
Creatinine
[**2164-6-6**] 04:15AM BLOOD Creat-1.3*
[**2164-6-7**] 05:34PM BLOOD Creat-1.2*
[**2164-6-8**] 03:06PM BLOOD Creat-0.8
[**2164-6-10**] 06:11AM BLOOD Creat-1.0
INR
[**2164-6-5**] 05:25PM BLOOD INR(PT)-3.0*
[**2164-6-6**] 04:15AM BLOOD INR(PT)-1.9*
[**2164-6-7**] 12:45AM BLOOD INR(PT)-1.4*
[**2164-6-8**] 04:24AM BLOOD INR(PT)-1.3*
[**2164-6-10**] 06:11AM BLOOD INR(PT)-1.2*
.
.
.
Discharge labs:
[**2164-6-21**] 04:36AM BLOOD WBC-9.0 RBC-3.06* Hgb-9.6* Hct-28.6*
MCV-94 MCH-31.5 MCHC-33.7 RDW-18.5* Plt Ct-349
[**2164-6-21**] 04:36AM BLOOD Plt Ct-349
[**2164-6-21**] 04:36AM BLOOD Glucose-97 UreaN-36* Creat-1.6* Na-135
K-4.0 Cl-94* HCO3-30 AnGap-15
[**2164-6-16**] 04:23PM BLOOD ALT-18 AST-41* AlkPhos-42 TotBili-0.4
[**2164-6-21**] 04:36AM BLOOD Calcium-9.4 Phos-3.6 Mg-1.9
.
MICROBIOLOGY
Blood and urine cultures: no growth
IMAGING
TTE [**6-18**]:
.
.
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. There is
mild regional left ventricular systolic dysfunction with
inferior akinesis. There is no ventricular septal defect. The
right ventricular cavity is mildly dilated with normal free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. A mitral valve annuloplasty ring is
present. The gradient across the mitral valve is increased (mean
= 17 mmHg). There is a moderate-sized vegetation on the mitral
valve ([**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] of the anterior leaflet, 0.8 cm). Mild to
moderate ([**2-12**]+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
Compared with the prior study (images reviewed) of [**6-11**]/201, the
tricupsid valve vegetation is not clearly seen (may be because
of poor image quality rather than resolution). The degree of
pulmonary hypertension and RV dilation has decreased. The mitral
vegetaiton appears similar.
.
.
EKG: The rhythm appears to be intermittent atrial paced and
sinus but low amplitude wave forms make assessment difficult.
Left bundle-branch block with left axis deviation. Since the
previous tracing of [**2164-6-6**] the rate is slower and ectopy is
absent.
Brief Hospital Course:
This is a 72 year old female with h/o CAD s/p CABG in [**2157**], DM2,
SSS s/p PM/ICD placement in [**2163-6-11**] and dilated cardiomyopathy
who presented to [**Hospital3 **] Hospital on [**6-3**] with fever and
lethargy, found to have vegetations on AICD leads, Mitral valve
and Tricuspid valvee and Enterococcal sepsis, was transfered to
[**Hospital1 18**] [**6-5**] where ICD leads were extracted and IV antibiotics
were initiated for endocarditis. Now discharged to rehab and
planned for completion of 6 week course of antibiotics.
.
#. enterococcal endocarditis with ICD lead + MV + TV
vegetations: Patient presented to OSH with fevers to 102 and
lethargy,Blood cultures revealed entercocci in [**9-17**] bottles as
well as in her urine culture. TTE showed vegetations involving
the AICD leads, likely [**3-14**] enterococci urosepsis. She was
started on vancomycin and ampicillin at the OSH. She was then
transferred to [**Hospital1 18**] on [**6-5**] for AICD lead extraction. Prior to
the procedure, her antibiotic regimen was switched to
ampicillin/gentamicin upon learning the sensitivities of the
organisms from the OSH culture. During the procedure, heavy
vegetations were seen involving the leads as well as the mitral
and tricuspid valves. Once the leads were extracted, great
efforts were made to snare these vegetations via femoral access,
but we were unable to remove them from their location in the
right ventricular cavity. With increased concern for
embolization, she was monitored in the CCU, with continued
airway protection with ET tube as well as central access with a
subclavian line. Due to post-procedure hypotension, her home
anti-hypertensives were discontinued and she was maintained
briefly on a dopamine gtt. Post-procedure TTE confirmed the
location of residual vegetations on tricuspid and mitral valves.
She was extubated without complication the next day, with
mental status intact. Daily surveillance blood cultures were all
negative and her repeat urine culture was negative as well. IV
antibiotic therapy with ampicillin/gentamicin was continued and
planned for a total of 6 weeks. Peak and trough levels of
gentamicin were checked and therapeutic. Her renal function was
monitored closely during this time and worsening renal function
prompted change from gentamycin to ceftriaxone. PICC line was
placed for continued Abx administration, her subclavian line was
pulled after confirmation of this line placement. Patient was
afebrile throughout her [**Hospital1 18**] course accept for a single spike
of fever on [**6-16**] to 100.7. Urine and Bcx remained negative. CXR
was without focal infiltrate. Most recent TTE on [**6-18**] showed
mild-mod MR [**First Name (Titles) 151**] [**Last Name (Titles) 1506**] mitral valve vegetation, vegetation
was no longer seen on the tricuspid valve but this may be
because of poor image quality rather than resolution. There was
moderate TR and moderate pulmonary artery systolic hypertension
and RV dilatation which were improved from [**6-11**] study. Patient
was seen by cardiac surgery who recommended repeating TTE after
completion of Abx course for assessment of need for valve repair
surgery. She will need to have this ECHO done per her outpatient
cardiologist and the report sent with pt to her appt with Dr.
[**First Name (STitle) **] and Dr. [**Last Name (STitle) **].
Patient is discharged on continue ampicillin and ceftriaxone for
total 6 week course, last day [**2164-7-17**].
.
Follow-up Plan:
-- Monitor fever curve and WBC
-- Close follow-up with Dr. [**Last Name (STitle) **] in the [**Hospital1 18**]
Infectious Disease outpatient clinic with weekly CBC w/ diff,
chem 7 (most important BUN,Cr) and LFT's.
-- Continue on ampicillin and ceftriaxone for total of 6 weeks,
last day [**2164-7-17**]
.
# Congestive Heart Failure. Admission TTE with LVEF= 25-30%, 2+
mitral regurgitation, 1+ tricuspid regurgitation. Due to initial
episodes of hypotension diuretic regimen held. On [**6-11**] patient
noted to be dyspneic and tachypneic. CXR consistent with
pulmonary edema with bilateral pleural effusions. Patient was at
that point 4 L positive since admission. Repeat TTE with
worsening valvular function, Moderate to severe [3+] TR. Severe
PA systolic hypertension. Patient aggressively diuresised with
Lasix ggt + daily Metalozone with good result. Patient diuresed
well and at time of transfer saturating 93-97% on 2L. Weight at
time of discharge is 65.7, she appears clinically euvolemic.
Patient was continued on home digoxin, carvedilol. ACEi and
diurises are currently held in the setting of renal failure.
Digoxin was decreased to three times a week because of renal
function. EF at time of discharge is 40%.
OUTPATIENT Follow-up plan:
-- Monitor weights daily, I/O and diurese as needed to maintain
clinical euvolemia.
-- Monitor renal function, restart ACEi when renal function
improves and stabilizes
-- Diuretic regimen at time of discharge: held
.
#. RHYTHM: The patient has a history of sick sinus syndrome,
prompting the original placement EP study in [**2163**] which showed
inducible polymorphic VT. AICD was placed for primary
prevention in the setting of depressed LV function (EF =
25-30%). Recent ICD interrogation did not show life threatening
arythmia in the prior year. Telemetry during her hospital course
showed multiple VPB's and runs of accelerated idioventricular
rythm but no life threatening arrythmias. Patient will require
continued telemetry monitoring while she is at rehab and at
discharge per her outpatient cardiologist. She will see Dr.
[**Last Name (STitle) 75381**] in [**Month (only) **] at which point it will be determined whether
re-implantation of ICD is indicated.
.
Out patient follow up plan
- continue telemetry monitoring
- follow-up with Dr. [**Last Name (STitle) **] on [**2164-8-1**] at 1:40 PM
#. Acute on Chronic renal insufficiency - baseline creatinin
1.2, trended up to peak of 2.4 in the setting of agressive
duresis for heart failure and pulmonary edema. Cr:BUN ratio
changes were consistent with pre-renal etiology evolving to ATN.
There was no periheral eosinophilia. Microscopy of the urine
showed rare muddy-brown cast.Patient was also on gentamycin at
the time, levels were theraputic but as contribution of
gentamycin to ATN could not be ruled out this was switched to
ceftriaxone. Diuresis was held upon achievment of euvolemia,
ACE-I was also held. Creatinin is trending down to 1.6 on day of
discharge.
OUTPATIENT FOLLOW_UP ISSUES:
-- Close monitoring of renal function.
-- please check Cme-7 on [**6-23**].
#. Elevated INR: Patient was not on anticoagulation on
admission, but her INR was 3.0. No evidence of liver injury or
failure at the OSH. Given her improving clinical condition,
this was unlikely to be DIC or acute liver failure. LFTs and
DIC labs were unremarkable. She was given vitamin K with good
result, reversing her INR appropriately for her lead extraction
procedure. INR remained stable throughout remainder of her stay.
#. Normocytic anemia: Hct was stable, without signs of active
bleeding. She was given 2 units of pRBCs prior to the
procedure, with an unimpressive Hct bump. However, her Hct
remained stably low and was followed closely. Fe studies wnl.
HCT did note to trend down on [**4-3**]. Patient transfused with
2u prbc with appopriate bump in HCT to 28. HCT stable prior to
transfer 28.6
#. DM2: Patient takes Amaryl and janumet at home with 20 units
of Glargine at hs, with last HbA1c > 7. Glucose at OSH trended
in 200s-300s in the setting of infection, with initiation of
Lantus to 40 (from 20) units nightly. Peri-procedurally, her
Lantus dosing was decreased to 15 units nightly, but then
increased again to her home dose once she was eating more
consistently. At time of transfer sugars were well controlled on
Lantus 30 units QHS with supplemental ISS. She should be
transitioned back to pills upon discharge.
#. CORONARIES: She is s/p 3-vessel CABG in [**2157**]. She was
otherwise asymptomatic, ruled out for MI at OSH, and was without
EKG changes compared to prior. She was continued on her ASA
325mg and statin.
#. Hyperlipidemia: She was continued on statin, niacin, but her
fenofibrate was held.
#. Hypothyroidism: She was continued on levothyroxine.
.
Medications on Admission:
-Lisinopril 10 mg daily
-Lasix 20 mg daily
-Coreg 6.25 mg [**Hospital1 **]
-Synthroid 150 mcg daily
-Fenofibrate 200 mg daily
-Calcium plus D one tablet [**Hospital1 **] (500/200)
-Niaspan ER 500 mg [**Hospital1 **]
-Digoxin 0.125 mg daily
-ASA 325 mg daily
-glimepiride 4 mg daily
-Lipitor 20 mg daily
-Janumet unknown dose
- Lantus 20 units at bedtime
Discharge Medications:
1. Ampicillin 2 g IV Q6H
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Calcium+D 500 mg(1,250mg) -200 unit Tablet Sig: One (1)
Tablet PO twice a day.
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
6. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. niacin 500 mg Capsule, Extended Release Sig: One (1) Capsule,
Extended Release PO BID (2 times a day).
10. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day.
11. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
12. digoxin 125 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
13. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
14. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
15. CeftriaXONE 1 gm IV Q12H
16. Outpatient Lab Work
Please check labs weekly starting on [**6-27**], Chem-7, CBC, LFT's
with results faxed to [**Doctor Last Name 2808**] from Infectious Disease at [**Hospital1 18**]
[**Telephone/Fax (1) 1419**]
17. Outpatient Lab Work
Please check chem-7 and CBC tomorrow [**2164-6-23**]
18. insulin glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
19. Humalog 100 unit/mL Solution Sig: 0-14 units Subcutaneous
four times a day: check FS before meals and at hs per sliding
scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Primary:
Endocarditis
Infected pacemaker and ICD
Acute Systolic Congestive Heart Failure: EF 40% ACE inhibitor
has been held because of acute kidney injury
Coronary Artery Disease
Acute on Chronic Kidney Injury
.
Diabetes Mellitus
Secondary diagnoses:
Hypothyroidism
Ventricular Tachycardia
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms [**Known lastname 69742**] it was a pleasure taking care of you.
.
You were admitted to the [**Hospital1 18**] for treatment of infection of
your ICD, pacemaker and heart valves. The pacemaker/ICD was
removed in the operating room and you had some trouble with low
blood pressures, fluid overload and kidney failure. Your blood
pressure is now stable and your kidney function is improving. We
have held some of your medicines and decreased others while your
kidneys are not working well. You were started on IV antibiotics
for a planned 6 week course to treat the infection on your heart
valves. You will need an echocardiogram again after the
antibiotics are finished on [**7-17**]. Please have Dr. [**Last Name (STitle) 89111**]
arrange this (he has been contact[**Name (NI) **]) and you will need
While hospitalized an ultrasound of your heart demonstrated that
your heart was not pumping forward as well as it could and as a
result fluid was pooling in your lungs and extremities. We
placed you on medications to faciliate diuresis. At time of
discharge your breathing was much improved.
.
CHANGES TO YOUR MEDICATIONS
To treat infection:
1. Start taking Ampicillin and Ceftriaxone; plan to complete 6
week course, last day [**7-17**] to treat the infection on your
heart valves
Start taking Gentamycin; plan to complete 6 week course
.
To prevent damage to your kidneys:
2. Stop Lisinopril and Furosemide until kidney function
stabilizes.
3. Decrease Digoxin to three days a week instead of daily until
your kidney function improves.
4. Stop taking fenofibrinate and glimepiride
5. Start taking tylenol as needed for minor pain
6. Start taking Lorazepam as needed for anxiety
7. Increase Vitamin D to 1000u daily
8. STart senna and colace as needed to prevent constipation
9. STop taking glimepiride and Janumet. Continue Glargine
insulin while you are in the rehabilitation at 30 units. You can
restart pills once you are home to control your blood sugar.
.
Again it was a pleasure taking care of you. Please contact with
any questions or concerns.
Followup Instructions:
Cardiologist: Dr. [**Last Name (STitle) 56071**] ([**Telephone/Fax (1) 34149**]): please make a
follow up appt for when you get out of rehabilitation.
.
Department: INFECTIOUS DISEASE
When: THURSDAY [**2164-7-12**] at 2:10 PM
With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: INFECTIOUS DISEASE
When: FRIDAY [**2164-8-3**] at 9:30 AM
With: [**Name6 (MD) 2324**] [**Name8 (MD) 2323**] MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) Basement, [**Hospital1 18**]
Department: CARDIAC SURGERY
When: MONDAY [**2164-7-23**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
Department: CARDIAC SERVICES
When: WEDNESDAY [**2164-8-1**] at 1:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2164-6-23**]
|
[
"996.61",
"250.00",
"V70.7",
"V45.81",
"425.4",
"041.04",
"416.8",
"995.91",
"599.0",
"244.9",
"428.0",
"421.0",
"274.9",
"584.5",
"272.4",
"038.0",
"428.23",
"397.0",
"790.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.79",
"37.77"
] |
icd9pcs
|
[
[
[]
]
] |
17851, 17949
|
7443, 15735
|
332, 417
|
18289, 18289
|
3981, 3981
|
20526, 21889
|
2791, 3006
|
16140, 17828
|
17970, 18201
|
15761, 16117
|
18440, 20503
|
5225, 7420
|
3021, 3021
|
18222, 18268
|
2112, 2310
|
3962, 3962
|
264, 294
|
445, 2018
|
3996, 5209
|
18304, 18416
|
2341, 2597
|
2040, 2092
|
2613, 2775
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,464
| 137,299
|
47337
|
Discharge summary
|
report
|
Admission Date: [**2173-3-30**] Discharge Date: [**2173-4-7**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
melena
Major Surgical or Invasive Procedure:
none
History of Present Illness:
85 y.o. M transferred from [**Hospital1 100**] Life for 1 day of melena.
Patient is a poor historian and denies any complaints other than
'diarrhea'. Per [**Hospital1 1501**] records, he was admitted to [**Hospital1 100**] Life on
[**3-25**] after prolonged hospitalization at [**Hospital3 **] for
appendectomy- hospital course was complicated by possible ARDS
and in the setting of known COPD. He was discharged on a
tapering dose of prednisone. He was recovering slowly at [**Hospital1 100**]
Life until yesterday ([**3-29**]) when dark stools were noted. He is
at baseline demented, has herpes zoster at the buttocks.
.
In the ED, initial vs were: T 98 BP 105/48 R 22 sat 95%. Patient
was given protonix 80IV then gtt of 8mg/hr. 18G and midline were
started. No BMs. Patient was not cooperative with NG tube.
Guaiac positive.
.
On the floor, pt is stable, demented. [**Hospital1 1501**] called - pt has VRE in
urine.
Past Medical History:
dementia
depression
CAD s/p MI, PCI
history of Vfib
COPD
ILD
DM II
HTN
OA
s/p CCY
s/p hernia repair
s/p recent appy
Social History:
Former smoker, ?etoh in the past. smoke 1ppd/30 yr, quit 35 yrs
ago, retired post-officer. lives with wife is 90 and wheelchair
bound. prior to recent admit, was walking with cane/walker
Family History:
Noncontributory
Physical Exam:
T 96.5 104 116/50 22 95%RA
General Appearance: Well nourished, No acute distress, No(t)
Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic
Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t)
Conjunctiva pale, No(t) Sclera edema
Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition,
No(t) Endotracheal tube, No(t) NG tube, No(t) OG tube
Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t)
Cervical adenopathy
Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal,
No(t) Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t)
Widely split , No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub,
(Murmur: Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),
(Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness
: ), (Breath Sounds: Clear : , No(t) Crackles : , No(t)
Bronchial: , No(t) Wheezes : , No(t) Diminished: , No(t) Absent
: , No(t) Rhonchorous: )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended, No(t) Tender: , No(t) Obese
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace, No(t) Cyanosis, No(t) Clubbing
Musculoskeletal: No(t) Muscle wasting, Unable to stand
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person, "[**2172**]", Movement:
Purposeful, No(t) Sedated, No(t) Paralyzed, Tone: Normal, Poor
short term memory
Pertinent Results:
Imaging:
CXR [**3-30**]:
HISTORY: ARDS and COPD, admitted with upper GI bleed.
FINDINGS: In comparison with the study of [**2163-3-26**], there is
continued enlargement of the cardiac silhouette. Diffuse
bilateral pulmonary opacifications could reflect pulmonary
edema, widespread pneumonia, or even ARDS. Extensive respiratory
motion somewhat blurs the resulting image.
CXR [**4-3**]:
FINDINGS: As compared to the previous radiograph, there is no
relevant change. Extensive bilateral diffuse parenchymal
opacities at low lung volumes and minimal pleural effusions. The
image is consistent with ARDS. Moderate cardiomegaly. No
interval recurrence of new parenchymal opacities.
CXR [**4-5**]:
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Extensive bilateral parenchymal opacities consistent
with the
underlying disease. Moderate cardiomegaly. No evidence of newly
occurred
focal parenchymal opacities, the presence of minimal pleural
effusions cannot be excluded.
Microbiology:
[**3-30**] Urine culture:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000 ORGANISMS/ML..
[**3-30**] MRSA screen negative
[**3-30**] Rectal VRE swab negative
[**4-6**] H. pylori serology negative
Admission labs [**2173-3-30**]:
WBC-14.9*# RBC-3.07*# Hgb-10.0*# Hct-29.9* MCV-97 MCH-32.5*
MCHC-33.4 RDW-15.1 Plt Ct-413
Neuts-88.1* Lymphs-7.1* Monos-3.1 Eos-1.3 Baso-0.3
PT-13.6* PTT-23.9 INR(PT)-1.2*
Glucose-228* UreaN-25* Creat-0.7 Na-137 K-4.6 Cl-100 HCO3-27
AnGap-15
ALT-31 AST-27 AlkPhos-112 TotBili-0.7
Albumin-2.9*
Lactate-2.2*
Discharge labs [**2173-4-7**]:
WBC-8.6 RBC-3.36* Hgb-10.4* Hct-32.3* MCV-96 MCH-31.1 MCHC-32.3
RDW-17.2* Plt Ct-339
Glucose-169* UreaN-9 Creat-0.6 Na-135 K-3.7 Cl-96 HCO3-32
AnGap-11
Calcium-7.8* Phos-2.4* Mg-1.9
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the intensive care unit for
evaluation/treatment of GI bleed. NG lavage was performed and
clear. He received a total of 4 units of pRBCs (2 on [**3-30**] and 2
on [**4-3**]) with stable hematocrit and no further episodes of
melena. He was treated with a Protonix drip, transitioned to IV
bid. The GI team was consulted, and there was some concern that
he might need to be intubated for the procedure given his
history of interstitial lung disease (complicated by recent ARDS
at OSH and high O2 requirement). Ultimately, the patient and his
HCP decided against an endoscopy with or without intubation.
Plavix and aspirin were held given bleeding, and GI felt that he
would be at high risk for rebleed with Plavix given no
definitive intervention was done. His need for Plavix was
discussed with his PCP, [**Name10 (NameIs) **] he was determined to no longer need
this medication. He was restarted on 81mg of aspirin daily
prior to discharge and transitioned to twice daily oral PPI. He
will be on this medication for two months and then can
transition to once daily.
Hypoxia/IPF/COPD: The patient's hypoxia was likely
multifactorial and was thought to be due to ARDS in addition to
his COPD and IPF. The patient's steroid taper had finished on
[**4-4**] (after 5 days of prednisone 5 mg po daily). His oxygen
saturations improved with diuresis although he continued to
require several liters of supplemental oxygen. His nebulizers
were continued.
Hx of CAD s/p PCI: He did not have any chest pain or discomfort
during the admission. His metoprolol and simvastatin were
continued but his plavix and aspirin were initially held in the
setting of his GI bleed. As mentioned above, his plavix was
completely stopped but he was restarted on 81mg of aspirin daily
prior to discharge.
Loose stool: Noted to have some loose stools on the day of
discharge, without melena or hematochezia. Did not test for C
diff, but GI advised testing for C diff if diarrhea continued.
Diabetes type II: He is on metformin and januvia as an
outpatient, but these had been held in the setting of variable
po intake. While in the hospital, he was treated with sliding
scale insulin.
Herpes Zoster: Patient has an outbreak of herpes zoster on his
buttocks. Upon review of his [**Hospital1 100**] records, he appears to have
started acyclovir treatment on [**3-25**], and this was stopped on
[**4-6**].
Hypertension: He was continued on metoprolol.
Hx of multifocal atrial tachycardia: He was in sinus rhythm
during the admission and continued on metoprolol.
Depression: His home sertraline was continued.
Nutrition: He was seen by speech and swallow and advised to have
1:1 supervision with feeds but can have regular diet with thin
liquids and meds whole with apple sauce.
Code status: DNR/DNI, confirmed with HCP
Medications on Admission:
acyclovir 800 mg PO tid
famotidine 75mg PO daily
plavix 75 daily
tylenol 650 mg po q6h prn
prednisone 10mg daily
nitro SL prn
heparin 5000 sc bid
metformin 1000mg [**Hospital1 **],
simvastatin 20mg daily,
januvia 50mg PO daily,
xopenex qid and q4hr prn,
metoprolol 25mg tid
zoloft 100mg PO daily
atrovent/albuterol nebs
Discharge Medications:
1. Januvia 50 mg Tablet Sig: One (1) Tablet PO once a day.
2. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Simvastatin 40 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)).
7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
8. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever/pain.
9. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) neb Inhalation every four (4) hours as needed for shortness
of breath or wheezing.
10. Xopenex HFA 45 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) neb Inhalation four times a day.
11. Xopenex HFA 45 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) neb Inhalation every four (4) hours as needed for shortness
of breath or wheezing.
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-12**]
Drops Ophthalmic TID (3 times a day).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for yeast.
16. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Melena
Hypoxia
Secondary:
COPD
Interstitial pulmonary fibrosis
Dementia
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 the hospital for dark stools concerning for
bleeding in your GI tract. You and your health care proxy
decided to not have an endoscopy done to evaluate your GI tract,
and the bleeding stopped with medications. You received 4 units
of blood to stabilize your blood count. You also had more
difficulty breathing and required more oxygen to help you
breathe.
The following changes were made to your medications:
1. Stopped plavix as it thins your blood and will make you more
likely to bleed.
2. Started pantoprazole twice daily to protect your stomach and
stabilize any ulcer or cause of bleeding in your GI tract.
3. Stopped prednisone as you completed your dose of steroids.
4. Stopped acyclovir as you completed treatment for shingles.
5. Stopped famotidine and started pantoprazole instead.
6. Started miconazole powder for scrotal fungal pain.
7. Started aspirin 81 mg daily for heart protection.
Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 18323**] in the next 2-4 weeks.
Please follow up with your Cardiologist Dr. [**Last Name (STitle) **] in the next [**1-14**]
weeks. You can call [**Telephone/Fax (1) 32100**] for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
[
"427.32",
"599.0",
"294.8",
"041.19",
"285.1",
"491.21",
"414.01",
"518.5",
"412",
"250.00",
"401.9",
"578.1",
"112.3",
"311",
"053.9",
"515"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9918, 9984
|
4986, 7836
|
233, 239
|
10110, 10110
|
3198, 4963
|
11244, 11656
|
1549, 1566
|
8207, 9895
|
10005, 10089
|
7862, 8184
|
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|
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|
187, 195
|
267, 1189
|
10125, 10271
|
1211, 1329
|
1345, 1533
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,440
| 132,443
|
22244
|
Discharge summary
|
report
|
Admission Date: [**2200-3-12**] Discharge Date: [**2200-3-19**]
Date of Birth: [**2154-5-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Empyema.
Major Surgical or Invasive Procedure:
[**2200-3-14**]: Right thoracotomy, decortication of lung.
History of Present Illness:
This is a 45 y/o gentleman with a PMH significant for IV drug
abuse that was transferred today from [**Hospital6 204**]
where he presented yesterday with complaints of chest pain,
fever and chills. Immaging of his chest was obtained at the OSH
(CXR, CT) and showed a large multiloculated R pleural effusion
with associated compressive atelectasis. US guided diagnostic
thoracentesis was performed and a small amount of cloudy yellow
fluid was obtained and sent for chemistry which showed a pH of
7.1, glucose of 71
and protein of 4.7. An attempt was made to place a 16 F chest
tube and was unsuccessful due to the small size of the
septations. Blood culture were also sent at the OSH and results
are still pending, no microorganisms identified to date. Other
causes of chest pain were ruled out. The patient is being
referred to our center for further care.
Past Medical History:
Hepatitis C
Bipolar disorder
Depression
Polysubstance abuse
Endocarditis in [**2191**]
Acute renal failure for which he was temporarily on HD
teeth abscesses
Social History:
The patient is homeless. He is currently at [**Hospital **] [**Hospital **]
hospital (voluntary admission for depression/SI). Previously he
was living in a sober house. He last lived in a shelter 4 yrs
ago. +tob (30 pack year hx). +EtOH (1 pint vodka per day, last
drink 5-6 days ago). h/o IVDU (used heroin 6 mos ago)
Family History:
non-contributory
Physical Exam:
T: 99.6 HR: 98 SR BP: 116/70 Sats 94% RA
General: 45 year-old male doing well
HEENT: multiple teeth missing, mucus membranes moist
Neck: supple
Card: RRR
Resp: decreased breath sounds on right with crackles RLL,
otherwise clear
GI: benign
Extr: warm no edema
Incision: Right Thoracotomy site clean dry intact
Neuro: non-focal
Pertinent Results:
[**2200-3-19**] WBC-16.7* RBC-3.20* Hgb-9.6* Hct-29.2 Plt Ct-583*
[**2200-3-18**] WBC-20.8* RBC-3.30* Hgb-10.2* Hct-30.6 Plt Ct-620*
[**2200-3-13**] 01:47AM BLOOD WBC-16.3*# RBC-3.63* Hgb-11.4* Hct-33.5*
MCV-92 MCH-31.5 MCHC-34.1 RDW-13.6 Plt Ct-402
[**2200-3-16**] WBC-22.3* RBC-2.90* Hgb-9.0* Hct-27.3* MCV-94 MCH-31.0
MCHC-33.0 RDW-13.3 Plt Ct-387
[**2200-3-18**] Glucose-104* UreaN-8 Creat-0.7 Na-141 K-4.1 Cl-101
HCO3-34
[**2200-3-13**] Glucose-144* UreaN-13 Creat-1.0 Na-137 K-4.6 Cl-101
HCO3-25
[**2200-3-18**] Calcium-8.3* Phos-3.1 Mg-2.2
Micro/imaging
[**2200-3-17**] TTE no vegetations, LVEF >55%
[**2200-3-17**] CXR residual R pl thick eff unchanged; atelectasis R>L;
[**2200-3-17**] Ucx no growth
[**2200-3-15**] tissue G stain: 1+PMNs, no micro
[**2200-3-15**] BAL R lung G stain: 2+ PMNs, no micro
[**2200-3-15**] BAL L lung G stain: 4+ PMNs, 2+ GPCs; Cx: yeast 10k/ml
[**2200-3-14**] pleural fl G stain: no PMNs, no micro
[**2200-3-14**] pleural fl Cx: pnd
[**2200-3-18**]: two of the three right-sided chest tubes have been
removed. One chest tube remains in place. Minimal right apical
pleural air inclusion. No evidence of tension. Mild improvement
of the pre-existing right parenchymal opacities. No newly
appeared focal parenchymal opacities. Unchanged aspect of the
left lung. Unchanged appearance of the PICC line.
[**2200-3-17**]: No evidence of pneumothorax. Prominence of
ill-defined pulmonary markings is consistent with elevated
pulmonary venous pressure in this patient with some enlargement
of the cardiac silhouette. Bibasilar atelectasis and small
effusions persists
[**2200-3-16**]: In comparison with the study of [**3-14**], the
endotracheal tube is no longer seen. Other monitoring and
support devices remain in place. No
evidence of pneumothorax with two chest tubes in place.
Bibasilar atelectasis is seen, with some residual effusion on
the right.
Echocardiogram [**2200-3-17**]: The left atrium is mildly dilated. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The estimated cardiac
index is normal (>=2.5L/min/m2). 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 diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Normal study. No structural heart disease or
pathologic flow identified.
Brief Hospital Course:
Mr. [**Known lastname 58007**] was admitted [**2200-3-12**] for right empyema. On
admission Vancomycin, levofloxacin & Ceftriaxone were continued.
Right PICC line was placed. The acute pain service was
consulted to assist with management of his postoperative pain.
The preop work-up was he was consented and taken to the
operating [**2200-3-14**] for Right thoracotomy, decortication of
lung. He was transfer to the ICU intubated and sedated and
Fentanyl drip for pain control. Three chest tubes were in place
to suction and a foley. He was successfully extubated [**2200-3-15**].
Pain: The acute pain service managed his pain. On [**2200-3-15**]
Fantanyl was changed to a ketamine drip for pain managment which
was titrated down secondary hullcinations.
Hydromorphone 1-2 mg IV q3h prn and PO 4-8 mg every 4 hrs prn
was started once the ketamine drip was stopped. Gabapentin 600
mg tid was started [**2200-3-16**] and continued.
Ativan prn was given. His home dose clonazepam 1 mg tid was
continued. His pain was better controlled and on discharge the
acute pain service recommended hydromorphone 4-8 mg every [**2-19**]
hrs, gabapentin 600 mg tid and give 1 week supply and have him
follow-up with his PCP for further management. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**]
his abuse counsler was notified and he was scheduled for an
appointment [**2200-3-20**].
ID: Vancomycin, levofloxacin, ceftriazone were continued. Once
the preliminary revealed no growth the levofloxacin was
discontinued. He completed an 8 day course of Vancomycin and
Ceftriazone.
IV access: The right PICC line was removed [**2200-3-19**].
Respiratory: aggressive incentive spirometer, neb and ambulation
he titated off oxygen with saturations of 94% RA.
Chest-tube: 3 chest tubes: a right angle and 2 apical chest
tubes were removed once the pleural and tissue cultures revealed
no organism. He was followed by serial chest films (see above
report)
Cardiac: Echocardiogram done [**2200-3-17**] was negative for
endocarditis. He remained hemodynamically stable in sinus
rhythm 80-90's, BP 110-120's.
GI: Tolerated a regular diet. Bowel regime with narcotics.
Renal: Normal renal function with good urine output. His
electrolytes were replete as needed.
Disposition: He was followed by physical therapy. He continued
to make steady progress and was discharged on 0/04/11. He will
follow-up with Dr. [**First Name (STitle) **]. his PCP and substance abuse counsler as
an outpatient.
Medications on Admission:
suboxone [**6-17**] [**Hospital1 **], doxepin 50 TID and HS, clonazepam 1 tid
meds added at OSH: vancomycin 1 gm [**Hospital1 **], levofloxacin 750mg
daily, ceftriaxone 2 gm daily
Discharge Medications:
1. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
2. clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. doxepin 50 mg Capsule Sig: One (1) Capsule PO three times a
day.
4. doxepin 50 mg Capsule Sig: One (1) Capsule PO at bedtime.
5. hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
for 7 days.
Disp:*70 Tablet(s)* Refills:*0*
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Right Empyema.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr[**Doctor Last Name **] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, cough or chest pain
-Incision develops drainage
-Chest tube site remove dressing Thursday and cover site with a
bandaid
Pain
-Take dilaudid as needed.
-Return to your outpatient pain clinic to start taking your
Suboxone
Activity
-Shower daily. Wash incision with soap & water, rinse, pat dry
-No tub bathing, swimming or hot tub until incision healed
-No driving while taking narcotics
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] Phone:[**0-0-**] Date/Time:[**2200-4-3**]
11:00 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clincial Center, [**Location (un) 24**]
Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your
appointment
Follow-up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] [**Telephone/Fax (1) 58008**] at 1:15 [**First Name8 (NamePattern2) 58009**] [**Hospital1 189**].
Follow-up with the Physician covering for Dr. [**Last Name (STitle) 58010**] your PCP.
[**Name10 (NameIs) **] with schedule for an appointment.
Completed by:[**2200-3-19**]
|
[
"518.0",
"511.89",
"303.90",
"V60.0",
"305.1",
"070.54",
"305.90",
"510.9",
"338.12",
"780.1",
"296.80"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.51",
"34.91",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
8293, 8299
|
5015, 7528
|
288, 349
|
8358, 8358
|
2161, 4992
|
9064, 9703
|
1778, 1796
|
7759, 8270
|
8320, 8337
|
7554, 7736
|
8509, 9041
|
1811, 2142
|
239, 250
|
377, 1238
|
8373, 8485
|
1260, 1419
|
1435, 1762
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,041
| 193,659
|
39132
|
Discharge summary
|
report
|
Admission Date: [**2154-4-18**] Discharge Date: [**2154-4-25**]
Date of Birth: [**2092-8-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Palpitaions
Major Surgical or Invasive Procedure:
[**2154-4-18**] Cardiac catheterization
[**2154-4-19**] Aortic valve replacement, [**Street Address(2) 11688**]. [**Hospital 923**] Medical Regent
valve
History of Present Illness:
61 year old female with atrial fibrillation and aortic valve
stenosis followed by serial echocardiograms. Her most recent
echocardigram revealed severe
aortic stenosis with significant gradients. Given the
progression of her disease, she has been referred for surgical
evaluation. She admits today after preoperative catherization
for heparin bridge with plans for AVR/? MAZE in am
Past Medical History:
Aortic stenosis
Atrial fibrillation
Asthma
Sleep Apnea (Uses CPAP)
Hyperlipidemia
Umbilical Hernia
Degenerative joint disease
Arthritis
Rheumatic fever
Inferior wall myocardial infarction
Hypertension
Anemia
Mitral valve prolapse
S/P Roux-en-y gastric bypass
Bilateral knee replacements [**2153-8-1**]
Social History:
Lives:alone, grandson may stay with her post-operatively. Lives
in [**Location (un) 5503**], MA
Occupation: Retired-ETT testing tech
Tobacco: Quit [**2129-1-16**](smoked 2ppd x20yrs)
ETOH: Rare use
Family History:
Notable only for cancer
Physical Exam:
Pulse:68 Resp:18 O2 sat: 97% RA
B/P Right:104/48 Left:
Height:5'5" Weight:250 #
General:
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 3/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
obese, well healed midline abdominal scar with umbilical hernia
at top of scar
Extremities: Warm [x], well-perfused [x] Edema: no
Varicosities:
mild, bilat
Neuro: Grossly intact, non-focal exam
Pulses:
Femoral Right: 1+ Left: 1+ - no hematoma
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Pertinent Results:
[**2154-4-22**] 05:15AM BLOOD WBC-8.5 RBC-3.27* Hgb-8.9* Hct-27.5*
MCV-84 MCH-27.2 MCHC-32.4 RDW-15.3 Plt Ct-191
[**2154-4-18**] 11:30AM BLOOD WBC-5.3 RBC-3.77* Hgb-10.1* Hct-31.6*
MCV-84 MCH-26.8* MCHC-32.0 RDW-14.9 Plt Ct-262
[**2154-4-18**] 11:30AM BLOOD PT-13.8* PTT-26.7 INR(PT)-1.2*
[**2154-4-25**] 05:35AM BLOOD PT-24.2* INR(PT)-2.3*
[**2154-4-24**] 05:05AM BLOOD Glucose-102* UreaN-30* Creat-0.9 Na-142
K-4.4 Cl-103 HCO3-33* AnGap-10
[**2154-4-18**] 11:30AM BLOOD Glucose-90 UreaN-21* Creat-0.6 Na-144
K-3.9 Cl-110* HCO3-28 AnGap-10
[**2154-4-18**] 11:30AM BLOOD ALT-9 AST-12 AlkPhos-72 Amylase-42
TotBili-0.3
[**2154-4-24**] 05:05AM BLOOD Mg-1.9
[**2154-4-18**] 11:30AM BLOOD VitB12-246
[**2154-4-18**] 11:30AM BLOOD %HbA1c-5.6 eAG-114
[**2154-4-18**] 11:30AM BLOOD Triglyc-42 HDL-63 CHOL/HD-2.1 LDLcalc-61
[**Hospital 93**] MEDICAL CONDITION:
61 year old woman with AVR
REASON FOR THIS EXAMINATION:
? effusions
Final Report
INDICATION: Aortic valve replacement. Please evaluate for
effusion.
PA AND LATERAL RADIOGRAPH OF THE CHEST: The mildly enlarged
heart size is
unchanged. The mildly enlarged mediastinal contour is unchanged.
Bibasilar
atelectatic changes are noted. Small bilateral pleural effusion
is
visualized. No pneumothorax is noted. Median sternotomy wires
and a replaced
aortic valve are unchanged.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Name (STitle) **]
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
Approved: MON [**2154-4-22**] 5:00 PM
Brief Hospital Course:
Admitted after cardiac catheterization and underwent
preoperative workup. Next day was brought to the operating room
for aortic valve replacement. See operative report for further
details. She received vancomycin for perioperative antibiotics.
Post operatively she was transferred to the intensive care unit
for management. In the first twenty four hours she was weaned
from sedation, awoke and was extubated without complications.
On post operative day two she was transferred to the floor.
Physical therapy worked with her on strength and mobility. She
was started on anticoagulation for her mechanical aortic valve
and atrial fibrillation. She continued to do well and was ready
for discharge home with services on post operative day six.
Medications on Admission:
Multivitamin
Omega 3 tabs 1200mg daily
Calcium with vitamin D 600mg-200units twice daily
Wellbutrin SR 200mg twice daily
Lamictal 300mg daily
Effexor XR 150mg daily
Beclomethasone inhaler 40mcg 2 puffs twice daily
Combivent 90mcg-18mcg/inh 2 puffs four times daily
Advair 500-50 i puff twice daily
Tricor 145mg daily
Magnesium oxide 500mg daily
Torsemide 40mg daily
Amiodarone 200mg daily
Coumadin 6mg daily - last dose 4/29
Singulair 10mg daily
Diovan 12.5mg-160mg once daily
Claritin 10mg once daily
Trazadone at bedtime
Cardizem CD 120mg once daily
Discharge Medications:
1. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day:
please take twice a day for 7 days then decrease to once a day .
Disp:*74 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H as
needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*0*
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:*0*
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for sleep.
7. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Magnesium Oxide 500 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
11. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2)
Inhalation four times a day.
Disp:*qs qs* Refills:*0*
12. Beclomethasone Dipropionate 40 mcg/Actuation Aerosol Sig:
One (1) Inhalation twice a day.
Disp:*qs qs* Refills:*0*
13. Effexor XR 150 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
14. Lamictal 150 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
15. Wellbutrin SR 200 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day.
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
16. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
17. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
18. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
19. Warfarin 5 mg Tablet Sig: Goal INR 2.5-3.0 Tablets PO once a
day: dose to be adjusted by coumadin clinic
.
Disp:*60 Tablet(s)* Refills:*2*
20. Warfarin 2 mg Tablet Sig: Goal INR 2.5-3.0 Tablets PO once a
day: dose to be adjusted by coumadin clinic .
Disp:*60 Tablet(s)* Refills:*2*
21. Coumadin
You will have INR drawn [**4-26**] for further dosing of coumadin
- you will receive your coumadin dose for [**4-25**] prior to leaving
22. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication Mechanical AVR
Goal INR 2.5-3.0
First draw [**4-26**]
Results to [**Hospital **] clinic - Dr [**Last Name (STitle) 83137**] office
phone [**Telephone/Fax (1) 18050**] fax [**Telephone/Fax (1) 86693**]
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Aortic stenosis s/p AVR
Atrial fibrillation
Asthma
Sleep Apnea on CPAP
Hyperlipidemia
Umbilical Hernia
Degenerative joint disease
Arthritis
Rheumatic fever
Inferior wall myocardial infarction
Hypertension
Anemia
Mitral valve prolapse
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait - s/p bilateral knee replacements
Incisional pain managed with dilaudid
Incisions:
Sternal - healing well, scant erythema at distal end from bra-
no drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Please continue CPAP as prior to admission
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2154-5-23**] 1:00
Please call to schedule appointments with your
Primary Care Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 83137**] - [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 72334**] (NP) in [**12-15**] weeks
Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**12-15**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Mechanical AVR
Goal INR 2.5-3.0
First draw [**4-26**]
Results to [**Hospital **] clinic - Dr [**Last Name (STitle) 83137**] office
phone [**Telephone/Fax (1) 18050**] fax [**Telephone/Fax (1) 86693**]
Completed by:[**2154-4-25**]
|
[
"V45.86",
"788.5",
"396.2",
"493.90",
"V43.65",
"715.90",
"412",
"041.4",
"553.1",
"272.4",
"599.0",
"327.23",
"401.9",
"V58.61",
"285.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"35.22",
"39.61",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
8017, 8073
|
3803, 4553
|
291, 446
|
8351, 8570
|
2176, 2993
|
9451, 10411
|
1417, 1443
|
5155, 7994
|
3033, 3060
|
8094, 8330
|
4579, 5132
|
8594, 9428
|
1458, 2157
|
239, 253
|
3092, 3780
|
474, 858
|
880, 1184
|
1200, 1401
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,115
| 188,008
|
47618+59019
|
Discharge summary
|
report+addendum
|
Admission Date: [**2133-9-2**] Discharge Date: [**2133-9-5**]
Attending:[**Name8 (MD) 100613**]
CHIEF COMPLAINT: Lightheadedness, melena, episode of
coffee-grounds emesis.
HISTORY OF PRESENT ILLNESS: This is an 83-year-old male with
a history of coronary artery disease, peptic ulcer disease,
congestive heart failure, and diabetes mellitus who presents
with two weeks of melena and lightheadedness.
Five days prior to admission, the patient had an episode of
coffee-grounds emesis. He also recalls some dyspnea on
REVIEW OF SYSTEMS: Review of systems reveals no chest pain,
abdominal pain, dysuria, fever, chills, or sweats. He
recalls a fall without loss of consciousness prior to the
melena. He has had stress from his daughter's death back in
[**2133-3-25**]. He admits to taking an aspirin per day for the
past 20 years. The patient quit smoking 28 years ago with a
+20-pack-year history and quit drinking 38 years ago.
In the Emergency Department, the patient's fingerstick blood
sugar levels were around the 400s, so he was given 8 units of
insulin subcutaneously, 6 units of insulin intravenously, and
put on a 2-units per hour insulin drip. He was also given
normal saline. An order was placed for packed red blood
cells because his hematocrit was 18, and Gastroenterology was
contact[**Name (NI) **]. Though he was guaiac-positive, the gastric lavage
revealed no blood or clots.
While in the Emergency Department, he had electrocardiogram
changes with ST depressions in leads I, aVL, V4, V5, and V6.
Therefore, the patient was given an aspirin.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Type 2 diabetes mellitus; non-insulin requiring.
2. Coronary artery bypass graft in [**2120**].
3. Coronary artery disease with 2-vessel disease; showing
right coronary artery that was stented and an occluded left
circumflex artery back in [**2133-4-25**].
4. Hypertension.
5. Hypercholesterolemia.
6. Peripheral vascular disease.
7. Congestive heart failure with an ejection fraction of
43% as documented on [**Initials (NamePattern4) **] [**2132-4-25**] percutaneous transluminal
coronary angioplasty.
8. Peptic ulcer disease.
9. History of alcohol abuse.
10. Cataracts.
11. Glaucoma.
12. Abdominal aortic aneurysm repair in [**2124**].
SOCIAL HISTORY: The patient quit smoking 28 years ago with a
+20-pack-year history. He also denies any alcohol use in the
past 38 years. He lives at home alone.
FAMILY HISTORY: Family history is significant for diabetes
mellitus, coronary artery disease, stroke, and pancreatic
cancer.
ALLERGIES: PENICILLIN.
MEDICATIONS ON ADMISSION: Mavik 2 mg p.o. q.d.,
Glucophage 850 mg p.o. b.i.d., Lopressor 50 mg p.o. q.d.,
aspirin 325 mg p.o. q.d., Lipitor 10 mg p.o. q.d.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed his pulse upon admission was 96, blood pressure
was 121/75, respiratory rate was 18, oxygen saturation was
92% on room air, temperature was 96.3. Head, eyes, ears,
nose, and throat revealed pupils were equal, round, and
reactive to light and accommodation. Extraocular movements
were intact. Mucous membranes were dry. The neck was supple
without lymphadenopathy or jugular venous distention.
Cardiovascular examination revealed a regular rate and
rhythm. Normal first heart sound and second heart sound. A
2/6 systolic ejection murmur at the left upper sternal border
without radiation. Chest revealed crackles at the bases
heard bilaterally. The abdomen was soft, nontender, and
nondistended, with decreased bowel sounds. Extremities
revealed no clubbing, cyanosis, or edema were noted. He felt
somewhat cool. Dorsalis pedis pulses were 1+ on the right
and 2+ on the left.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories upon
admission revealed his white blood cell count was 22.3 (with
77% neutrophils, 3% basophils, 12% lymphocytes, 5% monocytes,
2% eosinophils). Hemoglobin was 5.9, hematocrit was 18.9,
mean cell volume was 89, platelets were 389. Sodium was 131,
potassium was 5.1, chloride was 93, bicarbonate was 13, blood
urea nitrogen was 58, creatinine was 1.3, and blood glucose
was 403, anion gap was 25. PT was 13.3, PTT was 23, INR
was 1.2. ALT was 13, AST was 24, alkaline phosphatase
was 54, total bilirubin was 0.4. Creatine kinase was 132.
CK/MB was 10. CK/MB index was 7.6. Acetone was negative.
Troponin was 7.6. Urinalysis showed a glucose of greater
than 1000, was clear. Arterial blood gas done on 91%
saturation on room air revealed pH was 7.43, PCO2 was 31, PO2
was 95.
RADIOLOGY/IMAGING: Electrocardiogram showed a normal sinus
rhythm with heart rate of 98, normal axis, 2-mm ST
depressions in leads I, aVL, V4, V5, and V6.
A chest x-ray showed bibasilar patchy opacities that may be
consistent with some pulmonary edema.
HOSPITAL COURSE:
1. GASTROINTESTINAL: The patient was anemic secondary to a
peptic ulcer bleed or nonsteroidal antiinflammatory drug
induced gastritis. He was given 4 units of packed red blood
cells, and his hematocrit appropriately went from 18.9 to
28.3. He was given Protonix 40 mg p.o. q.d. for prophylaxis.
His aspirin was withheld due to the bleed. The patient was
scoped on [**2133-9-4**].
2. CARDIOVASCULAR: The patient had a demand ischemia and
lateral infarct, according to cardiac enzymes changes and
electrocardiogram changes. His infarct was located
laterally; according to the ST depressions that were found in
leads I, aVL, and V4 through V6. These electrocardiogram
changes remained stable and unchanged throughout the hospital
course.
Over a 24-hour period, his creatine kinase did rise from 132,
peaking at 696, and then declining down to 419. His CK/MB
was 10 on admission, peaking at 71, and trending down to 27.
His creatine kinase index was 7.6 on admission, peaking
at 12.1, and trending down to a normal value of 6.4.
His cardiologist, Dr. [**Last Name (STitle) **], did see him in house and
recommended that a beta blocker be added to his medication
regimen. Metoprolol 25 mg p.o. b.i.d. was added.
With regard to coronary artery disease, the patient's aspirin
was held in light of his gastrointestinal bleed. With regard
to the hypertension, the patient's blood pressure remained
within the normal systolic range of 90 to 135 over the
hospital course.
As for his congestive heart failure, the patient remained
clinically asymptomatic and was saturating above 90% during
the hospital stay.
3. RESPIRATORY: The patient did have a bilateral basilar
opacity on the chest x-ray. However, he did not have any
respiratory problems clinically. After his transfusion of
4 units of packed red blood cells, the patient was not given
any additional intravenous fluids that would exacerbate his
congestive heart failure. It was recommended that he follow
up with a chest x-ray within one week.
4. HEMATOLOGY: The patient's anemia resolved with a
transfusion of 4 units of packed red blood cells. His
hematocrit appropriately bumped from 18.9 to 28.3.
5. ENDOCRINE: Since the patient was started on a clear
liquid diet, per Gastroenterology recommendations, he was
restarted on his metformin 850 mg p.o. b.i.d. His medication
adequately controlled his fingerstick blood sugar levels of
below 100s.
6. RENAL: The patient did have a anion gap metabolic
acidosis with a transfusion and
hydration, the patient's acidosis did resolve. Also, the
hydration also helped resolve his prerenal azotemia because
his creatinine went from 1.7 back to a baseline of 1.3.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge status was to home.
MEDICATIONS ON DISCHARGE:
1. Protonix 40 mg p.o. q.d.
2. Metformin 850 mg p.o. b.i.d.
3. Lipitor 10 mg p.o. q.d.
4. Lopressor 50 mg p.o. q.d.
DISCHARGE DIAGNOSES:
1. Anemia secondary to upper gastrointestinal bleed.
2. Lateral myocardial infarction due to demand ischemia.
3. Coronary artery disease.
4. Hypertension.
5. Congestive heart failure.
6. Diabetes mellitus.
7. Prerenal azotemia.
DISCHARGE FOLLOWUP: The patient was to follow up with his
primary care provider (Dr. [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) 16791**]) within one week
after discharge. Recommendation of a follow-up chest x-ray
in one week and consideration of possibly restarting aspirin
at some time in the future.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4122**], M.D.
Dictated By:[**Last Name (NamePattern1) 4270**]
MEDQUIST36
D: [**2133-9-3**] 15:14
T: [**2133-9-8**] 08:51
JOB#: [**Job Number 42100**]
cc:[**Telephone/Fax (1) 100614**] Name: [**Known lastname 2596**], [**Known firstname 651**] Unit No: [**Numeric Identifier 16171**]
Admission Date: [**2133-9-2**] Discharge Date: [**2133-9-5**]
Date of Birth: [**2050-10-30**] Sex: M
Service:
ADDENDUM:
This is an addendum to the GI portion.
An EGD was performed showing a single non-bleeding 10 mm
ulcer of benign appearance without somata of recent bleeding
found in the duodenal bulb. Patient is just recommended to
be discharged on Protonix 40 mg p.o. q.d.
Also add to Cardiovascular that patient received an
echocardiogram which revealed ejection fraction of 35%, 2+
mitral regurgitation and 1+ tricuspid regurgitation. No new
cardiac medications are added.
DISCHARGE MEDICATIONS:
1. Metformin 850 mg p.o. b.i.d.
2. Protonix 40 mg p.o. q.d.
3. Lopressor 50 mg p.o. q.d.
4. Lipitor 10 mg p.o. q.d.
FOLLOW UP: Please follow up with Dr. [**Last Name (STitle) 16172**] within one week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4600**], M.D.
Dictated By:[**Last Name (NamePattern1) 4387**]
MEDQUIST36
D: [**2133-9-4**] 12:39
T: [**2133-9-7**] 10:50
JOB#: [**Job Number 16173**]
|
[
"272.0",
"401.9",
"424.0",
"285.1",
"428.0",
"410.51",
"276.2",
"531.40",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
2491, 2626
|
7821, 8057
|
9418, 9539
|
7679, 7800
|
2653, 4837
|
4855, 7552
|
9551, 9877
|
7567, 7653
|
549, 1580
|
123, 182
|
8078, 9395
|
211, 529
|
1603, 2309
|
2326, 2474
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,701
| 110,164
|
29768
|
Discharge summary
|
report
|
Admission Date: [**2130-12-23**] Discharge Date: [**2130-12-27**]
Date of Birth: [**2097-1-21**] Sex: M
Service: MEDICINE
Allergies:
Haldol
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Transfer of patient with mental status change, intubated for
airway protection.
Major Surgical or Invasive Procedure:
Extubation
History of Present Illness:
(per outside records, please note: Full details of his course
prior to presentation are not available as the OSH failed to
provide a discharge summary) This is a 33 year old gentleman
with a history of bipolar disorder, diabetes, and obesity who is
transferred from an OSH after being intubated for airway
protection when the patient presented to the ED obtunded. The
patient had presented originally to that ED for floridly
psychotic behavior per report. Per the patients father the
patient presented to [**Name (NI) **] for R foot cut on 6 pm [**2129-12-22**] and was
transferred to an inpatient psychiatry hospital (after being
medically cleared), at 9 pm. There the patient received 50 mg
of seroquel and 2 mg of ativan and became obtunded, prompting
his return to the ED. Tox screen negative. Head CT was negative
for acute process. Blood pressure and heart rate were w.n.l.
Narcan 2 mg was given without effect. The patient was intubated
for airway protection and, reportedly, for hypoxemia (though
this is not clear from documentation). He was mechanically
ventilated on SIMV--blood gas 7.38/46.2/83.5/26.6. The patient
was transferred to this MICU as no intensive care unit beds were
available there.
.
Per report the pt had a cellulitis and was started on Keflex.
Past Medical History:
1) Diabetes
2) Bipolar disease, has had multiple ED presentations for this
3) Obesity
Social History:
Single, homeless. Smokes a pack a day for past 5 years. Drinks
on social occasions.
Family History:
Not available
Physical Exam:
Wt 165, T 97, P 77, BP 131/61 Vent AC TV [**Age over 90 **]|RR 14|FiO2 70%|PEEP
5
Gen: Obese, male African American, sedated and intubated
Head: NCAT
Eyes: injected, pupils pinpoint
Nose: NG tube in place, some blood
Mouth: Intubated, secretions in ET tube
Neck: Supple
Chest: CTA b/l
Heart: RR S1S2
Abd: Obese, soft, non-tender
Ext: No edema, nl distal pulses, warm, small excoriation on
plantar R foot
Neurol: Reflexes mute, no Babinski sign elicited
Pertinent Results:
[**2130-12-23**] 04:16PM ASA-NEG ETHANOL-NEG ACETMNPHN-6.8
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2130-12-23**] 04:16PM URINE HOURS-RANDOM
[**2130-12-23**] 04:16PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2130-12-23**] 03:07AM TYPE-ART TEMP-36.2 RATES-14/0 TIDAL VOL-700
PEEP-5 O2-70 PO2-190* PCO2-51* PH-7.36 TOTAL CO2-30 BASE XS-2
-ASSIST/CON INTUBATED-INTUBATED
[**2130-12-23**] 03:07AM GLUCOSE-147* LACTATE-1.0 NA+-138 K+-3.8
CL--103
[**2130-12-23**] 03:07AM freeCa-1.22
[**2130-12-23**] 03:03AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2130-12-23**] 03:03AM URINE RBC-[**5-20**]* WBC-0-2 BACTERIA-OCC
YEAST-NONE EPI-0
[**2130-12-23**] 02:56AM GLUCOSE-140* UREA N-16 CREAT-0.9 SODIUM-140
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-24 ANION GAP-13
[**2130-12-23**] 02:56AM estGFR-Using this
[**2130-12-23**] 02:56AM CALCIUM-8.9 PHOSPHATE-3.9 MAGNESIUM-2.3
[**2130-12-23**] 02:56AM LITHIUM-1.0
[**2130-12-23**] 02:56AM WBC-14.0* RBC-4.68 HGB-11.2* HCT-33.2*
MCV-71* MCH-24.0* MCHC-33.8 RDW-16.5*
[**2130-12-23**] 02:56AM HYPOCHROM-3+ ANISOCYT-1+ MICROCYT-3+
[**2130-12-23**] 02:56AM PLT COUNT-386
[**2130-12-23**] 02:56AM PT-11.6 PTT-25.6 INR(PT)-1.0
Brief Hospital Course:
33 year old gentleman with diabetes, obesity, bipolar disorder
transferred after intubation for airway protection in the
setting of obtundation likely secondary to medication. He had
originally presented in florid psychosis and was transferred to
psychiatric hospital and became obtunded after receiving
seroquel and ativan; he was subsequently intubated for airway
protection. He was extubated [**12-23**] afternoon, with no
complications.
.
1) Mental status change. Pt originally was floridly psychotic,
than obtunded after receiving sedatives. Most likely the first
presentation was decompensated bipolarism (esp given he had not
taken medications for three days) and the obtundation was
iatrogenic. No localizing signs of infection including
meningitic signs. There is a mild leucocytosis on repeat labs,
however UA/UCx negative as well as unrevealing chest xray.
Leukocytosis is likely in the setting of stress respnse after
extubation. OSH head CT unremarkable. He is now Manic after
extubation managed with home meds and as needed im zyprexa
(15mg). Psychiatry has been following him during his
hospitalization and recommends placement in an extended care
facility.
.
2) Respiratory status. Intubated for airway protection, unclear
what respiratory status prior to intubation. No definite
medical indication for intubation. Extubated easily with sat's
98-100% on RA. Started on Levaquin on [**12-23**] for Moraxella in
sputum, he should continue this until [**12-29**].
.
3) Bipolar disorder: best explanation for initial presentation
of florid psychosis is decompensated bipolarism. Per father he
had been off all medications for three days. Started on
Lithium, but held geodon per psychiatry recommendations.
.
4) Diabetes, restarted metformin, covered with HISS
.
5) Tenia pedis: Found to have extensive cracking of feet and in
between toes. started on Lamisil on [**12-27**], should be continued
for the total of one week.
.
6) FEN: regular diabetic diet
.
7) Ppx: Will start protonix, ambulating.
.
8) Contact: Father Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (h) [**Telephone/Fax (1) 71252**], (c) ([**Telephone/Fax (1) 71253**].
Medications on Admission:
1) Metformin 1000 mg PO qHS
2) Geodon 40 mg [**Hospital1 **]
3) Eskalith 450 mg qAM,900 mg qPM
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Lithium Carbonate 450 mg Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO QAM (once a day (in the
morning)).
3. Lithium Carbonate 450 mg Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO QHS (once a day (at bedtime)).
4. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
8. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN
(as needed).
9. Olanzapine 10 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed for agitation:
Do not exceed 30mg/day.
10. Olanzapine 10 mg Recon Soln Sig: One (1) Recon Soln
Intramuscular TID (3 times a day) as needed for agitation: Do
not exceed 30mg/d.
11. Terbinafine 1 % Cream Sig: One (1) Appl Topical DAILY
(Daily) for 1 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 3844**] Hospital
Discharge Diagnosis:
Primary diagnosis:
Bipolar disorder, manic phase
Sedation from medications
Diabetes Mellitus
Discharge Condition:
Good
Discharge Instructions:
You were admitted with oversedation from medications. You were
intubated at an outside hospital and extubated at [**Hospital1 18**]. Please
call your doctor if you have any chest pain, shortness of
breath, fevers, chills, abdominal pain.
.
You were started on Levaquin on [**2130-12-23**], this should be taken
for a total of a 7 day course (to end on [**2130-12-29**]).
.
You also were started on lamisil for fungal infection of your
foot. Please apply this once a day for a total of a week to the
base of your foot and between your toes.
Followup Instructions:
Please make an appointment to follow up with your psychiatrist
one week after hospitalization.
|
[
"278.00",
"250.00",
"682.7",
"E939.4",
"780.09",
"296.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7231, 7286
|
3716, 5903
|
349, 361
|
7423, 7430
|
2402, 3693
|
8021, 8119
|
1898, 1913
|
6048, 7208
|
7307, 7307
|
5929, 6025
|
7454, 7998
|
1928, 2383
|
230, 311
|
389, 1672
|
7326, 7402
|
1694, 1781
|
1797, 1882
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,508
| 162,954
|
5747
|
Discharge summary
|
report
|
Admission Date: [**2159-11-18**] Discharge Date: [**2159-12-7**]
Date of Birth: [**2093-7-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
syncope, ICD firing
Major Surgical or Invasive Procedure:
epicardial and endocardial ablation x 2
cardiac catheterization
arterial line placement
central line and swan ganz catheter placement (right IJ)
History of Present Illness:
66F admitted to [**Hospital1 18**] on [**11-18**] with non-ischemic cardiomyopathy
(EF 20%), chronic atrial fibrillation on coumadin, s/p ICD [**7-24**]
for secondary prevention, with episode of syncope last night
while sitting in a chair. Reports feeling "haziness" just
before, then husband reports patient slumped over in chair and
"jumped" x 2, appearing like previous ICD firings. Pt
subsequently awoke, fully oriented, asymptomatic, brought to the
ED. Pt reports similar episode on Monday [**11-12**]. Prior to that,
last ICD firing was on Halloween. She has recently had increased
fatigability. She reports she went to see her outpatient
cardiologist last Monday, who told her to re-load with
amiodarone 200mg [**Hospital1 **] x 7 days (today is day 7). She was then
instructed to take 200mg daily starting tomorrow, an increase
from her prior dose of 100mg daily. She reports good compliance
with her medications. Pt denies preceding or recent chest pain,
shortness of breath, increase in LE swelling, PND, orthopnea, or
palpitations. She reports occasional sensation of ICD getting
hot without firing. ROS positive for 1 day of loose stools on
Monday, no associated abd pain/F/C/melena/BRBPR, self-resolved.
She has had normal po intake, urine output, and BMs since.
Past Medical History:
1. Idiopathic cardiomyopathy with LVEF = 20% diagnosed in [**2150**]
2. Atrial fibrillation - Multiple past attempts at DC
cardioversion. Anticoagulated, rate controlled with metoprolol
succinate and digoxin.
-s/p Pacemaker/ICD: placed by Dr. [**Last Name (STitle) **]/Dr. [**Last Name (STitle) **] in [**7-24**]
for secondary prevention and VT arrest, [**Company 1543**] Virtuoso VR;
RV Lead = 6949; VVI pacing at 40bpm
3. Asthma/COPD
4. Diabetes mellitus
5. Hypothyroidism - secondary to subtotal thyroidectomy for
nodule
6. Allergic rhinitis
7. Hypertension
8. Glaucoma
9. Gout
10. S/P removal of 9lbs. benign intra-abdominal tumor, patient
does not know primary
11. "[**Last Name 22899**] problem" for which she takes meclizine
Social History:
She lives with her husband, has a daughter who is very involved
in her healthcare. She does not smoke cigarettes, denies
drinking alcohol. She is not working currently and denies
regular exercise.
Family History:
She has a mother who had an enlarged heart and died suddenly at
age 62. She has a father who died during gallbladder surgery.
She has no siblings.
Physical Exam:
VS 97.2 HR 72 122/80 RR 20
Gen: aaox3, nad
HEENT: NCAT, sclerae anicteric, conjunctivae pink, moist MM
Neck: JVP of 7cm.
CV: irregularly irregular, no m/r/g
Chest: ICD in L chest, not hot to touch, no skin changes
overlying
Pulm: CTAB, no rales/wheezes/rhonchi.
Abd: Soft, NTND, +BS,
Ext: 1+ ankle edema, DP pulses 2+ b/l, 2+ symmetric radial
pulses
Pertinent Results:
EKG demonstrated atrial fibrillation 70bpm, normal axis, QRS
136, <1mm ST depression V5-6/I/aVL (seen on prior [**10-30**]), QRS
slightly longer vs [**10-30**] study.
TELEMETRY: AF 60s, occ PVCs
CXR: Left-sided ventricular pacer -fibrillator is seen with lead
in unchanged position. Marked cardiomegaly is stable. There is
no focal consolidation or pneumothorax. There is mild blunting
of the right costophrenic angle likely representing a small
pleural effusion. The osseous structures are unremarkable.
ECHO [**11-19**]: The left atrium is moderately dilated. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. The right atrial pressure is indeterminate.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is severe global
left ventricular hypokinesis (LVEF = XX %). No masses or thrombi
are seen in the left ventricle. Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg).
There is no ventricular septal defect. Right ventricular
systolic function appears depressed. The aortic arch 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 leaflets are mildly thickened. There is
no mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. The
tricuspid valve leaflets are mildly thickened. At least moderate
[2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is a very small
pericardial effusion. There are no echocardiographic signs of
tamponade.
ECHO [**11-29**]: There is severe global left ventricular hypokinesis
(LVEF = 10-15%). There is a small echodense pericardial
effusion, limited to the posterolateral aspect of the
pericardium, adjacent to the left ventricle and abutting the AV
groove. The effusion is echo dense, consistent with blood,
inflammation or other cellular elements. There is no apparent
free-flowing fluid in the pericardial space, and no effusion
anterior to ehe right ventricle. No right atrial or right
ventricular diastolic collapse is seen.
IMPRESSION: Small, loculated echodense pericardial effusion.
Severe global left ventricular systolic dysfunction.
ECHO [**11-30**]:
The left atrium is dilated. The right atrium is dilated. The
estimated right atrial pressure is 10-20mmHg. There is severe
global left ventricular hypokinesis (LVEF = [**10-6**] %). There is
moderate global right ventricular free wall hypokinesis. The
aortic valve leaflets (3) are mildly thickened. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is a small to moderate sized pericardial effusion mostly
adjacent to the LA and inferolateral/posterolateral LV measuring
1.3 cm in the largest dimension (taken in the subcostal view).
Upon 45 degrees sitting position, the effusion remains in the
same location with no significant component near the apical
region and only a small 0.4 cm component anterior to the RV.
There is mild variation of MV inflow with respiration but
overall no major convincing echocardiographic signs of
tamponade. No right atrial or right ventricular diastolic
collapse is seen.
Compared with the prior study (images reviewed) of [**2159-11-29**],
the effusion is in the same position but appears to be smaller,
otherwise no changes.
ECHO [**11-30**]: There is a small to moderate sized pericardial
effusion. There are no echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2159-11-30**], the findings are similar. Left ventricular
contractile function remains profoundly reduced.
ECHO [**12-6**]: The left atrium is elongated. The left ventricular
cavity is dilated. Overall left ventricular systolic function is
severely depressed (LVEF= 10-15%). Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
Moderate [2+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is a small
pericardial effusion. No right atrial or right ventricular
diastolic collapse is seen.
IMPRESSION: Small pericardial effusion. Severe left ventricular
systolic dysfunction.
CARDIAC CATH [**12-5**]: Selective coronary angiography of this
right dominant system reveals no angiographically apparent
coronary artery disease. The LMCA, LAD, LCx, RCA and their
branchs are without angiographically significant coronary artery
disease.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
CAROTID ULTRASOUND: FINAL READ PENDING UPON DISCHARGE. tech
read- no flow limiting lesions seen in the carotids, limited
study on the right side given right central line / swan ganz
catheter.
ABDOMINAL ULTRASOUND:
CHEST X RAY PORTABLE AP: [**12-6**]:
Tip of right PICC line projects over the right brachiocephalic
vein just before its junction with the left. Pulmonary artery
catheter tip projects over the main and proximal right pulmonary
arteries. Right ventricular, pacer-defibrillator lead is
unchanged in position.
Multifocal airspace opacities are improved, particularly in the
right mid-lung and left mid and lower lungs, but airspace
opacification at the right lung base persists, findings
consistent with improved pulmonary edema persistent pneumonia in
the right lower lung. An indistinct, nodular opacity projecting
over the left mid-lung field is more apparent today. Attention
should be paid to this area on followup studies to exclude
pulmonary infarction and/or septic embolus. No pneumothorax is
present. Small bilateral pleural effusions are unchanged.
IMPRESSION:
1. Tip of right PICC line in right brachiocephalic vein just
before its
junction with the left.
2. Improving pulmonary edema. Persisting right pneumonia.
3. Suggest followup study to evaluate possible left lung
infarct or septic Embolus.
LABS:
[**12-7**] procainamide and NAPA levels
[**12-6**] Proc level 3.4, NAPA 9.3
Hepatitis serologies: HBsAg negative, HBsAb negative, HBcAb
Negative, HAV Ab negative, HCV Ab negative
[**12-6**]: Haptoglobin 227, B12 967, Folate 15.6, Ferritin 1109,
TIBC 270, LDH 399, T bili 1.0, Retic 3.3%
12/19 ALT 58, AST 30, T bili 0.8
discharge CBC [**12-7**]: WBC 21.9, Hct 29.9, Plt 412
Admission CBC [**11-18**]: WBC 6.6, HCT 44, Plt 298
discharge Chem 10 [**12-7**]: Na 144, K 3.9, Cl 104, HCO3 30, Cr 1.2,
BUN 42, glucose 116
Coags [**12-7**]: PTT 23.6, INR 1.4
TSH 4.8, free T4 1.7
Hgb A1C: 6.7%
Micro data:
[**2159-11-28**] 8:28 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2159-11-28**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH OROPHARYNGEAL FLORA.
FURTHER WORK-UP PER DR [**Last Name (STitle) **] ([**Numeric Identifier **]).
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
ESCHERICHIA COLI. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- <=2 S =>32 R
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ <=1 S 4 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
BLOOD CULTURES X 2 NEGATIVE ON [**11-28**].
C DIFF [**11-28**] NEGATIVE
URINE CULTURE NEGATIVE [**11-18**]
Brief Hospital Course:
Patient is a 66 y/o female who was admitted for for syncope
while in chair on [**11-17**] w/ reported ICD firing, similar to past
firings, nonischemic cardiomyopathy EF 20%, chronic afib on
coumadin who is admitted to hospital for ICD firing, while
inpatient cardiac arrest s/p 60 beat run of VT resolved after 2
minutes of CPR and shocking herself out of it- s/p epicardial
and endocardial ablation x 2 for VT, on procainamide, also in
decompensated heart failure with a cardiac index of 2 (nadir of
1.5) intermittently on pressors and being transferred to [**Hospital1 2025**] for
evaluation for heart transplantation.
VT: Non ischemic cardiomyopathy with an EF originally of 20%,
s/p ablations inpatient and continues to be fluid overloaded,
repeat echos reveal an EF of [**10-1**]% consistently. She has been
tried on multiple antiarrhythmics, she was admitted on
amiodarone 200mg po bid. While inpatient she was switched to
mexilitine and quinidine- eventually switched to procainamide
without much effect initially. S/p an epicardial and
endocardial by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] ablation without much effect.
While on procainamide and s/p 1 ablation procedure the patient
was still having frequent episodes of VT, her ICD was also
adjusted so she was able to anti-tachycardic pace herself out of
her VT rather than shock herself out. Her procainamide dosage
was increased from an initial dose of 500mg po q6hrs to 1.25g po
q6hrs and she underwent a second ablation of 5 foci under a
higher power, both epicardial and endocardial. This ablation
procedure was performed by Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) **] on [**12-6**],
subsequent to this upon review of 12 hours of telemetry she had
non sustained VT with a maximum duration of 11 beats and only
about 8 episodes of this. Prior to the ablation and the
increase of procainamide she was having more frequent episodes
(up to 60 runs of NSVT per day with multiple (roughly [**4-26**])
episodes of antitachycardic pacing to terminate VT. Her
procainamide and NAPA levels were monitored, on discharge her
Proc and NAPA levels were pending, on [**12-6**] her proc level was
3.4 and NAPA 9.3, this was on a dose of 750-mg po q6hs, this
level should be monitored closely.
CHF / cardiogenic shock: Acute on Chronic Systolic CHF with an
EF 10-15%, unclear etiology of her CHF however she reports a
viral illness (URI type) of 3 months duration prior to her
diagnosis of heart failure and states that her CHF has been
attributed to this. She has global hypokinesis and dilation and
her coronary arteries were evaluated during this admission and
found to be completely clean- idiopathic versus viral
cardiomyopathy. The patient has been volume overloaded
throughout her stay. Her most recent echo reveals 2+ TR and
1+MR with an EF of [**10-1**]%. Post ablation procedure she had a
dedicated echo study to rule out increase effusion prior to
pericardial drain pull (placed for PPX post ablation procedure)-
this was preliminarly read as negative for increased size of
effusion but the final report is pending. Her PCWP corresponds
to her PA diastolic pressure (PCWP 4 points lower than PAD
usually), her PAD had reached a maximum of 40 and we were able
to diurese to a PA diastolic pressure of 18 roughly. Throughout
her stay she was diuresed with a lasix drip usually at a rate of
5 and diuresed very briskly, she is still fluid overloaded on
exam and continues to require diuresis of a goal negative 1 to
1.5 liters on day of discharge [**12-7**]. Her blood pressure was
usually in the systolic range of 90-100 and for this reason
bolus doses of lasix were avoided so a lasix drip was used. Her
cardiac index had been as low as 1.5 but around the time of
discharge was 2.0 off of pressors. She had only been on
neosynephrine for 12 hours and then transiently on levophed
which was thought to be a better pressor for her cardiogenic
shock than neosynephrine. She did not have evidence of end
organ damage as she was mentating appropriately and was making
urine with a stable if not improving creatitine. She does have
decompensated heart failure and does require pressors
intermittently, our choice of pressors is limited by her
ventricular tachycardia and her V tach was symptomatic and was
associated with transient drops in her SBP to the 40s. Her
diuresis is limited by her blood pressure and cardiac index
however she continues to be diuresed with a lasix drip. For
these reasons she was evaluated by the heart failure team
inpatient who thought a thorough evaluation for a heart
transplant was a viable option. She will be transferred to [**Hospital1 2025**]
to be futher evaluated for heart transplant as they are a
transplant center.
DM: her diabetes was under moderately good control until steroid
taper, patient was started on a insulin drip for her
hyperglycemia with BG to the 400s, well controlled when insulin
drip started.
PNEUMONIA: hospital aquired pneumonia, started on cefepime as
inpatient and improved clinically, finished 10 day course on
discharge date [**2159-12-7**].
ASTHMA: she has a history of asthma since childhood and
continued to have diffuse wheezes on exam, given a 5 day course
of steroids, this caused a leukocytosis and did improve her
wheezes. She has no other obvious source of infection, was
afebrile and her pneumonia was clinically improving so this
leukocytosis was thought to be due predominantly to her 5 day
steroid course. Asthma also controlled with levalbuterol and
atrovent nebulizers.
CRI: unclear etiology of her renal failure, her admission Cr was
1.5, discharge was 1.2. Baseline Cr seems to be roughly 1.0.
DISPO:
Patient was transfered to [**Hospital1 2025**] for heart transplant evaluation.
Medications on Admission:
Amiodarone 100mg po daily
Brimonidine ophthalmic
Colchicine 0.6mg 1 tab daily
Combivent 18mcg 2 puffs [**Hospital1 **]
Digoxin 0.0625mg daily
Fexofenadine 60mg po bid
Fluticasone 50mcg one spray in each nostril [**Hospital1 **]
Lasix 60mg daily
Glimeperide 2mg po daily
Levothyroxine 200mcg daily
Lipitor 10mg po daily
Meclizine 25mg po daily
Metformin 500mg po bid
Moexipril 15mg po daily
Montelukast 10mg daily
QVAR 80mcg [**Hospital1 **]
Toprol XL 25mg po daily
Coumadin 2mg daily
Discharge Medications:
1. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for gout.
8. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day) as needed.
9. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1) ML
Inhalation q6 prn ().
10. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
11. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4H
(every 4 hours) as needed for pain, fever.
12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
13. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
14. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Ten
(10) ML PO Q6H (every 6 hours) as needed.
15. Insulin Regular Human 100 unit/mL Solution Sig: insulin drip
Injection ASDIR (AS DIRECTED).
16. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for anxiety.
17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
18. Furosemide 10 mg/mL Solution Sig: lasix drip for goal I/O
balance of negative 1 liter / 24 hours Injection INFUSION
(continuous infusion).
19. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
20. Procainamide 250 mg Capsule Sig: Five (5) Capsule PO Q6H
(every 6 hours).
21. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1)
Inhalation every six (6) hours.
22. Norepinephrine Bitartrate 1 mg/mL Solution Sig: 0.03-0.25
titrate to CI > 2.0 Intravenous as directed.
23. Heparin (Porcine) in NS 10 unit/mL Kit Sig: as directed
Intravenous continuous drip: continuous heparin drip for goal
PTT 60-80.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis:
Ventricular Tachycardia
Acute on Chronic decompensated systolic heart failure
Nosocomial Pneumonia
Asthma exacerbation
Secondary Diagnosis:
Chronic renal insufficiency
Diabetes Mellitus
Discharge Condition:
Fair. On insulin drip, recently off pressors and recently
extubated on day of discharge. In decompensated heart failure
and continuing to have Non sustained ventricular tachycardia.
Discharge Instructions:
You were admitted because your ICD (defibrillator) fired because
your heart was in an abnormal fast rhythm. This happened
numerous times throughout your admission and was in slightly
better control by the time of your discharge after two ablation
procedures of both the inside and outside of your heart as well
as medication adjustments.
Many of your medications were adjusted, please pay special note
to your new medication regimen.
Please call your doctor or return to the emergency room if you
have additional symptoms such as lightheadedness, if you pass
out, chest pain, shortness of breath or any other worrisome
symptoms.
Followup Instructions:
Please follow up with your PCP [**Name Initial (PRE) 176**] 10 days of discharge from
the hospital.
Please follow up with your cardiologist within 10 days of
discharge from the hospital.
|
[
"585.9",
"425.4",
"483.8",
"493.22",
"428.23",
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"427.1",
"584.9",
"428.0",
"427.5",
"423.9",
"785.51",
"997.1",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.34",
"37.22",
"38.93",
"37.27",
"88.56"
] |
icd9pcs
|
[
[
[]
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20013, 20028
|
11598, 17388
|
336, 482
|
20278, 20464
|
3308, 8073
|
21145, 21336
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2773, 2922
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17922, 19990
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20049, 20049
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17414, 17899
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8090, 10350
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20488, 21122
|
2937, 3289
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10391, 11575
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277, 298
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510, 1787
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20209, 20257
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20068, 20188
|
1809, 2542
|
2559, 2757
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,443
| 175,319
|
19790
|
Discharge summary
|
report
|
Admission Date: [**2156-12-22**] Discharge Date: [**2157-1-24**]
Date of Birth: [**2128-3-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Haldol / Compazine / Desipramine / Chlorpromazine
/ Imipramine / Zoloft / Shellfish Derived
Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
1. Intubation
2. Transesophageal ECHO
3. Right PICC line placement
4. Left PICC line placement
History of Present Illness:
Ms. [**Known lastname **] is a 28 year old morbidly obese female with a
history of asthma and of DVT/PE presenting with a chief
complaint of chest pain. She was recently discharged after an
ICU stay. She was admitted during that stay for this chest
pain. PE and ischemia were ruled out as causes of her chest
pain, however, her hospital course was complicated by an episode
of hypercarbic respiratory failure and an episode of respiratory
alkalemia, both requiring intubation. She complained of [**2158-7-18**]
chest pain throughout her hospital stay. A thorough history and
physical exam, EKG, Cardiac Enzymes, Echocardiogaphy (TTE &
TEE), breast discharge cultures, blood cultures, chest x-rays,
CT scan, abdominal ultrasound, and CT failed to discover an
organic etiology of her pain. A comprehensive review of outside
hospital records from [**Hospital3 **], Caritas [**Hospital3 **],
Caritas [**Hospital3 **], and [**Hospital6 **] indicated that
the she has chronically complained of unexplained chest pain in
the past 6 months. Psychiatry was involved in her care and
during her stay lithium was discontinued d/t polyuria and
incontinence, risperdal was converted to abilify because of
hyperprolactinemia. She was d/c'd to Shattock on [**2156-12-16**].
.
At [**Hospital1 **], she intermittently used her BIPAP. She complained
of generalized sharp chest pain and SOB on [**2156-12-19**], EKG showed
no changes, CXR was unremarkable, and Ddimer was 325. She
spiked a fever on [**2156-12-19**]. Blood cultures were drawn and she
was placed on vancomycin because of her history of MRSA. Staph
simulans and enterococcus avium were grown from the PICC line.
She was switched to daptomycin 1100 mg IV daily because the
enterococcus was vancomycin resistant, but she refused the
daptomycin. Her PICC was removed on [**2156-12-22**]. On [**2156-12-21**], a
maculopapular rash was noted on her left maxilla and she
complained of blurry vision. Vision was grossly intact at that
time and there were no noted concerning physical findings. She
refused any topical and oral/IV antibiotics per report. She
denied any pain with EOM. She reported "blurriness" in her left
eye.
.
Per report, she did not like her care at [**Hospital1 **] and left AMA
on the day of presentation. However, in the cab ride home, she
developed chest pain and reported to the [**Hospital1 18**] ED. Her chest
pain was similar to previous episodes, stretched across her left
and right chest, radiated to her right shoulder, and was
associated with N/V. She denied diaphoresis. She reported some
worsening DOE over the last few days.
.
ED vitals: 100.0 HR 97 101/34 92% on 4L RR 20
CXR was poor quality and repeat was recommended. Her EKG had
stable abnormalities from previous.
Past Medical History:
1. Borderline personality disorder
2. Mood Disorder, NOS
3. History of self-mutilation
4. History of DVT/PE
5. Obesity hypoventilation vs. sleep apnea
6. Asthma
7. Urinary Incontinence
8. History of hypercarbic respiratory failure
9. Obesity
10. History of suicidal ideation with multiple past attempts
11. History of MRSA cellulitis
12. History of Pneumonia
13. History of Bacteremia
Social History:
Non-smoker, no IV drug use but does have a history of marijuana
use. She has a history of alcohol abuse with DTs and withdrawal,
occasional current use. Only child, raised by IV drug addict,
physically abusive parents until age 8 when taken into DSS
custody. States she was "mad at the world" and set fires. Was
psychiatrically hospitalized and grew up between [**Doctor Last Name **] homes,
residential facilities, and inpatient psychiatric hospitals.
Remained institutionalized in various settings including years
in intermediate care at [**Hospital6 4331**]. One year ago,
tried it on her own and describes struggling since being outside
of a group home or other institutionalized setting. She has
spent much of the past year bouncing between medical and
psychiatric institutions, often creating medical complaints
while in psychiatric settings to move to medical units. Of
note, the anniversary of mother's death is [**12-10**] and the
anniversary of her father's death is [**8-13**]. She generally
psychiatrically decompensates and becomes suicidal on these
dates.
Family History:
Parents deceased; otherwise noncontributory.
Physical Exam:
Vitals: T 99.3, HR 91, BP 102/52, 95% 2L NC
General: Obese, NAD, laying flat in bed
HEENT: NC/AT, PERRL, EOMI, nonicteric sclera. Mild erythema over
left maxilla and bruising over left superior orbit
Neck: supple, no elevated JVD
Pulmonary: Lungs CTA bilaterally- no wheezing limited by
habitus.
Cardiac: RRR, nl. S1S2, no M/R/G noted. limited by body habitus.
Abdomen: obese, soft, NT/ND, normoactive bowel sounds, no masses
or organomegaly noted.
Extremities: No C/C/E bilaterally, notable well healed scars
from cutting.
Skin: no rashes or lesions noted. many well healed scars on
forearms.
neuro: aox4 grossly, cn 2-12 intact grossly, moves all
extremities
eye: vision 20/50 bilaterally
Pertinent Results:
Admission Labs:
WBC-6.5 RBC-3.60* Hgb-9.2* Hct-31.0* MCV-86 MCH-25.6* MCHC-29.7*
RDW-15.8* Plt Ct-443*
Neuts-53.5 Lymphs-38.2 Monos-5.7 Eos-2.2 Baso-0.4
PT-16.0* PTT-24.2 INR(PT)-1.4*
Glucose-118* UreaN-9 Creat-0.6 Na-139 K-3.8 Cl-102 HCO3-26
CK(CPK)-35 cTropnT-<0.01 Lactate-2.9*
.
[**2156-12-22**] 5:45 pm BLOOD CULTURE #2.
Blood Culture, Routine (Preliminary):
REPORTED BY PHONE TO [**Last Name (LF) 53482**], [**First Name3 (LF) 8081**] ON [**2156-12-23**] @ 1840.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
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.
Rifampin should not be used alone for therapy.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SECOND MORPHOLOGY.
FINAL SENSITIVITIES.
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.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
CLINDAMYCIN----------- 4 R =>8 R
ERYTHROMYCIN---------- =>8 R =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- =>8 R =>8 R
OXACILLIN------------- =>4 R =>4 R
PENICILLIN G---------- =>0.5 R =>0.5 R
RIFAMPIN-------------- <=0.5 S <=0.5 S
TETRACYCLINE---------- 2 S 2 S
VANCOMYCIN------------ 2 S 2 S
Aerobic Bottle Gram Stain (Final [**2156-12-23**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
.
[**2156-12-23**] 5:05 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2156-12-27**]**
Blood Culture, Routine (Final [**2156-12-27**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
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.
Rifampin should not be used alone for therapy.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SECOND MORPHOLOGY.
FINAL SENSITIVITIES.
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.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
CLINDAMYCIN----------- =>8 R =>8 R
ERYTHROMYCIN---------- =>8 R =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- =>8 R =>8 R
OXACILLIN------------- =>4 R =>4 R
PENICILLIN G---------- =>0.5 R =>0.5 R
RIFAMPIN-------------- <=0.5 S <=0.5 S
TETRACYCLINE---------- <=1 S 2 S
VANCOMYCIN------------ 2 S 2 S
Aerobic Bottle Gram Stain (Final [**2156-12-24**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2156-12-24**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
.
Studies:
[**2156-12-22**] EKG - Sinus tachycardia with baseline artifact. Diffuse
non-diagnostic repolarization abnormalities. Compared to the
previous tracing of [**2156-12-13**] heart rate is increased with new
non-diagnostic repolarization abnormalities.
[**2156-12-22**] CXR - FINDINGS: As compared to the previous radiograph,
the right costophrenic sinus and the left distal part of the
costophrenic sinus are still not included on the image. In the
visible part of the thorax, there is no obvious abnormality. No
parenchymal opacities, masses. The artifact described on the
previous radiograph is no longer seen. Borderline size of the
cardiac silhouette, no overhydration.
[**2156-12-23**] TTEcho - The left atrium is normal in size. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). The number of aortic valve
leaflets cannot be determined. No masses or vegetations are seen
on the aortic valve, but cannot be fully excluded due to
suboptimal image quality. No mass or vegetation is seen on the
mitral valve. Trivial mitral regurgitation is seen. There is no
pericardial effusion.
IMPRESSION: Limited study due to lack of patient cooperation. No
mitral valve vegetation or significant regurgitation seen.
[**2156-12-24**] EKG - Sinus rhythm. Diffuse non-specific ST-T wave
changes. Compared to the previous tracing of [**2156-12-22**] the T
waves are more flattened.
[**2156-12-25**] Right finger x-rays - FINDINGS: There is a dislocation
of the distal interphalangeal joint with persistent flexion at
this level. No evidence of underlying fracture.
[**2156-12-26**] Right UE ultrasound - IMPRESSION: No evidence of deep
vein thrombosis in the right upper extremity. Right cephalic
superficial venous thrombosis.
[**2156-12-27**] TEEcho - No spontaneous echo contrast or thrombus is
seen in the body of the left atrium or left atrial appendage. A
small color Doppler signal of left-to-right flow across the
interatrial septum is seen at rest c/w a small secundum atrial
septal defect with 2mm width. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque to 45 cm from the incisors. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. No masses or vegetations are seen on the aortic
valve. No aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. No mass
or vegetation is seen on the mitral valve. No masses or
vegetations are seen on the tricuspid valve. No vegetation/mass
is seen on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: No valvular pathology or pathologic flow identified.
Small secumdum ASD with left to right shunt. Normal
biventricular systolic function.
[**2156-12-28**] Left UE ultrasound - IMPRESSION: No evidence of deep
venous thrombosis in the left upper extremity.
[**2156-12-28**] Right finger x-rays - FINDINGS: Three views of the
right fourth finger show no fracture. Again seen is a palmar
subluxation of the distal phalanx. This is unchanged in
appearance when compared to the previous study from [**2156-12-25**]. Joint spaces appear well preserved with no degenerative
change. There are no soft tissue calcifications.
[**2156-12-30**] IMPRESSION: Uncomplicated ultrasound and
fluoroscopically guided double-lumen PICC line placement via the
right basilic venous approach. Final internal length is 53 cm,
with the tip positioned in SVC. The line is ready to use.
[**2157-1-18**] IMPRESSION: Uncomplicated ultrasound and
fluoroscopically guided 5 French intraluminal PICC line
placement via the left brachial venous approach. Final internal
length is 47 cm, with the tip positioned in SVC. The line is
ready to use.
[**2157-1-22**] Right hand x-rays - There are no signs for acute
fractures or dislocations. In particular, the fourth PIP joint
is well aligned. No bony erosions are seen. There is normal
osseous mineralization. There is some soft tissue swelling
throughout the whole hand and wrist.
[**2157-1-23**] Left hand x-rays - final report not posted, but
preliminary report states no acute fractures.
Brief Hospital Course:
Ms. [**Known lastname **] is a 28 year-old morbidly obese female with severe
borderline personality disorder a history of DVT/PE and OSA vs.
obesity hypoventillation syndrome who presented after leaving
AMA from [**Hospital1 **] with her usual chest pain and in addition,
recent fevers and documentation of bacteremia. The patient was
initially admitted to the MICU due to her history of
unresponsive episodes requiring intubation as well as
difficulties with behavioral control on the medicine floor
requiring frequent nursing attention during her previous
admission. These issues were resolved and the patient was
transferred to the general medical floor on [**2157-1-11**] where she
remained until her discharge.
# Borderline Personality Disorder / Psychiatric issues: Ms.
[**Known lastname **] has severe borderline personality disorder and may
additionally have a mood disorder, although exact
characterization is difficult due to the severity of her
personality disorder. Previous providers have diagnosed her
with "depression", "PTSD", and "bipolar disorder". The patient
was actively followed by the psychiatry consult service who
created a behavioral plan to assist the medical team in working
with the patient and to minimize splitting of staff. The
psychiatry consult service also provided recommendations
regarding psychiatric medications for the patient. Many of the
patient's former psychiatric medications were tapered and
stopped as it was felt that they were providing little benefit
to the patient and contributing to her somnolence. After her
PICC line was placed on [**12-30**], droperidol 1.25 - 2.5 mg IV and
ativan 05.- 1.0 mg IV were used for chemical restraint and the
patient was also allowed to request these medications if she
felt herself becoming agitated. While these medications did not
completely calm the patient, they did help to take the edge off
of her agitation. When the patient did allow EKG monitoring and
blood draws after receiving these medications, no abnormalities
were noted. Additionally, she did not become hypoxic after
receiving ativan. After her guardianship hearing zyprexa [**6-19**]
mg PO and ativan 0.5-1.0 mg PO were made available to the
patient, however, she did not utilize the former. The only
standing psychiatric medication that the patient was ordered for
was Aripiprazole (Abilify) 10 mg PO daily, however, the patient
routinely refused this medication throughout the course of her
admission, taking it only intermittantly.
The patient frequently exhibited difficulties around periods of
transition and change in her care, often requiring additional
monitoring for safety. The following is a summary of the
behavioral plan extracted from Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 53483**] note of
[**2157-1-11**]:
a) Emotional Dysregulation/impulsivity: Ms. [**Known lastname **] tends to
get very mad very quickly. During these times, trying to talk
through the situation tends to only make the anger worse. When
this happens use the following strategies:
--Tell [**Known firstname **]: "I see that you are very angry. I'm going
to give you 20 minutes to cool off then come back to check in on
you." Come back in 20 minutes and say, "[**Known firstname **], it has been 20
minutes, I've come back to check in. Are you ready to discuss
your medical care."
--Encourage [**Known firstname **] to utilize "distraction" techniques
such
as watching television, listening to music, or drawing/coloring.
--Encourage [**Known firstname **] to place ice on her arms/wrists to help
decrease the urge to cut herself.
--[**Known firstname **] will rate her anxiety/agitation on a scale
("emotions thermometer"). If her self-rating is over 60, she
may
request .5mg IV lorazepam up to twice daily. This medication
will be closely monitored given concern for respiratory
depression.
--If [**Known firstname **] is acutely agitated c extreme agitation &
warrants "chemical restraint", may use zydis 5mg, may repeat x 1
for max dose of 20mg in 24 hours. Alternatively, if refusing
oral medication and in need of chemical restraint, may use IM
olanzapine 5-10mg &/or lorazepam .5-2mg PO/IM/IV.
Alternatively,
--If possible, avoid placing hands on patient when she is
dysregulated, unless there is a fear that patient is a danger to
self, others, or is attempting to leave. In those cases physical
force may be necessary and this was told to the patient.
b) Consistency for [**Known firstname **]: Ms. [**Known lastname **] has a difficult time
adapting to new treaters and changes in the routine. She does
better with those she is more familiar with. As much as is
possible in an academic hospital, she would do best with having
the same staff involved in her care. At changes of shift, new
staff should make an extra effort to introduce themselves and
let
her know the plan for the shift.
c) Consistency for treaters: There should be extra efforts to
ensure that all treaters are on the same page. All treaters
should be instructed to read this treatment plan. We should
have, at a minimum, weekly interdisciplinary team meetings to
discuss ongoing challenges to providing Ms. [**Known lastname **] with the
highest level of care.
d) Safety issues: Patient should have all sharps removed from
room. She should be given only plastic silverware. Silverware
should be removed immediately after she finishes eating.
In further regards to safety, hospital security had to be called
on several occassions to return the patient to her room when she
left the MICU or to forcibly restrain her after she hit and spit
at staff or after she refused to stop harming herself. During
most of her hospital stay she was 1:1 with either a security
sitter or a hospital staff sitter. Security were also called on
several occassions when the patient's room was searched.
# Facial cellulitis: On the morning of discharge the patient was
noted to have an erythematous left cheek that was slightly
warmer than her right cheek. No induration or fluctuance was
noted. Given her history, it is possible that this finding was
self-induced, though no evidence of trauma was noted. As the
patient has a prior history of facial cellulitis she was started
on bactrim for a 10 day course given her history of medication
non-compliance. The area of erythema was outlined with a pen
prior to discharge. If this area expands significantly or
becomes indurated, a medicine consult should be obtained to
evaluate for a change in therapy.
# Positive blood cultures: Documentation from Shattock showed
Staph. simulans (a coagulase negative Staph.) and Enterococcus.
The Enterococcus was resistant to vancomycin. The two bacteria
together were only both sensitive to linezolid and rifampin.
Two blood cultures drawn at the beginning of this admission were
sensitive to vancomycin. The nidus of the patient's infection
was never discovered. A transthoracic echo showed no
endocarditis or valvular vegetations. Her admission chest
x-ray was without infiltrates. Urine culture on admission was
negative. A dental consult was obtained, as the patient
complained of tooth pain, however, dental panorex was negative
for abscess and the dentist felt there was no acute oral
disease. A right upper extremity ultrasound did show a
partially occluded thrombus in the cephalic vein. However,
blood cultures from [**12-26**] through [**1-4**] did not grow any
bacteria. On admission the patient was started on a 14 day
course of linezolid to treat her documented bacteremia at
Shattock. The patient intermittantly refused to take this
medication. She had no further fevers during her hospital stay.
She did intermittantly have mildly elevated temperatures, but
these often occurred in association with episodes of agitation.
# History of DVT/PE: The patient has a documented history of DVT
in the right subclavian and branchial veins with associated PE
in [**10-18**] at Caritas [**Hospital3 **]. A CTA performed at [**Hospital1 18**] on
[**2156-11-28**] demonstrated no central or segmental pulmonary
embolism. On this admission the patient was initially placed on
a heparin gtt due to a subtherapeutic INR. Heparin was stopped
when the patient's INR became therapeutic. The patient
frequently refused warfarin as well as blood draws (despite
having a PICC line) for INR monitoring. However, despite only
taking about 50% of her prescribed doses (4 mg daily) the
patient maintained an INR of ~2. Initial recommendations from
the ICU team were for warfarin anticoagulation for a period of 6
months following her [**10-18**] PE. On transfer to the medical floor
the patient continued to complain of chest pain and request a
repeat CT scan. She was informed that this was not medically
indicated and that she was already receiving the recommended
medical therapy for this condition. She continued to frequently
refuse to take warfarin, despite multiple conversations on this
subject. On [**2157-1-22**] warfarin anti-coagulation was discontinued
after the patient intentionally harmed herself by gouging
herself with a pen, requiring three stitches, and punching her
hand into a door multiple times. The following day she punched
her other hand into a door. Given that the patient's DVT/PE
occurred in the setting of having a PICC line, that she is now
nearly three months after initiating anticoagulation with
documented resolution of her PE in [**11-17**], that she is
intermittantly compliant with warfarin therapy, that she
routinely refuses blood draws for INR monitoring, and that she
is at risk for intentionally harming herself and for bleeding,
it is recommend that the patient no longer be anticoagulated.
If, in the future, the patient agrees to take warfarin on a
regular basis, to submit to INR monitoring, and stops physically
harming herself, anticoagulation could be reconsidered. If this
occurs, consideration of fingerstick monitoring of INR should be
considered as placement of a PICC line imposes a risk of
infection and permits the patient an opportunity to fight over
the types of labs drawn and whether the PICC needs to be
removed. If the patient has new hypoxia, it would be reasonable
to initiate medical evaluation and reassessment for PE.
# OSA / Obesity hypoventilation syndrome: On her prior [**Hospital1 18**]
admission, the patient had an episode of somnolence with
hypercarbia requiring intubation. It was felt that this episode
was related to oversedation. Her psychiatric regimen has
changed considerably since that episode and the patient has not
been allowed to have ambien for sleep as the team wanted to be
able to use ativan if necessary and not risk oversedation.
During episodes on this admission in which the patient was found
"unresponsive" and intubated, her blood gases were within the
range of normal for her (baseline pCO2 50s-60s). Subsequently,
the MICU team began further investigating these episodes. The
patient's O2 sat was generally in the low- to mid-90s during
these episodes and arm drop tests often indicated volitionality.
The medical team subsequently decided to monitor O2 sats and
not to proceed with further intervention if her O2 sat was >
85%. During her stay on the general medical floor, the patient
became upset several times when her episodes of
"unresponsiveness" were "ignored" by medical staff (i.e., O2 sat
> 85%). When questioned further, the patient stated that she
could hear what staff were saying when they came to check her O2
sat and she was "unresponsive".
The patient was repeatedly advised to wear BiPAP/CPAP while
sleeping and consistently refused to do so. She also refused
supplemental oxygen by nasal cannula. Continuous O2 sat
monitoring in the ICU demonstrated that the patient does
occasionally desat to the 70s or 60s ([**First Name9 (NamePattern2) 53484**] [**Location (un) 1131**] was at times
poor) while sleeping, but recovers spontaneously on her own.
From a medical standpoint, the patient would benefit from
wearing BiPAP/CPAP, but has clearly demonstrated that she is in
no imminent danger when not wearing it and she consistently
refuses to wear it. The change in her psychiatric medications
with less sedating medications have likely helped in this
regard. Her most recent ??????unresponsive?????? episodes appear to be
psychogenic and not true medical emergencies. If the patient
ever does indicate a willingness to wear a BiPAP/CPAP mask, she
would benefit from a formal sleep study and fitting of an
appropriate mask.
# Suture removal: On the evening of [**1-21**] the patient gouged
herself with a pen that she had hidden and was not discovered on
a room search earlier in the evening. Three sutures were placed
on [**1-22**]. They should be removed sometime between [**1-29**] and
[**2-1**].
# Urinary incontinence: The patient has previously taken
ditropan, but this medication was stopped as she claimed it was
not helping her. She was frequently incontinent of urine, and
often this incontinence was volitional. The patient requested a
trial of Detrol, however, this medication was not started due to
its anti-cholinergic effects and potential to exacerbate her
underlying psychiatric issues.
# Restless leg syndrome: The patient was formerly on Requip.
That was changed to Gabapentin 100mg QHS per psychiatry recs.
The patient frequently declined this medication.
# Headaches: Could be related to a variety of factors including
poor sleep cycle. The patient stated that she has a history of
migraine headaches which she treats with caffeine, typically by
drinking large amounts of coffee. This habit was discouraged
and she was offered tylenol and ibuprofen, but often refused
these medications.
# Asthma: The patient was written for scheduled fluticasone and
bronchodilators. She routinely refused these medications.
There was no clinical suspicion for asthma exacerbation during
her hospital stay.
# Diarrhea: Most likely an antibiotic side effect which resolved
with time. Her stools were C. diff negative x 3. Stool O&P
negative x 2. The patient was written for prn immodium.
# Vaginal yeast infection: The patient was treated several times
during her admission for this condition with both miconazole
vaginal cream daily x 7 days and oral fluconazole. She was
advised to stop purposefully wetting herself and lying in her
urine to prevent recurrence of yeast infections. She was also
written for miconzole powder for yeast in her intertriginous
folds.
# Medication non-compliance: The patient frequently refused her
scheduled medications and rarely used her prns.
# The patient frequently refused to participate in her own
medical care, but also often voiced somatic complaints as a way
of seeking attention and often requested specific medical
interventions. Many of these complaints and their subsequent
evaluation are further outlined below. Additionally, she
frequently quizzed staff on medical topics and then later
manipulated that information when she voiced medical concerns.
a) Chest pain - The patient frequently complained of chest pain
during her admission. At times chest pain was reproducible with
palpation. At times the pain was anterior, at other times
lateral, and at times in her low to mid back. Multiple EKGs and
cardiac enzyme checks during this hospitalization were negative
for ischemia. The patient was already on appropriate therapy
for PE as described above. As outlined in her previous [**Hospital1 18**]
discharge summary and briefly reviewed in her HPI, this
complaint has been a frequent and chronic one for the patient
over the past year and despite multiple evaluations no organic
etiology for her pain has been defined. The patient was written
for omeprazole per prior regimens to treat presumed GERD,
however, she took this medication only intermittently.
b) Abdominal pain/Nausea - LFTs, amylase, lipase normal. UA
normal. Vital signs normal, afebrile. The patient's
intermittant abdominal pain and/or nausea was attributed to poor
diet.
c) Finger subluxations - The patient has repeatedly subluxed her
right ring finger, and at times other fingers. The initial
episode occured when attempting to push herself up from bed,
however, multiple subsequent episodes appear to be purposeful
and attempts to seek attention. Plastic surgery was consulted
and saw the patient several times and finger x-rays were
performed. Per plastic surgery, the patient has a swan neck
deformity caused by a lax ligament which she can fix on her own
or can be easily reduced by staff. The finger is not truly
dislocated and does not require emergent/urgent reduction. They
recommended a special splint for the patient, however, she
refused to wear it. When the patient requested a hard cast,
plastic surgery stated that this was not indicated. The patient
was provided prn tylenol, ibuprofen, and ultram for pain. No
narcotics were given.
The patient also endorsed hypoasthesia in the dorsal aspect of
the 4th and 5th digits, consistent with a disruption of the
dorsal sensory branch of the ulnar nerve, potentially caused by
one of her numerous lacerations to the right forearm and wrist.
This is condition is chronic and does not require further
evaluation.
When the patient is more stable psychiatrically, and if she has
no ongoing medical issues, the patient may pursue surgical
correction of the lax ligament. The plastic surgery team felt
that this should be done as an outpatient.
d) Mouth lesion: The patient bit the inside of her lip while
eating one day. Despite her request for stitches, these were
not placed as it was not felt to be indicated. Her laceration
is healing well.
e) Polydypsia/polyuria: Blood glucose normal. Patient with high
PO fluid intake at times. No need to evaluate further.
f) Hot/cold flashes: The patient intermitantly complained of
"hot flashes" or being extremely cold. She did not have any
fevers during these periods and blood cultures were drawn and
were negative during some of these occassions. TSH was 2.2 on
[**2156-12-9**]. The patient requested "hormonal testing" and was
advised that she should follow-up with an endocrinologist as an
outpatient. Of note, during her previous [**Hospital1 18**] admission the
patient did have hyperprolactenemia induced by risperdal and
that medication was stopped.
g) Left shoulder pain: For several days during her MICU stay the
patient complained of left shoulder pain. It was unclear if
this was an attempt to get attention or if it was real. She had
full ROM of on exam and x-rays were deemed unnecessary.
Ibuprofen, tylenol, and ultram were provided on a prn basis.
After a few days the patient no longer complained of shoulder
pain.
h) "Laryngitis": One day prior to discharge the patient
complained of "a sqeaky voice", speaking is a whispered/raspy
voice in association with a sensation of throat swellinng and
her typical chest and "lung" (really low back) pain. There was
good air movement and no wheezing on exam. There was no
evidence of facial or neck swelling. She was offered a cepacol
losenge. The patient's voice improved markedly a few hours
later when she became agitated at staff. By the following day
her vocal issues had resolved.
i) Unresponsive episodes: as outlined above.
# Access: The patient is extremely difficult, if not impossible
to obtain peripheral access in. A PICC line was placed by IR on
[**12-30**]. It was removed a couple of weeks later due to discomfort
at the site and continued picking at the site on the part of the
patient. A new PICC line was placed in the opposite arm,
however, the patient continued to complain of pain at the site
(the patient routinely complained of IV or PICC site pain
throughout her hospital course). As the patient repeatedly
refused lab draws, even noninvasive lab draws from the PICC
line, and due to the risk of infection and thrombophelbitis
posed by invasive lines, it no longer made sense to maintain a
PICC line solely for lab draws given tenderness at the PICC
site. Reinsertion of a PICC line would be indicated if the
patient develops a need for IV medications or treatment.
# Indications for further medical evaluation:
- widening area of facial cellulitis and/or induration or
fluctuance
- new hypoxia (room air O2 sat < 90% while awake, not holding
her breath, or < 85% while asleep)
- fever > 101 F
# Legal: Given the patient's repeated demonstrations of
emotionally-driven and often irrational behavior and choices not
congruent with her own well-being, guardianship for this patient
was pursued. In a court hearing on [**2157-1-20**] [**First Name4 (NamePattern1) 3608**] [**Last Name (NamePattern1) 4334**] (ph:
[**Telephone/Fax (1) 5350**]) was appointed as the patient's guardian.
Medications on Admission:
Meds from [**Hospital1 **]:
Advair [**Hospital1 **]
mvi
detrol 1mg po bid
colace 100 [**Hospital1 **] prn
senna 2 qhs
omeprazole 20 qday
requip 1.5 qhs
miconazole cream topical
tylenol 650 q 6 hrs prn
motrin 600 q 8 hrs prn
celexa 60 qday
abilify 10 mg qday prn anxiety
abilify 15 qday
percocet 5/325 q 6hrs prn pain
ambien 5 qhs depakote 2000mg qhs
combivent 2 puffs qid
maalox 30cc p 8 hrs prn indigestion
bipap
nystatin powder topical
coumadin 2mg qday (being held)
.
Allergies: Penicillins / Haldol / Compazine / Desipramine /
Chlorpromazine / Imipramine / Zoloft / Shellfish Derived
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: Not to exceed 4g in 24 hours.
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
5. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
7. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
8. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
9. Tramadol 50 mg Tablet Sig: 0.5 - 1 Tablet PO Q6H (every 6
hours) as needed.
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed.
11. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q8H (every 8 hours) as needed.
14. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
15. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO ONCE MRX1 PRN () as needed for
agitation/anxiety.
16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO ONCE MRX1 PRN
() as needed for agitation, anxiety, sleep.
17. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Mucous
membrane lozenge as needed.
18. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 5016**] [**Doctor Last Name 1495**] Raphaels TCU - [**Location (un) 7661**]
Discharge Diagnosis:
Primary Diagnoses:
1. Severe borderline personality disorder
2. Bacteremia with coagulase negative Staph and Enterococcus
3. History of pulmonary embolism
4. Obstructive sleep apnea vs. obesity hypoventilation syndrome
5. Mood disorder NOS
Secondary Diagnoses:
1. Asthma
2. Self-injurious behavior
3. Urinary incontinence
4. Facial cellulitis
Discharge Condition:
Good. Vital signs stable (SBP 90s-140s, HR 80s-110, O2 sat >
94% on room air, afebrile).
Discharge Instructions:
You were admitted to [**Hospital1 18**] with a complaint of chest pain. No
specific cause for this chest pain was identified. You were
also treated for a blood infection during your stay which
resolved, and you were anticoagulated with warfarin because of
your history of PE. Because you did not take this medication on
a regular basis, refused blood draws to monitor your levels, and
have recently demonstrated self-injurious behavior, you are not
currently considered a candidate for this therapy. A previous
CT scan here has demonstrated resolution of your previous PE.
You were also recommended to wear CPAP/BiPAP at night for your
obstructive sleep apnea. It will help you to feel less tired
and better overall, however, you have repeatedly chosen to
refuse this therapy.
On the day of discharge you were started on the antibiotic
bactrim for a 10 day course for left-sided facial cellulitis.
You should complete this course. Please seek medical attention
if the area of redness increases in size.
Followup Instructions:
It is recommended that you reside in a structured environment
and seek further care for your psychiatric issues.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]
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icd9pcs
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[
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37279, 37394
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378, 474
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5568, 5568
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328, 340
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502, 3274
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5584, 5904
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3699, 4778
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,766
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44369
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Discharge summary
|
report
|
Admission Date: [**2160-10-12**] Discharge Date: [**2160-10-26**]
Date of Birth: [**2085-11-25**] Sex: F
Service: GENERAL SURGERY
HISTORY OF PRESENT ILLNESS: 74-year-old woman, recently
admitted to [**Hospital6 2561**], presented to [**Hospital1 346**] complaining of right lower quadrant
pain. The patient was discharged from [**Hospital6 2561**]
in the morning of [**2160-10-11**]. The patient states pain
denies any radiation of pain. No nausea or vomiting. The
patient denies any bowel movement or flatus today.
PAST MEDICAL HISTORY: Chronic obstructive pulmonary
disease/asthma, ileocolonic intussusception, gastrointestinal
bleed, myocardial infarction, coronary artery disease, atrial
fibrillation, bipolar disorder, cerebrovascular accident,
PAST SURGICAL HISTORY: Cholecystectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS: Amiodarone, Levoxyl, Depakote, lasix, zinc,
Prevacid, Zyprexa, Serzone, and Atrovent.
SOCIAL HISTORY: The patient lives in an [**Hospital3 **]
facility. The patient denies any history of tobacco,
alcohol, or drug use. The patient is married.
PHYSICAL EXAMINATION: The patient is afebrile, vitals are
stable. The patient was in no acute distress.
Cardiovascular examination was tachycardic, with a regular
rhythm. The patient's lungs were clear to auscultation
bilaterally. The patient's abdomen was soft, slightly
distended. The patient had right lower quadrant tenderness,
positive guarding and rebound tenderness. No masses were
palpated. Rectal examination showed no masses. The patient
was guaiac positive.
LABORATORY DATA: CT scan at [**Hospital6 2561**] showed a
large ileocolic intussusception with no evidence of
obstruction or bowel ischemia, a small right adrenal mass,
diverticulosis with no evidence of diverticulitis,
gastroesophageal hernia.
HOSPITAL COURSE: The patient was admitted under the General
Surgery service, and underwent ileocecectomy on [**2160-10-12**]. The patient tolerated the procedure well. Estimated
blood loss was 150 cc. No transfusions were given.
On postoperative day number one, Cardiology was consulted for
management of the patient's atrial fibrillation. The patient
was started on Lovenox for deep venous thrombosis
prophylaxis. Lopressor was increased to 10 mg intravenously
every six hours for better control of heart rate. The
patient was encouraged to get out of bed and ambulate.
Physical Therapy consult was obtained, and rehabilitation
screening was initiated.
On postoperative day number two, Lovenox was discontinued.
The patient was started on aspirin 81 mg once daily.
Lopressor was changed to 25 mg three times a day. Amiodarone
was discontinued.
On postoperative day number three, intravenous fluids were
hep-locked. The patient was started on sips of clears.
Psychiatric consultation was obtained to evaluate the
patient's psychiatric status, given prior history of rapid
decompensation. Psychiatry recommended the patient to be
continued on her psychiatric medications.
On postoperative day number four, antibiotics were
discontinued. On postoperative day number five, the patient
was continued on sips of clears.
On hospital day number six, the patient's diet was advanced
as tolerated. The Foley was discontinued. On postoperative
day number eight, the patient was ready for discharge to
rehabilitation when she passed a large amount of melanotic
stool. Hematocrit dropped from 30 to 18.9. Blood pressure
was in the 70s and 80s. Heart rate increased to the 130s in
atrial fibrillation. The patient was given a 500 cc normal
saline bolus, and 400 mg of oral amiodarone.
Gastroenterology consult was obtained for endoscopy. The
patient underwent an esophagogastroduodenoscopy on [**2160-10-20**], which showed a polyp in the second part of the
duodenum, but otherwise normal esophagogastroduodenoscopy without
evidence of upper GI bleeding.
The patient was admitted to the Surgical Intensive Care Unit
on [**10-20**] for monitoring. The patient was given four
units of packed red blood cells on [**2160-10-20**].
On postoperative day number nine, the patient's hematocrit
increased to 29.6 and no further melena occurred. The patient's
heart rate decreased to the 80s. Blood pressure stabilized to
120/60.
On postoperative day number ten, the patient was given two
additional units of packed red blood cells. Hematocrit was
increased to 32.2. On postoperative day number 11, the
patient was transferred from the Surgical Intensive Care Unit
to the floor. The patient's hematocrit was monitored
closely, which has stabilized to the low 30s. The patient
was started on clears on [**2160-10-23**].
On postoperative day number 12, Patient-controlled analgesia
was discontinued. The patient's medications were switched to
oral form. Intravenous was hep-locked. On postoperative day
number 13, the patient tolerated a full diet. Lopressor was
increased to 25 mg by mouth once daily for better control of
the patient's tachycardia. The patient was started on lasix
20 mg by mouth once daily for mild pulmonary edema which
responded to diuretics.
On postoperative day number 14, the patient was discharged to
a rehabilitation facility tolerating a regular diet and with
stable hematocrits.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: To rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Ileocolic intussusception secondary to Stage II
adenocarcinoma with negative lymph nodes status post
ileocecectomy on [**2160-10-12**]
2. Lower Gastrointestinal bleed
3. Hypovolemia and acute anemia on chronic anemia
4. Urinary retention then incontinence requiring replacement of
catheter.
5. Bipolar Disorder controled on current regiment
6. Atrial Fibrillation with rapid ventricular response
7. COPD with CO2 retention
8. Malnutrition requiring TPN post op
9. Mild CHF from fluid shifts perioperatively requiring diuresis
DISCHARGE MEDICATIONS: The patient was discharged on her
previous medications.
1. Levothyroxine 50 mcg by mouth once daily
2. Albuterol nebulizer every four hours
3. Depakote
4. Ipratropium nebulizer every six hours
5. Protonix 40 mg by mouth once daily
6. Amiodarone 200 mg by mouth once a day
7. Olanzapine 7.5 mg by mouth daily at bedtime
8. Venlafaxine 37.5 mg by mouth once daily
9. Lopressor 25 mg by mouth twice a day
FOLLOW-UP PLANS: The patient is to follow up with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**] as well as the medical oncology service for
consideration of adjuvant therapy if deemed necessary . The
patient was instructed to call Dr.[**Name (NI) 11471**] office for an
appointment in [**1-27**] weeks.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 19318**]
Dictated By:[**Last Name (NamePattern1) 1909**]
MEDQUIST36
D: [**2160-10-25**] 20:48
T: [**2160-10-26**] 00:00
JOB#: [**Job Number **]
|
[
"427.31",
"557.0",
"428.0",
"153.4",
"263.9",
"493.20",
"276.5",
"578.9",
"560.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.73",
"99.15",
"45.13",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5933, 6346
|
5369, 5909
|
1860, 5276
|
802, 959
|
1141, 1842
|
5291, 5348
|
6364, 6954
|
179, 542
|
565, 778
|
976, 1118
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,925
| 133,360
|
6859
|
Discharge summary
|
report
|
Admission Date: [**2139-4-2**] Discharge Date: [**2113-4-10**]
Service: UROLOGY
HISTORY: The patient is an 87-year-old male with bladder
cancer, initially treated with transurethral resection of
bladder tumor by Dr. [**Last Name (STitle) 365**] in [**2138-9-10**]. Treatment
failed, and he presented to [**Hospital1 188**] for elective cystectomy.
PAST MEDICAL HISTORY: Negative stress test in [**2139-9-10**], with an ejection fraction of 55%, status post coronary
artery bypass graft in [**2137-9-10**]. Hypertension,
hypercholesterolemia, bladder cancer.
HOME MEDICATIONS: Lipitor 40 mg by mouth once daily,
Tenormin 50 mg by mouth once daily, Adalat 30 mg by mouth
once daily, Prinivil 20 mg by mouth once daily.
ALLERGIES: Narcotics.
HOSPITAL COURSE: The patient was taken to the operating room
by Dr. [**Last Name (STitle) 365**] on [**2139-4-3**]. The patient underwent a
cystectomy and ileal conduit diversion and pelvic lymph node
dissection. Postoperatively, the patient was doing well, and
condition was stable to the recovery room. The patient was
initially admitted to the Intensive Care Unit. In the
Intensive Care Unit, the patient was clinically stable, and
hypertension was under control. The patient was transferred
to the floor on postoperative day number two.
The patient's recovery course was complicated by an episode
of disorientation and dementia while on the floor, and an
episode of confusion while on the floor. The patient was on
intravenous fluids and nothing by mouth, and awaiting bowel
function.
On postoperative day number four, the patient appeared to be
agitated and pulled out the nasogastric tube, and appeared to
be disoriented. Geriatric consult was obtained. With their
recommendation, the narcotics were discontinued. The patient
was put on Vioxx for pain control. They believe the patient
is suffering from long-term cognitive decline, and has some
underlying cognitive decline but this is impossible to
diagnose in the face of delirium. Iron sulfate has been
changed to 225 mg once a day oral dosing. The patient's
delirium has resolved, and the patient is to arrange follow
up with Dr. [**First Name (STitle) **] from Geriatrics in two to three months
after discharge from [**Hospital1 69**].
The patient was doing well since then. On postoperative day
number five, the patient has been started on some oral
intake. On postoperative day number seven, one of the stents
was pulled. On postoperative day number eight, the other
ureteral stent and [**Location (un) 1661**]-[**Location (un) 1662**] drain will be discontinued.
The patient will be discharged with an ileal conduit and a
Foley. Prior to discharge, the patient was tolerating a
regular diet. Vital signs were stable. The patient was
afebrile. The chest was clear to auscultation. The heart was
regular rate and rhythm. The abdomen was soft, nontender,
nondistended. The mucosa was pink. The ileal conduit was
putting out urine. The incision was clean, dry and intact,
with no drainage, no pus. The patient was tolerating a
regular diet and passing flatus, and having normal bowel
movements. The Foley is still in place.
DISCHARGE MEDICATIONS: Included Prinivil 20 mg by mouth
once daily, Tenormin 50 mg by mouth twice a day, Vioxx 50 mg
by mouth once daily as needed, Adalat 30 mg by mouth once
daily, Lipitor 40 mg by mouth once daily, iron sulfate 325 mg
by mouth once daily, Colace 100 mg by mouth twice a day.
The patient is to follow up with Dr. [**First Name (STitle) **] from Geriatrics in
two to three months, and the patient is to follow up with Dr.
[**Last Name (STitle) 365**] in one to two weeks. Prior to discharge, the patient
was taught ileal conduit care and Foley care.
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 12485**], MD [**MD Number(1) 12486**]
Dictated By:[**Name8 (MD) 186**]
MEDQUIST36
D: [**2139-4-10**] 22:42
T: [**2139-4-11**] 00:10
JOB#: [**Job Number 25920**]
|
[
"V45.81",
"185",
"293.9",
"272.0",
"311",
"188.9",
"E942.6",
"414.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"56.51",
"57.71",
"96.07",
"40.3"
] |
icd9pcs
|
[
[
[]
]
] |
3203, 4017
|
781, 3178
|
596, 763
|
387, 577
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,307
| 125,723
|
22869
|
Discharge summary
|
report
|
Admission Date: [**2121-2-13**] Discharge Date: [**2121-2-24**]
Date of Birth: [**2072-10-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
Positive Exercise Tolerance Test
Major Surgical or Invasive Procedure:
CABGx3(LIMA->LAD, SVG->OM1, PDA) [**2121-2-17**]
Cardiac Catheterization [**2121-2-14**]
History of Present Illness:
Mr. [**Known lastname 59124**] is a splendid 48 year old gentleman with a three
month history of intermittant dyspnea and chest pressure. He
underwent a stress mibi which was positive for apical and
adjoining anteroseptal wall ischemia. He was subsequently
transferred to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for a
cardiac catheterization.
Past Medical History:
Coronary artery disease
Percutaneous coronary intervention
Diabetes mellitus
Hypercholesterolemia
Hypertension
Social History:
Married with 5 children. Works as a janitor. Never smoked.
Drinks [**1-5**] beverages every few weeks.
Family History:
Mother with stroke at age 72.
Two brothers with strokes at ages 53 and 48.
Physical Exam:
Temp: 98.5 BP: 118/58 Pulse: 62 Weight: 178
GEN: Middle aged hispanic man in no distress
HEENT: PERRL, EOMI, Anicteric sclera. Oropharynx clear.
NECK: No Jugular venous distention
CARDIAC: RRR, Normal S1-S2. No murmur.
LUNGS: CLear
ABDOMEN: Normoactive bowel sounds, soft, nontender, nondistended
EXT: No edema, Pulses 2+ throughout. No varicosities, no edema
Pertinent Results:
[**2121-2-13**] 10:35PM WBC-8.4 RBC-4.79 HGB-15.0 HCT-42.0 MCV-88
MCH-31.4 MCHC-35.8* RDW-12.5
[**2121-2-13**] 10:35PM PLT COUNT-218
[**2121-2-14**] 05:30AM BLOOD PT-13.3 PTT-72.2* INR(PT)-1.1
[**2121-2-14**] 05:30AM BLOOD Glucose-96 UreaN-16 Creat-0.8 Na-142
K-4.0 Cl-105 HCO3-29 AnGap-12
[**2121-2-14**] 11:50AM BLOOD ALT-40 AST-19 AlkPhos-66 Amylase-53
TotBili-0.9 DirBili-0.2 IndBili-0.7
[**2121-2-24**] 09:50AM BLOOD Glucose-186* UreaN-18 Creat-0.8 Na-136
K-4.6 Cl-99 HCO3-28 AnGap-14
[**2121-2-24**] 09:50AM BLOOD WBC-10.9 RBC-3.23* Hgb-9.6* Hct-28.3*
MCV-88 MCH-29.7 MCHC-33.9 RDW-13.9 Plt Ct-435#
[**2121-2-24**] 09:50AM BLOOD Glucose-186* UreaN-18 Creat-0.8 Na-136
K-4.6 Cl-99 HCO3-28 AnGap-14
[**2121-2-13**] CXR
Normal chest radiograph.
[**2121-2-18**] CXR
No pneumothorax. Left-sided pleural effusion with reactive
collapse/atelectasis.
[**2121-2-14**] Cardiac Catheterization
1. Two vessel coronary artery disease including left main
coronary
artery disease.
2. Normal left ventricular systolic function.
3. Moderate left ventricular diastolic function.
[**2121-2-13**] EKG
Sinus rhythm
Nonspecific ST segment elevation - clinical correlation is
suggested
No previous tracing
[**2121-2-17**] elevation - repeat if myocardial injury is suspected
Possible old inferior myocardial infarction
Since previous tracing, further ST-T wave changes noted
Brief Hospital Course:
Mr. [**Known lastname 59124**] was admitted to the [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical
Center on [**2121-2-13**] for a cardiac catheterization. This revealed a
70% stenosed left main coronary artery, an occluded left
anterior descending artery and a 50% stenosed right coronary
artery. The ejection fraction was noted to be 64%. Due to the
severity of his disease, heparin was started and the cardiac
surgical service was consulted for surgical management. Mr.
[**Known lastname 59124**] was worked-up in the usual preoperative manner. On
[**2121-2-17**], Mr. [**Known lastname 59124**] was taken to the operating room where he
underwent coronary artery bypass grafting to three vessels.
Postoperatively he was taken to the cardiac surgical intensive
care unit for monitoring. On postoperative day one, Mr. [**Known lastname 59124**] [**Last Name (Titles) **]e neurologically intact and was extubated. He was slowly
weaned from pressor support over the next three days. The
physical therapy service was consulted for assistance with his
postoperative strength and mobility. He was gently diuresed
towards his preoperative weight. On postoperative day four, Mr.
[**Known lastname 59124**] was transferred to the cardiac surgical step down unit
for further recovery. His drains and epicardial pacing wires
were removed per protocol. Toradol was used for treatment of his
sternal pain with good effect. The [**Last Name (un) 387**] diabetes service was
consulted for assistance with his diabetes medications as his
blood sugars remained high on his preoperative regimen. Mr.
[**Known lastname 59124**] continued to make steady progress and was discharged
home on postoperative day seven. He will follow-up with Dr.
[**Last Name (STitle) 70**], his cardiologist and his primary care physician as an
outpatient.
Medications on Admission:
Accupril 20mg daily
Amitriptyline 100mg at bedtime
Lipitor 80mg Daily
Nitroglycerin As needed
Toprol XL 100mg Daily
Glucovance 5/500mg Twice daily
Aspirin 81mg Daily
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. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 7 days.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. 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*
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Glyburide-Metformin 5-500 mg Tablet Sig: One (1) Tablet PO
BREAKFAST (Breakfast): 2 PO at dinner.
Disp:*90 Tablet(s)* Refills:*2*
9. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Amitriptyline HCl 100 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Disp:*30 Tablet(s)* Refills:*0*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
12. Lancets Regular Misc Sig: One (1) Miscell. four times
a day.
Disp:*1 months supply* Refills:*2*
13. One Touch Ultra Test Strip Sig: One (1) Miscell. four
times a day.
Disp:*1 months supply* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
Discharge Diagnosis:
Coronary artery disease.
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:
Make an appointment with Dr. [**Last Name (STitle) **] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 70**] for 6 weeks.
Make an appointment with [**Hospital **] Clinic for diabetic teaching @
[**Telephone/Fax (1) **]
Completed by:[**2121-3-24**]
|
[
"V45.82",
"413.9",
"414.01",
"401.9",
"458.8",
"272.4",
"250.00",
"790.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"37.22",
"88.56",
"88.53",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6761, 6809
|
3071, 4955
|
356, 446
|
6878, 6885
|
1680, 3048
|
7127, 7395
|
1207, 1283
|
5172, 6738
|
6830, 6857
|
4981, 5149
|
6909, 7104
|
1298, 1661
|
284, 318
|
474, 937
|
959, 1071
|
1087, 1191
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,976
| 148,937
|
38301
|
Discharge summary
|
report
|
Admission Date: [**2166-2-6**] Discharge Date: [**2166-3-4**]
Date of Birth: [**2083-3-26**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
1. Drainage of abscess, intra-abdominal.
2. Open cholecystectomy.
3. Argon beam of hepatic surface for coagulation.
Flexible bronchoscopy.
History of Present Illness:
The patient is a 82 y/o M with h/o acute cholecystitis on [**6-17**]
which was accompanied by a STEMI epsiode.A cholecystotomy tube
was placed for acute cholecystitis.The tube fell out and he
subsequently developed bile peritonitis. He then underwent ERCP
with stent placement for the same.His hospital stay was
complicated by post ERCP pancreatitis. A couple of months
later,on [**2165-8-27**] ,he redeveloped acute cholecystis and
cholecystostomy tube was placed to relieve the symptoms.He had
been doing well since then and his cholecystostomy was removed.
The patient now presents with 2 day history of sharp abdominal
pain esp in epigastric region radiating to RUQ and right
shoulder.This was accompanied by nausea and an episode of
vomiting. He denies fever.
ROS:
(+) per HPI
(-) Denies fevers, chills, night sweats, unexplained weight
loss, fatigue/malaise/lethargy, changes in appetite, trouble
with sleep, pruritis, jaundice, rashes, bleeding, easy bruising,
headache, dizziness, vertigo, syncope, weakness,
paresthesias,hematemesis, bloating, cramping, melena, BRBPR,
dysphagia, chest pain, shortness of breath, cough, edema,
urinary frequency, urgency
Past Medical History:
- CAD s/p STEMI, Vfib arrest [**2165-6-20**], and BMSx2 to RCA on
[**2165-6-22**]
- CHF, echo [**2165-6-23**] post-MI: Regional left and right ventricular
systolic dysfunction c/w CAD (proximal RCA distribution
involving RV and PDA territories).
- h/o complete heart block [**2165-6-20**], with pacemaker implanted and
subsequently removed due to poor positioning and return to NSR
- Type 2 Diabetes on insulin
- Hypertension
- Osteoporosis
- CKD stage III-IV, on Procrit, baseline over past 2 mos
([**Month (only) **]-[**Month (only) 205**]) approx. 1.5-2.0
- CEA in [**2162-7-9**] with repeat imaging [**5-17**] showing plaque L w/
50% stenosis, no stenosis on R
- s/p TURP in [**2137**]
- Cataracts
Social History:
Lives with wife, two sons and grandson. Originally from
[**Country 13622**] Republic. Previously independent with ADL's. Worked in
construction. Now retired. Wife, [**Name (NI) **], is HCP.
-Tobacco history: Denies
-ETOH: Denies
-Illicit drugs: Denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
99.6 99.6 82 134/62 20 97RA
AOX3, NAD, able to ambulate with walker or one assist
RRR
Breath sounds throughout but decreased in the RLL. Fine crackles
bilaterally
Abdomen softly distended, appropriately tender, nl bowel sounds
Incision c/d/i
JP putting out dark SS fluid
PTC putting out cream colored fluid
Diffuse edema in all extremities
Scrotal and penile edema.
Pertinent Results:
ADmission labs:
[**2166-2-6**] 04:50PM BLOOD WBC-8.5 RBC-3.82* Hgb-12.0* Hct-35.8*
MCV-94 MCH-31.4 MCHC-33.5 RDW-14.1 Plt Ct-167
[**2166-2-6**] 05:50PM BLOOD PT-17.3* PTT-29.9 INR(PT)-1.6*
[**2166-2-6**] 04:50PM BLOOD Glucose-257* UreaN-63* Creat-2.4*#
Na-132* K-5.5* Cl-98 HCO3-24 AnGap-16
[**2166-2-6**] 04:50PM BLOOD ALT-20 AST-23 CK(CPK)-61 AlkPhos-39*
Amylase-10 TotBili-0.5 DirBili-0.2 IndBili-0.3
[**2166-2-7**] 01:00AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.2*
Discharge labs
[**2166-3-4**] 08:50AM BLOOD WBC-8.7 RBC-2.80* Hgb-8.0* Hct-24.7*
MCV-88 MCH-28.6 MCHC-32.5 RDW-16.4* Plt Ct-544*
[**2166-3-4**] 08:50AM BLOOD Glucose-94 UreaN-23* Creat-1.2 Na-139
K-4.6 Cl-104 HCO3-29 AnGap-11
Brief Hospital Course:
Mr [**Known lastname **] was admitted to the West 3 service on [**2-6**] and kept
NPO, on IVF with a foley for UOP monitoring, and on unasyn with
IV pain control. His home meds were started and he was placed on
an ISS for blood sugar mgmt. He had an abdominal US which
showed: Gallbladder sludge. Evidence of air within the
gallbladder lumen; may be result of prior procedure. Air was
also seen in the gallbladder on CT from [**2165-7-19**]. No biliary
dilatation.
- [**2-8**] his foley was d/ced and he voided. His diet was advanced
to a clears, diabetic diet.
- [**2-9**] his IVF were heplocked after adequate PO intake.
- [**2-10**] his ranitidine was changed to IV PPI. He also was
restarted on IVF and got a 500 cc IVF bolus for concern for c
diff and increased WBC with decreased UOP. His Unsyn was
switched to zosyn and vancomycin.He had a CT of the abdomen and
pelvis which showed: Findings suggestive of acute cholecystitis,
with associated bile leak causing large hepatic sub-capsular
biloma, with adjacent secondary inflammation of the ascending
colon and hepatic flexure.
- [**2-11**] Mr. [**Known lastname **] had his CCY with biloma drainage. He was then
Admitted to TICU post-op. OR: 3500 LR, 7 PRBC, 4 FFP, 1 PLTs/
[**Age over 90 **] F EBL 3500. PACU: 2 FFP, 2 PRBC. total of 3 Liters bolused
post-op for low UOP. Given addition 2 PRBC in ICU. L axillary
line ([**Last Name (un) 18821**]). Bedside echo performed, demonstrates poor EF
without evidence of fluid overload.
- [**2-12**]: Transfused 1 unit PRBCs, started on dobutamine gtt for
low SBP despite levophed. On serial echos, EF and volume
overload worsening. Renal consulted, feels CRRT not currently
indicated. JP#2 with high output and HCT down - HCT on JP fluid
pending.
- [**2-13**]: s/p transfusion 1 unit platelets for platelets 79, bumped
to 98. RIJ cordis switched to dialysis catheter. Packed by ENT.
Cardiology recs: consider swan, transfuse hct > 25. Renal:
volume status acceptable, plan CVVH 'shortly'. Bedside echo
showed mildly improved cardiac function.
- [**2-14**]: Off pressors in AM. CPAP 5/5. Vanc 17 in AM(holding), PM
Vanc=15. Nutrition consult for TF's (likely to start [**2-15**]).
Renal: trial of lasix goal 1 L negative over 24 hr, lasix gtt
started. bedside Echo: fluid overloaded EF~35%. ENT
cauterized/packed epistaxis.
- [**2-15**]: Abx changed to levo/flagyl/vanc per ID recommendations,
started albuterol/atrovent MDI for wheezing. Good diuresis, but
worsening cardiac output; bolused with albumin with improvement.
Lasix gtt stopped, CXR much improved.
- [**2-16**]: Extubated. ID recommended changing antibiotics
meropenem/vancomycin (-[**2-21**]). Levo/flagyl d/c'd ([**Date range (1) 75508**]). No
HSQ, aspirin, plavix, or TFs today (TFs likely to start
tomorrow) per primary team. D/c'd insulin gtt. Vanc trough 16.5.
KUB pending for abdominal pain.
- [**2-17**]: SCH started. Off albuterol. changed protonix to
famotidine. Auto-diuresing (goal 1.5 L negative). HD line
d/c'ed. Dobhoff placed, written to start TF's when post-pyloric.
- [**2-18**]: IR-guided post-pyloric DHT placed, Na increasing, so
free water DHT flushes initiated (250ml 6). Pt delirious;
started on zyprexa. Diuresing w/ lasix, with worsened metabolic
acidosis. 500ml free H2O given via DHT. Continued agitation,
started zyprexa. Metabolic acidosis improving, but hypernatremia
worsening.
- [**2-19**]: discontinued diuresis. Started standing tylenol and
oxycodone, off zyprexa, cont'd seroquel, changed famotidine to
omeprazole per [**Female First Name (un) **] recs. Sent urine cx as part of delirium
work-up. Free water in all meds and flushes, and stopped NaHCO3
and increased free water flush via Dobhoff to Q4H from Q6H for
hypernatremia. (Renal aware and OK with that.) IV Lopressor
changed to metoprolol 25 [**Hospital1 **]. Had [**Month (only) **] UOP but Foley kinked,
improved with opening.
- [**2-20**]: free water flush q6h from q4h. PT consult; OOB/IS. d/c
a. line. Home dose lantus 15 qAM. Vanc decreased to 750 for
trough of 19. Decreased standing oxycodone to 5Q6H and dereased
IV dilaudid. Dobhoff self dc'ed. Replaced, TF's held until AM
when can be positioned post-pyloric. Started D5W@50 and required
D50 for hypoglycemia as he is on lantus.
- [**2-21**]: Transferred to floor under Dr. [**Last Name (STitle) **], [**First Name3 (LF) 479**] 3 service. On
ISS, PO pain meds, PO metoprolol, tube feeds, telemetry, with a
foley.'
- [**2-22**]: A physical therapy consult was placed and his diet
advanced to full liquids.
- [**2-23**]: Tubefeeds were adjusted per nutrition recs. He received
IV furosemide to help with his anasarca/fluid overload. A cdiff
toxin assay was sent which was ultimately negative.
- [**2-24**]: Another c diff was sent which was ultimately negative.
Calorie counts were intiated to quantitate his nutritional
intake.
- [**2-25**]: He was started on PO oxycodone and his ISS adjusted.
Boost supplements were added to his diet to augment his calorie
intake. He received another dose of IV lasix to reduce fluid
overload.
- [**2-26**]: Mr. [**Known lastname 85357**] foley was d/ced and he voided. He was
started on a bowel regimen. He recieved a course of albuterol
nebulizer treatments and his SSI adjusted. He received another
dose of IV lasix. He was started on the rest of his home PO
medications. Cardiology was consulted and his ASA 81 mg switched
to ASA 325, and plavix WAS NOT started. He self d/ced his
dobhoff and tubefeeds were discontinued. He received kayexylate
for a potassium of 5.6.
- [**2-27**]: He was switched to a regular diet with multiple
supplements. His morning potassium was 5.2. He was started on
his home [**Month/Year (2) 21177**]. He complained of some right sided lower
back pain that improved after he got out of bed. As a precaution
an EKG showed NSR, troponin series was obtained, a CXR showed
worsening right sided RLL effusion.
- [**2-28**]: There was continued concern over his low drain output. A
urinalysis was negative. He had a CT of the abdomen and pelvis
which showed multiloculated fluid collections in the GB fossa,
perihepatic space, and R abdomen/pelvis.
- [**3-1**]: He had a percutaneous drain placed by interventional
radiology.
- [**3-2**]: He received a 250 cc free water bolus as an assay to see
if his UOP would respond appropriately and it did.
- [**3-3**]: Mr. [**Known lastname **] had a CXR in preparation for discharge as his
lung exam had improved. The CXR showed decreased lung volumes in
the RLL that were stable and new decreased lung volume in the
LLL that could be indicative of new consolidation or
atelectasis. As Mr. [**Known lastname **] was afebrile, did not have symptoms
of pneumonia, and a normal white blood cell count, he was
encourage to use his incetive spirometry. He pulled 250cc
regularly on incentive spirometry.
- [**3-4**]: His cholecystostomy tube was checked by interventional
radiology team and it functioned well. He was discharge to rehab
in stable condition with close follow up with Dr. [**Last Name (STitle) **] in
clinic. His stables were removed before discharge. He was given
instructions for drain and postoperative care.
Medications on Admission:
Aspirin 81 mg p.o. once daily, Plavix 75 mg p.o.
once daily, metoprolol 25 mg p.o. b.i.d., [**Last Name (STitle) 21177**] 5 mg
one-half tablet p.o. once daily, Lipitor 40 mg two tablets
p.o.once daily, torsemide 20 mg one tablet p.o. once daily,
Lantus insulin, Humalog sliding scale, ranitidine 150 mg p.o.
b.i.d., calcium carbonate 500 mg p.o. once daily, ferrous
sulfate
325 mg p.o. once daily, folic acid, oxycodone 5 mg one tablet
p.o. q.6h. p.r.n., acetaminophen 650 mg p.o. q.6h. p.r.n.,
gabapentin 100 mg p.o. q.h.s., trazodone 50 mg p.o. q.h.s. p.r.n
Discharge Medications:
1. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic TID (3 times a day).
2. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours).
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
12. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. [**Last Name (STitle) 21177**] 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] House Nursing Home - [**Location 9583**]
Discharge Diagnosis:
1. Subhepatic abscess.
2. Perforated gallbladder.
3. Acute and chronic cholecystitis.
Acute blood loss anemia
Epistaxis
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:
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 [**6-17**] 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 steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in 1 week. Please call his
office at Phone: [**Telephone/Fax (1) 2723**] to make this appointment.
|
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78,814
| 105,817
|
36026
|
Discharge summary
|
report
|
Admission Date: [**2126-12-7**] Discharge Date: [**2126-12-8**]
Date of Birth: [**2049-5-4**] Sex: M
Service: MEDICINE
Allergies:
Levofloxacin / Quinolones
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
abdominal pain, marroon colored stools
Major Surgical or Invasive Procedure:
ERCP
IR attempt at embolization of bleeding gastroduodenal artery
Intubation
Trauma line insertion
History of Present Illness:
77 yo M with history of coronary artery disease s/p CABG [**2116**],
PCI native left circumflex [**2124**], systolic heart failure, and
multiple sclerosis, presents with melena from [**Hospital3 **]. Of note, patient had a recent admission to [**Hospital1 18**] from
[**2126-9-2**] to [**2126-9-4**] for elective ERCP during which he had
removal of CBD stones as well as a biliary stent placed. That
hospital course was complicated by atrial fibrillation with RVR.
He then presented on [**2126-11-19**] to [**Hospital6 5016**] for
additional ERCP to have his previously placed biliary stent
removed. At time of that procedure, [**Hospital3 **] ERCP team
reported some [**Hospital3 **] from around the stent at the ampulla, which
they cauterized to gain hemostasis. Patient was discharged from
[**Hospital3 **] and reports that he was not feeling like he ws back
to his baseline at any point in [**Month (only) 1096**]. This morning at 0600,
he awoke with severe mid-abdominal pain and then had urgency to
have bowel movement, which was described as "mahagony-colored".
He then proceeded to Holy [**Hospital 81777**] hospital, where he received
one unit of [**Hospital **] and ~1 L IVF. Due to poor respiratory status,
he received furosemide. He was then urgently transferred to
[**Hospital1 18**] for suspected upper GI bleed related to his history of
multiple ERCPs.
.
Of note, patient has had upper respiratory sypmtoms for the last
3 to 4 weeks and presented to his primary care physician several
days prior to coming in for his acute complaint at this
admission. He was prescribed an antibiotic of which he does not
recall the name. Regardless, he never filled the prescription.
He notes his breathing is a bit labored and though denies acute
complaints, later admits that he has had increased cough and
sputum production in last week.
.
Vitals upon presentation to the ED were: T 98, HR 120, BP
100/74, RR 16, O2Sat 100% on NRB. Once arriving at [**Hospital1 18**], ED
obtained NG lavage, which failed to clear of [**Hospital1 **] and noted
large amounts of melena. Additionally, U/A which showed moderate
bacteria and positive nitrite, but was without WBCs. Urine
culture and [**Hospital1 **] cultures are pending. Patient was given
pantoprazole IV as only medical intervention. Patient was
maintained on a non-rebreather throughout his stay in the ED and
sats were 100%. He was noted to be in atrial fibrillation with
RVR and HR was in the 110s to 120s throughout his ED stay with
no intervention performed. GI, hepatology, and ERCP were
consulted. GI attending in ED felt that source of bleed was
likely to be sphincterotomy site as patient had an ERCP in
[**8-/2126**], which was complicated by ulcerative bleed around stent.
Surgery deferred managment decisions to GI and ERCP team.
Patient was then transferred to the [**Hospital Unit Name 153**] prior to signout of the
patient to the admitting medicine ICU team due to need for
emergent ERCP.
.
Patient originally came to [**Hospital Unit Name 153**] and went urgently to ERCP, where
was quickly noted to be exanguinating from duodenum, though
bleeding was too brisk to localize further as several units of
[**Hospital Unit Name **] were reported to be seen in stomach as well as in the
small bowel. ERCP was aborted and trauma line was plaed by
anesthesia in ERCP suite prior to patient being transferred back
to [**Hospital Unit Name 153**] for stabilization. Massive transfusion protocol was
activated and paitent was transfused 5 units PRBC and 2 units
FFP prior to transfer to the [**Hospital Ward Name **] MICU [**Location (un) 2452**] for
stabilization prior to IR attempted angio and embolization.
.
REVIEW OF SYSTEMS:
(+)ve: fatigue, hematochezia, melena, focal weakness
(-)ve: fever, chills, night sweats, loss of appetite, chest
pain, palpitations, rhinorrhea, nasal congestion, cough, sputum
production, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal
dyspnea, nausea, vomiting, diarrhea, constipation, dysuria,
urinary frequency, urinary urgency, focal numbness, myalgias,
arthralgias
Past Medical History:
1) Multiple sclerosis with left hemiparesis/neurogenic bladder
2) CAD s/p 2 vessel CABG [**2116**], PCI LCX [**2124**]
3) Chronic systolic heart failure (EF 45-50% with mild
hypokinesis of the basal to mid inferior and inferolateral
segments)
4) Atrial fibrillation (complicated by RVR at prior admissions,
not on anticoagulation)
5) 15 x 7 mm spiculated left upper lobe pulmonary nodule ([**2124**])
6) Diabetes mellitus type II
7) COPD, on 2L home 02 at night and while ambulatory in summer,
no current pulmonologist
8) Recurrent pseudomonal urinary tract infections
9) Recurrent aspiration pneumonia ([**12-28**] and [**2-25**])
10) Chronic left ankle fracture c/b non-healing malleolar ulcer
11) MRSA colonization
12) Hypertension
13) Trigeminal neuralgia
14) Benign prostatic hypertrophy
15) GERD
Social History:
Home: Lives with wife and daughter in [**Name (NI) 8072**], NH
Occupation: retired electronics tester.
EtOH: Denies
Drugs: Denies
Tobacco: roughly 120 PPY history (3 PPD x 40 y)
Family History:
Non contributory
Physical Exam:
VS: T 97.5, HR 119, BP 119/62, RR 20, O2Sat 99% NRB
GEN: NAD
HEENT: PERRL, EOMI, oral mucosa dry, NG tube in place, patient
on non-rebreather
NECK: Supple, no [**Doctor First Name **]
PULM: CTAB
CARD: Irregular, nl S1, nl S2, II/VI sys murmur RUSB
ABD: obese, BS+, soft, non-tender, non-distended
EXT: 1+ BLE edema to level of knees
SKIN: No rashes
NEURO: Oriented to self, month, year, location. Can not name
specific day of week. CN II-XII grossly intact. BLE weakness.
PSYCH: Restricted affect appropriate for clinical situation
Pertinent Results:
[**2126-12-7**] 02:25PM [**Month/Day/Year 3143**] WBC-6.6 RBC-3.46* Hgb-9.7* Hct-29.2*
MCV-85# MCH-28.2 MCHC-33.3 RDW-17.2* Plt Ct-245#
[**2126-12-7**] 02:25PM [**Month/Day/Year 3143**] PT-14.4* PTT-24.2 INR(PT)-1.3*
[**2126-12-7**] 02:25PM [**Month/Day/Year 3143**] Glucose-151* UreaN-22* Creat-0.7 Na-139
K-4.1 Cl-100 HCO3-31 AnGap-12
[**2126-12-7**] 02:25PM [**Month/Day/Year 3143**] ALT-47* AST-80* CK(CPK)-11* AlkPhos-554*
TotBili-2.7* DirBili-2.3* IndBili-0.4
[**2126-12-7**] 09:38PM [**Month/Day/Year 3143**] Albumin-2.4* Calcium-7.3* Phos-5.1*#
Mg-1.8
[**2126-12-8**] 01:08AM [**Month/Day/Year 3143**] WBC-10.3 RBC-3.74* Hgb-11.2* Hct-32.1*
MCV-86 MCH-30.0 MCHC-34.9 RDW-15.8* Plt Ct-230
[**2126-12-8**] 01:08AM [**Month/Day/Year 3143**] PT-15.3* PTT-25.8 INR(PT)-1.3*
[**2126-12-8**] 01:08AM [**Month/Day/Year 3143**] Glucose-123* UreaN-26* Creat-0.8 Na-141
K-3.7 Cl-106 HCO3-30 AnGap-9
[**2126-12-8**] 01:08AM [**Month/Day/Year 3143**] ALT-36 AST-54* LD(LDH)-145 AlkPhos-289*
TotBili-9.1*
Brief Hospital Course:
77 yo M with history of coronary artery disease s/p CABG [**2116**],
PCI native left circumflex [**2124**], systolic heart failure, and
multiple sclerosis, presented with melena from [**Hospital3 **]. Found to be having massive upper GI bleed as well as
cholangitis and pneumonia. Suspected source of bleeding was from
recent biliary stenting where he had bled in the past. He
urgently went to ERCP where he was seen to be bleeding near the
duodenal papilla at the site of a prior spincterotomy and bleed.
Sclerosis and ligation were unsuccessful at ERCP. IR was called
and he went to angio. At angio the gastroduodenal artery was
identified as the bleeding source. Embolization was
unsuccessful. Surgery was following throughout. After IR could
not embolize the source of bleeding, surgery was urgently called
to the bedside. Surgery felt the patient was an extremely high
operative risk given his CHF, PNA, Afib, MS, and cholangitis on
top of his GI bleed. His wife was [**Name (NI) 653**] by surgery and she
agreed to defer surgery. The patient was made DNR at that point.
He continued to massively hemorrhage. Again his wife was
[**Name (NI) 653**] and he was made [**Name (NI) 3225**]. He expired shortly thereafter
from exsanguination.
Medications on Admission:
1) Carbamazepine 200 mg PO QID
2) Simvastatin 10 mg PO DAILY
3) Zonisamide 100 mg PO DAILY
4) Albuterol Sulfate 90 mcg 2 puffs Q6H:PRN dyspnea
5) Furosemide 20 mg PO DAILY
6) Tamsulosin 0.4 mg PO HS
7) Fluticasone-Salmeterol 250-50 mcg/Dose 1 inhalation [**Hospital1 **]
8) Metformin 500 mg PO BID
9) Sertraline 50 mg Tablet PO DAILY
10) Hydromorphone 2 mg PO Q4H:PRN pain
11) Carvedilol 3.125 mg PO BID (at 8AM and 10PM)
12) Pantoprazole 40 mg PO Q12H
13) Glyburide 2.5 mg PO DAILY
14) Gabapentin 600 mg PO QID
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
upper GI bleed
Discharge Condition:
death
Discharge Instructions:
death
Followup Instructions:
death
Completed by:[**2126-12-11**]
|
[
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[
[
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244, 284
|
451, 4122
|
4541, 5347
|
5363, 5543
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,773
| 192,620
|
43836
|
Discharge summary
|
report
|
Admission Date: [**2193-5-27**] Discharge Date: [**2193-6-11**]
Date of Birth: [**2130-3-25**] Sex: F
Service: UROLOGY
Allergies:
Iodine-Iodine Containing / Macrobid
Attending:[**First Name3 (LF) 6440**]
Chief Complaint:
Intractable urinary incontinence and likelihood of a vesicle
vaginal fistula with urethra necrotic and the vaginal vault
completely stenosed on examination. Urinary diversion was
advised.
Major Surgical or Invasive Procedure:
[**2193-5-27**]: Initial OPERATION: Urinary diversion with ileo
conduit complicated secondary to previous abdominal surgery and
external beam
radiation, as well as vaginal brachytherapy for gynecologic
malignancy
[**5-29**]: PROCEDURE: Exploratory laparotomy, revision of bilateral
ureteroileal anastomoses, revision of ileal conduit stoma.
History of Present Illness:
Ms. [**Known lastname 15532**] [**Last Name (Titles) 1834**] a radical hysterectomy followed by
radiation therapy and then brachytherapy for vaginal
recurrence. She developed severe rectal bleeding related to the
radiation as well as intractable urinary
incontinence and likelihood of a vesicle vaginal fistula. Her
urethra was found to be completely necrotic and the vaginal
vault was completely stenosed on examination. Urinary diversion
was advised.
Past Medical History:
-Endometrial CA s/p resection, XRT, and vaginal brachytherapy
(c/b urethral burning pain)
-Chronic LBP x many years s/p spinal fusion, seen by Dr. [**Last Name (STitle) 39330**]
at [**Hospital1 112**] pain clinic
-Hypertension
-MVP (does not take prophylactic antibiotics)
-HL
Past Surgical History:
-s/p urinary diversion with ileal conduit ([**2193-5-27**])
-s/p L3-S1 spinal fusion in [**2164**]
-s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 931**] rod removal with hardware revision in [**2164**]
-s/p laparoscopic cholecystectomy
-s/p TAH [**2190**] with subsequent chemo/brachy therapy
From [**8-/2192**]: Hypertension, osteoarthritis with chronic low back
pain s/p spinal surgery at [**Hospital6 2910**] in the
[**2161**] including spinal fusion of L5-S1 in [**2164**]. Incidental
adrenal adenoma, acute renal failure secondary to dehydration in
[**2189**], laparoscopic cholecystectomy in [**2172**], left breast
fibroadenoma on ultrasound in [**2190-11-18**], psoriasis.
She does report a history of mitral valve prolapse, which used
to be associated with palpitations, but now those were
controlled with atenolol.
OB/GYN History: She is a gravida 0. She denies any history of
abnormal Pap smears or pelvic infections. She denies any history
of ovarian cysts. Endometrial Cancer as above.
Social History:
The patient is single and lives in [**Location 1411**] with her dog. No
children. She is a former nurse who worked at the [**Hospital1 16549**] for 12 years.
worked in [**2165-9-17**]. She has since been on disability due to
her severe low back pain. Smoked a pack per day for the past 30
years until recently quitting. Denies recreational drug use.
Does not drink alcohol.
Family History:
Father with coronary artery disease. Mother with aortic
stenosis.
Father with bladder cancer and gastric cancer, died at age 62.
Paternal aunt with endometrial cancer in her 50s.
Physical Exam:
WdWn femal in NAD
Abdomen obese, soft, appropriately tender
Urostomy at RLQ: pink stoma w/ two ureteral stents protruding.
Well healed stoma edges. Urine dripping clear and yellow.
Midline incision with steristrips; a few intermittent staples
left in place for removal at discharge (due to size of abdomen
and tension applied to abdomen area for ostomy appliance changes
and planned physical therapy.)
upper extremities without edema. bilateral lower extremities
with minimal non-pitting edema. No calf pain.
Pertinent Results:
[**2193-6-5**] 04:58AM BLOOD WBC-10.3 RBC-3.36* Hgb-10.3* Hct-31.0*
MCV-92 MCH-30.7 MCHC-33.3 RDW-14.9 Plt Ct-471*
[**2193-6-3**] 05:09AM BLOOD WBC-11.2* RBC-3.30* Hgb-10.4* Hct-30.4*
MCV-92 MCH-31.5 MCHC-34.2 RDW-15.0 Plt Ct-428
[**2193-5-31**] 04:23AM BLOOD PT-14.5* PTT-30.3 INR(PT)-1.2*
[**2193-6-5**] 04:58AM BLOOD Glucose-111* UreaN-16 Creat-0.6 Na-144
K-4.8 Cl-115* HCO3-25 AnGap-9
[**2193-6-4**] 05:51AM BLOOD Glucose-120* UreaN-31* Creat-1.2* Na-147*
K-4.8 Cl-118* HCO3-24 AnGap-10
[**2193-6-4**] 05:51AM BLOOD ALT-7 AST-20 AlkPhos-142* TotBili-0.2
[**2193-6-5**] 04:58AM BLOOD Calcium-8.1* Phos-2.6* Mg-1.7
ASCITES
ASCITES CHEMISTRY Creat
[**2193-6-4**] 09:46 1.1
PERITONEAL FLUID
[**2193-6-3**] 02:16 2.0
JP FLUID
[**2193-5-28**] 03:52 37.3
JP
[**2193-5-30**] 5:12 am URINE Source: Catheter.
**FINAL REPORT [**2193-5-31**]**
URINE CULTURE (Final [**2193-5-31**]): NO GROWTH.
[**2193-5-30**] 5:11 am BLOOD CULTURE Source: Line-Arterial.
**FINAL REPORT [**2193-6-5**]**
Blood Culture, Routine (Final [**2193-6-5**]): NO GROWTH.
Brief Hospital Course:
ICU Course at transfer to ICU:
Mrs [**Known lastname 15532**] is a 63 y/o F with history of chronic lower back
pain, recurrent endometrial CA s/p resection, XRT, and vaginal
brachytherapy, was admitted for ileal conduit and urinary
diversion and appendectomy on [**5-27**]. Her post-operative course
was complicated by severe lower abdominal pain at the site of
her ureterostomy, requiring high dose opioids and hydromorphone
PCA. She triggered early in the morning of [**5-29**] for anuria over
six hours, and marked nursing concern for fluid overload and
change in pulmonary status; after receiving continuous IVF and
increasing dyspnea despite supplemental oxygen.
.
On [**5-29**], she was considered for percutaneous nephrostomy tube
placement by IR, but was ultimately taken back to the OR for
exploratory laparotomy for ureteral obstruction and
intraabdominal ureteral leak, with revision of ileal-ureteral
anastomoses and stomal revision. Her left ureter was found to
have a small leak. Both ureters at anastamosis were discolored
and possibly ischemic, so they were dissected to a higher level
and reanastamosis was performed. She had a CVL and arterial line
placed in the OR. Intraoperatively, she received intermittent
hemodynamic support with phenylephrine, and was given cefazolin
4 gm, metronidazole 500 mg, 5 mg IV vitamin K, and several
boluses of hydromorphone and Ketamine for analgesia. She was
also administered 3.6L LR, 2 units pRBCs. EBL was 300 cc.
.
On the floor, the patient is intubated with sedation on maximal
ventilatory support. She was transferred to the ICU for
difficulty weaning from the vent.
#Ureteral reanastamosis
Significant quantity of intra-abdominal urine found on
laparotomy, now s/p repair. Good UOP overnight, urology pleased
with progress. JP drain in place. She also continued to receive
prophylactic cefazolin and metronidazole per urology
recommendations.
#Prolonged intubation
In the ICU she was extubated and did well post-extubation,
breathing well with O2sat >95% on 1L x NC.
# Chronic pain
On large amounts of opioids at baseline for years. Followed by
chronic pain service between surgeries. Pre-operative regimen
included hydromorphone PCA @ 1.0 mg Q6H and basal 1.5 mg/hr.
Received multiple hydromorphone boluses during procedure, as
well as Ketamine bolus. Currently on Ketamine infusion and
Dilaudid PCA. Of note, the patient became extremely sedated
after receiving 2 mg Ativan (with stable VS), requiring
additional O2. Pain service followed the patient in the ICU and
will continue to follow on the floor. They reduced the Ketamine
dose prior to transfer.
# Acute kidney injury
Creatinine elevated to max 3.4 from baseline 0.9, trending down
at time of transfer. [**Last Name (un) **] presumed to be secondary to ureteral
obstruction/dehiscence, given anuria, rapid rise in Cr and
intra-operative findings. Now with steady urine output from
bilateral ureteral stenting.
# Endometrial cancer: S/p surgery, XRT as above, with
aforementioned complications. Not an active issue during this
admission. Not written for anastrazole on this admission.
# Leukocytosis
WBC count peaked at 21 on [**5-29**] then trended down. She was given
prophylactic antibiotics for gram positive and anaerobic
coverage. Likely to have partial reactive component after
laparotomy. Last documented fever was [**5-30**].
Blood and urine cultures without growth to date.
# Hypertension
Pt with history of hypertension, on beta blocker and ACE
inhibitor as outpatient. BP elevated while inpatient. Held home
anti-hypertensives for now, given recent intra-operative
hypotension requiring transient vasopressors, but beta blocker
was re-started before floor transfer. HTN also likely increased
by acute on chronic pain.
# Dyslipidemia
Held home statin, patient NPO.
# Normocytic anemia
Hct dropped from post-transfusion high 34.4. No significant
bleed detected, but does have steady serosanguinous drainage
from JP drain. Hct remained stable.
UROLOGY COURSE:
Ms. [**Known lastname 15532**] was admitted to Dr.[**Name (NI) 6444**] Urology service after
undergoing radical cystectomy and ileal conduit. No concerning
intraoperative events occurred; please see dictated operative
note for details. Patient received perioperative antibiotic
prophylaxis. The patient had an NGT in place post-operatively,
which was removed on POD 2. Her post-operative course was
complicated by severe lower abdominal pain at the site of her
ureterostomy, requiring high dose opioids and hydromorphone PCA.
She triggered early in the morning of [**5-29**] for anuria over six
hours, and marked nursing concern for fluid overload and change
in pulmonary status; after receiving continuous IVF and
increasing dyspnea despite supplemental oxygen. She was
subsequently transferred to the ICU. ICU course as per above.
Once stabilized she was transferred back to the general surgical
floor where she remained for several days with specialty
services weighing in on her management and progress. She
continued with pain management evaluations, physical therapy,
nutrition recommendations and visits by nursing specialists for
urostomy care. Her medications were titrated and her diet was
slowly advanced with resolution of nausea and bloating. She was
eventually weaned from oxygen support and her JP drain was
discontinued and prior to discharge her surgical skin clips were
discontinued. The patient was ambulating and pain was controlled
on oral medications as recommended by the pain service. The
ostomy nurse saw the patient for ostomy teaching on several
occasions. At the time of discharge the wound was healing well
with no evidence of erythema, swelling, or purulent drainage.
The ostomy was perfused and patent.
On discharge Ms. [**Known lastname 15532**] was given explicit instructions for
follow up with the respective specialty services and
recommendations to follow-up with her PCP as well. All of her
questions were answered.
Medications on Admission:
anastrozole 1 mg
atenolol 50 mg [**Hospital1 **]
orphenadrine citrate [Norflex] 100 mg
simvastatin 40 mg
lisinopril 10 mg
diphenhydramine HCl 50 mg
ibuprofen 800 mg TID
Morphine Sulfate Extended Release 120 mg TID
Morphine Sulfate Immediate Release 15 mg QID
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever>101.
2. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain/anxiety.
Disp:*35 Tablet(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. PRUNE JUICE
Continue prune juice and other bowel movement aids as necessay
to inhibit constipation
6. morphine 30 mg Tablet Extended Release Sig: Four (4) Tablet
Extended Release PO Q8H (every 8 hours) as needed for Pain
Control.
Disp:*170 Tablet Extended Release(s)* Refills:*0*
7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain > [**3-26**].
Disp:*110 Tablet(s)* Refills:*0*
8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. anastrozole 1 mg Tablet Sig: One (1) Tablet PO once a day as
needed for endometrrial CA.
10. atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Hold for SBP < 100, HR < 60 .
11. PAIN MANAGEMENT
Please call to schedule your follow-up with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Hospital1 112**] pain clinic upon discharge for continued titration of pain
medications.
Office Address: [**Last Name (NamePattern1) 14305**], [**Location (un) 86**], [**Numeric Identifier 6425**]
Phone: ([**Telephone/Fax (1) 94163**]
12. Centrum Oral
13. calcium carbonate-vitamin D3 Oral
14. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care--[**Hospital1 8**]
Discharge Diagnosis:
FIRST) [**5-27**]: recurrent endometrial cancer and now s/p
hysterectomy and radiation treatment with intractable urinary
incontinence and likelihood of a vesicle vaginal fistula,
urethral necrosis.
SECOND) [**2193-5-29**]: PREOPERATIVE DIAGNOSES:
1. Urine leak and acute renal failure.
2. Nonfunctioning [**Location (un) 1661**]-[**Location (un) 1662**] drain.
POSTOPERATIVE DIAGNOSES:
1. Urine leak and acute renal failure.
2. Nonfunctioning [**Location (un) 1661**]-[**Location (un) 1662**] drain.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It has been a pleasure participating in your care. You will be
discharged to a rehab facility that will further assist you with
management of your ongoing physical therapy and postoperative
rehabilitation.
-Resume your pre-admission medications unless otherwise noted.
***Please note that you Lisinopril has NOT been added back to
your daily regimen as your blood pressures have been well
controlled with atenolol. Please discuss this with Dr. [**Last Name (STitle) 1968**],
your PCP.
--Also, ibuprofen has been held as well. Do NOT resume NSAID
therapy (ibuprofen/aleve/motrin/advil etc.) UNLESS specifically
advised to do so by your Urologist or PAIN service (Dr. [**Last Name (STitle) 39330**].
-You may resume the Iron Tablets (Ferrous Sulfate) when cleared
by Dr. [**Last Name (STitle) 365**] and your Oncologist.
-Please also refer to educational materials provided by the
nurse specialist in urostomy care and management
-The maximum dose of Tylenol (ACETAMINOPHEN) is 4 grams (from
ALL sources) PER DAY.
-The prescribed pain medication may also contain Tylenol
(acetaminophen) so this needs to be considered when monitoring
your daily dose and maximum.
-Please do not drive, operate dangerous machinery, or consume
alcohol while taking narcotic pain medications.
-Do not drive while urostomy bag is in place and until you are
cleared to resume such activities by your PCP or urologist
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener--it is NOT a laxative.
-You may shower but do not tub bathe, swim, soak, or scrub
incision
-Skin clips (staples) have been removed from your abdomen and
bandage strips called ??????steristrips?????? have been applied to close
the wound. Allow these bandage strips to fall off on their own
over time. You may get the steristrips wet.
-No heavy lifting for 4 weeks (no more than 10 pounds)
[**Hospital 16237**] medical attention for fevers (temp>101.5), worsening pain,
drainage or excessive bleeding from incision, chest pain or
shortness of breath.
Followup Instructions:
Follow up in [**5-26**] days for wound check and post op evaluation.
Please call Dr.[**Name (NI) 6444**] office to confirm that appointment when
you get to [**Hospital3 **] later today.
Please contact Dr.[**Name (NI) 6444**] office upon discharge to arrange
follow up appointment [**Telephone/Fax (1) 18725**]. Your other upcoming
appointments are listed below.
Please call your PCP to arrange [**Name Initial (PRE) **] follow up and to discuss your
medication changes and postoperative course.
Please call to schedule your follow-up with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Hospital1 112**] pain clinic upon discharge for continued titration of pain
medications. Office Address: [**Last Name (NamePattern1) 14305**], [**Location (un) 86**], [**Numeric Identifier 6425**]
Phone: ([**Telephone/Fax (1) 94163**]
Please call and schedule an appointment to see the Ostomy nurse
at [**Hospital1 18**] for 2 - 4 weeks from her discharge to rehab. The
clinic number is [**Telephone/Fax (1) 23664**].
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5777**]
Date/Time:[**2193-6-20**] 1:00
Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2193-10-7**] 10:30
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 1125**] Date/Time:[**2194-1-17**] 1:00
Completed by:[**2193-6-11**]
|
[
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"996.39",
"568.0",
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"997.5",
"401.9",
"E879.2",
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"286.9",
"794.9",
"788.30",
"424.0",
"715.90",
"338.29",
"E878.2",
"285.9",
"288.60",
"E878.1",
"623.2",
"909.2",
"584.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"56.51",
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] |
icd9pcs
|
[
[
[]
]
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12858, 12956
|
4947, 10911
|
484, 829
|
13502, 13502
|
3789, 4924
|
15861, 17322
|
3064, 3245
|
11220, 12835
|
12977, 13481
|
10937, 11197
|
13685, 15838
|
1635, 2654
|
3260, 3770
|
256, 446
|
857, 1313
|
13517, 13661
|
1335, 1612
|
2670, 3048
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,464
| 164,919
|
29744
|
Discharge summary
|
report
|
Admission Date: [**2197-3-10**] Discharge Date: [**2197-3-16**]
Date of Birth: [**2121-4-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Found Down and suggestion of adventitious apendicular movements.
Major Surgical or Invasive Procedure:
Intubated briefly for one night.
History of Present Illness:
75F transferred from [**Hospital3 3583**] for likely seizure
activity. Could not obtain hx from either pt or husband (cannot
reach him by phone), so much of following history is from
neurology. Around 9:30AM, pt went to the bathroom. Awhile
later, husband entered bathroom and found pt slumped over. He
called 911. Prior to EMS arrival, pt had episode of limb
shaking for a few minutes, which stopped when he touched her
arm. Husband denied that she had any incontinence or tongue
biting. Husband told neurologist that pt has not been herself
over the last 3-4 days, with pacing and difficulty with tasks.
Pt denies HA, visual changes, N/V, fevers, chills, night sweats,
or bowel/bladder incontinence. Pt has no h/o prior seizures.
.
Pt was initially taken to [**Hospital3 3583**] ED, where she was
intubated and started on dilantin. She was unresponsive.
Sodium was 160 reportedly (no electrolytes in the records they
sent), was given 1/2NS. EMS noted seizure activity and gave pt
Valium. At OSH, head CT was negative for bleed. She was
transferred here for further management.
.
In the [**Name (NI) **], pt was given ceftriaxone, levofloxacin, and flagyl.
Acyclovir ordered. Neurology evaluated pt, and recommended EEG,
LP, and MRI/MRA. LP obtained in ED.
Past Medical History:
bipolar disorder
hypertension
hypothyroidism
skin cancer
osteoporosis
Social History:
Lives with husband. [**Name (NI) **] in ADLs, Smoked 60 pack years
but quit 1 year ago.
Family History:
noncontributory
Physical Exam:
VS: 101.4 110/70 104 14 98% on AC 550x14/0.7/5
Gen: intubated, sedated
HEENT: PERRL, ETT in place
CV: RRR, nl S1/S2, no murmurs appreciated
Pulm: coarse upper airway sounds anteriorly but clear
Abd: soft, NT/ND, +BS, no masses; NG tube in place and to
suction
Ext: no c/c/e
Neuro: sedated, increased tone in lower extremities, toes
neither up nor downgoing, PERRL
Pertinent Results:
EKG: 80bpm, NSR, nl axis and intervals, no ST/T wave changes
suggestive of ischemia
.
CXR: no evidence of aspiration
.
CT C spine: No evidence of acute fracture or gross malalignment
of the cervical spine. Bilateral posteriorly seen atelectasis
as described above.
.
CT head: chronic small vessel infarcts, no acute process
.
CT chest: IMPRESSION: Multifocal pulmonary consolidation most
readily explained by pneumonia particularly aspiration. Followup
advised to exclude the simultaneous presence of
bronchioloalveolar cell carcinoma.
It would be useful to obtain a chest radiograph today to
correlate with the CT findings In order to determine the rate of
change of the multifocal pulmonary abnormality seen.
.
MRI Head:IMPRESSION:
1. Edema within the C6 and C7 vertebral bodies, without
associated edema of the C6/7 intervertebral disc. The finding
could be degenerative in nature, though other etiologies of
marrow edema cannot be entirely excluded, such as infection,
although the absence of disc T2 hyperintense signal argues
against this possibility.
2. Small disc osteophyte complexes at C5/6 and C6/7 indent the
thecal sac without mass effect on the spinal cord at these
levels.
.
CXR PA/LAT [**2197-3-15**] -
IMPRESSION: No significant interval change in the appearance of
the lungs since [**2197-3-12**]. Right upper lung opacity is also
stable. Continued short-interval followup is recommended.
.
EEG [**3-13**] - IMPRESSION: This is a normal routine EEG in the
waking and sleeping states. No focal or epileptiform features
were seen.
ECHO [**2197-3-14**] - IMPRESSION: Preserved global and regional
biventricular systolic function. Mild mitral regurgitation. No
structural cardiac cause of syncope identified.
.
Carotid U/S [**2197-3-15**] - IMPRESSION: Normal study.
[**2197-3-10**] 01:10PM WBC-16.1* RBC-4.25 HGB-14.5 HCT-41.3 MCV-97
MCH-34.0* MCHC-35.1* RDW-13.0
[**2197-3-10**] 01:10PM ASA-NEG ETHANOL-NEG CARBAMZPN-<1.0*
ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2197-3-10**] 01:10PM PHENOBARB-<1.2* PHENYTOIN-17.2 LITHIUM-LESS
THAN VALPROATE-<3.0*
[**2197-3-10**] 01:10PM DIGOXIN-<0.2* THEOPHYL-<0.8*
[**2197-3-10**] 01:10PM T4-1.6*
[**2197-3-10**] 01:10PM TSH-82*
[**2197-3-10**] 01:10PM ALBUMIN-4.7 CALCIUM-9.2 PHOSPHATE-1.7*
MAGNESIUM-2.7*
[**2197-3-10**] 01:10PM cTropnT-<0.01
[**2197-3-10**] 01:10PM ALT(SGPT)-19 AST(SGOT)-32 CK(CPK)-335* ALK
PHOS-91 AMYLASE-28 TOT BILI-0.7
[**2197-3-10**] 01:10PM GLUCOSE-164* UREA N-22* CREAT-1.6* SODIUM-140
POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-20* ANION GAP-18
[**2197-3-10**] 01:20PM GLUCOSE-168* LACTATE-6.1* NA+-145 K+-3.5
[**2197-3-10**] 05:30PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-0 POLYS-0
LYMPHS-86 MONOS-14
[**2197-3-10**] 05:30PM CEREBROSPINAL FLUID (CSF) PROTEIN-41
GLUCOSE-85
[**2197-3-10**] 08:24PM LACTATE-1.7
[**2197-3-10**] 10:23PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-6.5
LEUK-SM
.
[**2197-3-15**] 07:10AM BLOOD WBC-8.4 RBC-4.15* Hgb-13.6 Hct-39.4
MCV-95 MCH-32.9* MCHC-34.6 RDW-14.0 Plt Ct-223
[**2197-3-15**] 07:10AM BLOOD Plt Ct-223
[**2197-3-15**] 07:10AM BLOOD Glucose-105 UreaN-10 Creat-1.1 Na-141
K-4.2 Cl-105 HCO3-23 AnGap-17
Brief Hospital Course:
What follows is a hospital course by problem:
[**Name (NI) **] recieved a complete syncope, seizure and meningitis
workup. This workup as detailed below did not identify a clear
etiology. Our hypothesis is thus neurocardiogenic syncope in
the setting of micturation.
.
1. Telemetry failed to identify arrhythmia.
2. CT head normal except for chronic small vessel infarcts.
3. An LP revealed wbc 2, RBC 0. protein 41, glucose 85. CSF HSF
HSV PCR negative. Was treated empirically with Acyclovir. CSF
was culture negative.
4. MRI/MRA was performed to evaluate for possible CVA, but
revealed no evidence of acute infarct. Possible NPH - seems
unlikely in setting of mild gait abnormality and no Urinary
symptoms. Also patient didn't get any reported relief from LP.
5. Treated with levofloxacin for PNA posteriorly seen on CT scan
and CXR. Currently Day 7. Needs a total of 10 days.
6. EEG - normal. Was maintained briefly on phenytoin.
7. Carotid Duplex - normal.
8. Cardiac Echo - No structural cardiac cause of syncope
identified.
9. Cardiac enzymes negaive. orthostatics vital signs normal.
.
Regarding hypoxemic respiratory failure - Patient was intubated
at outside hospital for airway protection, as she was reported
as unresponsive on her initial presentation. On arrival to
[**Hospital1 18**], she did have significant A-a gradient with PO2 in 170s on
FIO2 70%. Extubated after 1 day without any problems.
1. hypoxia resolved.
2. urinary Legionella antigen: negative.
3. on levoquin for poss infiltrate (as above), but looks better
on CXR [**3-12**].
4. CT chest shows PNA and possible BAC cancer - will follow
nodule as outpatient - radiology reports will accompany the
patient.
.
Patient intially complaining of neck pain, but subsequently
reported that this was a long term/stable issue. Patient did
have midline TTP on exam. Cervical collar was placed. CT c spine
negative; MRI negative but did show edema of cervical vertebrae.
Advise outpatient follow up. Radiology reports will accompany
the patient.
5. cleared C-spine [**3-13**]
6. Cervical verterbral edema will be communicated to PCP.
.
Patient has diagnosis of depression - held bupropion because of
concern for seizure. Will restart after d/c
.
Hypothyroidism - Patient found to have elevated TSH despite
normal T4
- increase dose of levothyroxine to 150mcg qd. PCP should check
TSH in 6 weeks.
Medications on Admission:
levoxyl 125mcg daily
lisinopril 5mg daily
bupropion - unknown dose
ativan
ambien
occ MVI
Discharge Medications:
1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
2. Bupropion 75 mg Tablet Sig: One (1) Tablet PO once a day:
Please note that the dose of this medication is uncertain.
Patient did not recieve this medication because of seizure risk
but should be restarted. Please check with PCP. .
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
4. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for agitation/anxiety.
5. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 3320**]
Discharge Diagnosis:
Syncope, likely of neurocardiogenic (vasovagal) etiology.
Two incidental findings on imaging studies.
1. Right upper lobe nodule. PCP should follow this.
2. Edema of the C6/7 vertebrae - possibly degenerative. PCP
should just follow.
Discharge Condition:
Stable. Ready for short term rehab.
Discharge Instructions:
You were admitted to the hospital with a loss of consciousness.
We ruled out serious neurological, cardiac, and vascular cuases
including seizure, stroke, heart attack, abnormal heart rhythm,
and low blood pressure. That said, we did not find out exactly
why you slumped over in the bathroom. One of the most common
causes of passing out is called vasovagal syncope (also called
neurocardiogenic syncope). This is a sudden drop in blood
pressure that can be caused by many triggers, but urination is
one of them and your episode occured after you had used the
bathroom. Unfortunately there is no clear treatment for this,
but to be aware of it and not stand up too quickly after
urinating or moving your bowels.
Finally:
Despite treatment of your pneumonia your chest x-rays and
CT-scan have shown a persistent nodule in your lungs. Please
inform your primary care doctor regarding this finding and give
him the radiology reports that we will include with your
paperwork.
Also, the MRI of your spine showed some excess water (edema) in
two of your cervical vertebrae. Per the radiologist, this
finding does not imply a poor prognosis, but is rather an
unusual abnormality. Please tell your primary care doctor about
this finding.
Followup Instructions:
Please follow up with your primary care provider.
[**Name10 (NameIs) **] set an appointment up for you with Dr. [**Last Name (STitle) **] on Thursday
[**2197-3-23**] at 12:15pm.
Completed by:[**2197-3-16**]
|
[
"780.2",
"401.9",
"733.00",
"486",
"296.80",
"518.89",
"244.9",
"782.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
8730, 8801
|
5591, 5609
|
379, 414
|
9081, 9120
|
2352, 2620
|
10405, 10614
|
1930, 1947
|
8107, 8707
|
8822, 9060
|
7993, 8084
|
9144, 10382
|
1962, 2333
|
274, 341
|
5637, 7967
|
442, 1715
|
2629, 5568
|
1737, 1808
|
1824, 1914
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,205
| 194,409
|
7259
|
Discharge summary
|
report
|
Admission Date: [**2133-9-11**] Discharge Date: [**2133-10-5**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Admitted to OSH with L hip fracture following a mechanical fall.
He was transferred to [**Hospital1 18**] for hypoxia and management of femur
fracture.
Major Surgical or Invasive Procedure:
Endotracheal Intubation
Left hip hemiarthroplasty
Picc line
History of Present Illness:
Mr. [**Known lastname **] is a [**Age over 90 **] year old male with a history of chronic afib,
inferior MI requiring PPM placment, CHF,left MCA stroke with
expressive aphasia, admitted to OSH with L hip fracture
following a mechanical fall. Transferred to [**Hospital1 18**] for ICU admit
after an episode of respiratory distress with O2 sats in the
80s, but admitted to the floor after respiratory status
improved, with good oxygenation on 4 litres O2 by NC.
.
By report, CTA at OSH showed mild fluid overload, for which pt
was given 40 mg lasix 1v. He was also given ASA 81 and
ceftriaxone/vanc, presumably for concern for pneumonia in
setting of h/o MRSA bacteremia. Patient does have a history of
CHF, with last documented EF of 40% in [**3-10**]. This was improved
from an EF of 25% 11/05.
.
Per patient and patient's PCP, [**Name10 (NameIs) **] is able to easily climb a
flight of stairs at baseline. He denies CP, dyspnea, orthopnea,
PND or lower extremity swelling.
.
Since arrival on the floor, patient's respiratory status has
improved steadily. He is now at 100% O2 saturation on room air.
Past Medical History:
Chronic atrial fibrillation on anticoagulation
CAD s/p RCA stent, [**2125**]
Inferior MI requring PPM placment for bradycardia, [**2125**]
Left MCA embolic stroke with residual expressive aphasia, [**2125**]
MRSA bacteremia [**2-6**] pacemaker wire infection, [**2131**].
S/p left carotid endarterectomy
S/p left retinal detachment
S/p appy
HTN
Hyperlipidemia
Social History:
Social history: Independent until MI/stroke in [**2125**]; lives in
[**Location 26841**] [**Hospital3 **] facility, wife also lives in same
building (?different units). Protestant, worships at [**University/College **]
congregational Village Church.
Family History:
Family history: Non-contributory
Physical Exam:
T98.1 HR97 BP124/64 RR18 O2sat 100% on RA
General: Pleasant elderly man. Awake and alert but with
expressive aphasia/word finding difficulties
HEENT: Minor cut over left eyebrow; otherwise NCAAT
Neck: No JVD, left carotid bruit
CV:irregularly irregular, no murmurs/rubs/gallops.
Resp: Difficult exam because it is painful for pt to roll over.
Good air movement, no obvious rhonci or rales.
Abdomen: Tense musculature but non-tender, non-distended. No
hepatosplenomegaly.
Ext: Minimal pitting peripheral edema. No cyanosis/clubbing.
Pertinent Results:
[**2133-9-11**]
.
GLUCOSE-116* UREA N-24* CREAT-1.2 SODIUM-144 POTASSIUM-4.3
CHLORIDE-106 TOTAL CO2-31 ANION GAP-11
.
CK(CPK)-68 CK-MB-NotDone cTropnT-0.01
.
WBC-12.1* RBC-3.95* HGB-13.5* HCT-40.2 MCV-102* MCH-34.2*
MCHC-33.6 RDW-13.9 PLT COUNT-167
PT-28.4* PTT-37.4* INR(PT)-2.9*
.
CALCIUM-9.2 PHOSPHATE-2.7 MAGNESIUM-2.0
DIGOXIN-0.6*
.
RADIOLOGY Final Report
CT CHEST W/CONTRAST [**2133-9-29**] 3:40 PM
CT CHEST W/CONTRAST
Reason: pulmonary infiltrates. signs of infection
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man with continues leucocytosis and fever and
hypoxia despite Abx.
REASON FOR THIS EXAMINATION:
pulmonary infiltrates. signs of infection
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: [**Age over 90 **]-year-old man with leukocytosis, fever and hypoxia
despite antibiotics.
COMPARISON: Multiple prior chest x-rays dating back to
[**2125-11-16**], more recently from [**2133-9-15**] to [**2133-9-25**].
TECHNIQUE: MDCT imaging of the chest was performed following the
administration of 75 cc of intravenous Optiray. Images were
obtained with 1.25-mm slice thickness and displayed in soft
tissue and lung windows. Coronal reformatted images were also
obtained.
CT CHEST WITH INTRAVENOUS CONTRAST: A right PIC catheter
terminates in the distal SVC. A left chest wall pacemaker has
leads adjacent to the right atrium and right ventricle. There is
no mediastinal, hilar, or axillary lymphadenopathy. The heart
and particularly the right atrium are enlarged. Mild
calcifications line the intrathoracic aorta. Moderate
calcifications line all three coronary arteries. Incidental note
is made of mild bilateral gynecomastia.
Layering, nonhemorrhagic pleural effusions are large on the
right and moderate on the left. Patchy consolidation in the
right upper lobe is consistent with infection. Right upper lobe
bronchus is severely narrowed by the right pulmonary artery.
Ground-glass opacity within the lingula may represent an
additional focus of infection versus residual of interstitial
edema. Relaxation atelectasis in both lower lobes is due to
underlying effusions.
Imaging of the upper abdomen is not sufficient for diagnosis. A
5-mm low- density lesion in the left liver lobe was not clearly
seen on prior CTs from [**2125-11-6**]. Calcified gallstones are seen
within an otherwise normal-appearing gallbladder. The spleen is
nonenlarged. The adrenal glands are normal. A right upper pole
renal cyst measures 25 x 23 mm and was present on [**2125-11-16**],
but appears slightly larger. An exophytic hyperdense cyst in the
left kidney is unchanged since [**2125-11-16**]. Two additional
low-density lesions are likely larger.
BONE WINDOWS: There are no findings concerning for malignancy
within the imaged bones. Degenerative changes are noted in the
upper lumbar spine.
IMPRESSION:
1. Parenchymal consolidation in the right upper lobe is
consistent with infection.
2. Additional ground-glass opacity in the lingula may represent
infection or mild interstitial edema.
3. Bilateral nonhemorrhagic, layering pleural effusions, large
on the right and moderate on the left. Relaxation atelectasis
bilaterally.
4. Low-density lesions within both kidneys are stable or
slightly larger than [**2125-11-16**], and could be further evaluated
with ultrasound.
5. Cardiomegaly.
.
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2133-9-25**] 11:57 AM
CT HEAD W/O CONTRAST
Reason: eval for acute CVA
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man with new dysphagia and slurred speech
REASON FOR THIS EXAMINATION:
eval for acute CVA
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: [**Age over 90 **]-year-old man with new dysphagia and slurred
speech. Evaluate for acute CVA.
COMPARISONS: [**2133-9-23**].
FINDINGS: The appearance of the large left MCA territory infarct
with encephalomalacia and ex vacuo dilatation of the posterior
[**Doctor Last Name 534**] of the left lateral ventricle is unchanged. There is a
stable central brain atrophy. There is mild periventricular
white matter hypodensities, consistent with chronic small vessel
angiopathy. A small lacunar infarct in the left external capsule
is unchanged. There are no new areas suggestive of infarction.
There is no acute intracranial hemorrhage. Atheroslcerotic
calcifications of the cavernous internal carotid arteries
bilaterally. Again noted is fluid in the right mastoid air cells
and mild thickening of several ethmoid air cells. The bony
structures and surrounding soft tissue structures are unchanged.
IMPRESSION:
1. Unchanged from [**2133-9-23**], without CT evidence for
new ischemic infarction.
Findings were discussed with Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 23537**] on [**9-25**], [**2133**].
2. Fluid in the right mastoid air cells, which could represent
mastoiditis.
.
RADIOLOGY Final Report
CT PELVIS W/O CONTRAST [**2133-10-1**] 11:43 AM
CT PELVIS W/O CONTRAST
Reason: soft tissue bleed on fractured site
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man with Afib, s/p L femoral Fx repaire and post op
hypoxia. Dropping HCT from 25 to 20 in two days.
REASON FOR THIS EXAMINATION:
soft tissue bleed on fractured site
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: Decreasing hematocrit, suspect soft tissue bleed at
fracture site. Comparison is made to [**2125-12-2**] CT
examination.
TECHNIQUE: MDCT acquired axial images were obtained through the
pelvis without intravenous contrast. Retained/recently
administered oral contrast was noted within loops of bowel.
Sagittal reformations were evaluated.
CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: There is
hyperdensity and expansion involving the right psoas and iliacus
muscle measuring approximately 5 x 9 cm on coronal reformations
and in a similar location as retroperitoneal hemorrhage in [**2125**].
The soft tissues around the left hemiarthroplasty site are
difficult to evaluate due to large amount of streak artifact,
but appears grossly symmetric. Remaining intrapelvic contents
including the bowel, calcified aorta and its branches, and
prostate/urinary bladder appear unremarkable. A small amount of
air is noted within the bladder fundus likely related to recent
instrumentation. There is mild-to- moderate soft tissue anasarca
and small bilateral fat-containing inguinal hernias. Multilevel
degenerative changes of the joint and disc are seen within the
lower lumbar spine. Visualized left hemiarthroplasty is
unremarkable and in appropriate position.
IMPRESSION:
Moderate right psoas/iliacus retroperitoneal hematoma. Symmetric
soft tissues adjacent to the operative left hip site, although
evaluation is limited due to a large amount of streak artifact.
Findings discussed with Dr. [**Name (STitle) 26842**] at date of exam at
approximately 3:30 p.m.
.
[**2133-10-5**]
White Blood Cells 19.6* K/uL 4.0 - 11.0
Red Blood Cells 3.03* m/uL 4.6 - 6.2
Hemoglobin 9.9* g/dL 14.0 - 18.0
Hematocrit 30.6* % 40 - 52
MCV 101* fL 82 - 98
MCH 32.8* pg 27 - 32
MCHC 32.5 % 31 - 35
RDW 19.5* % 10.5 - 15.5
Platelet Count 463* K/uL 150 - 440
[**2133-10-5**] 05:13AM
Report Comment:
Source: Line-PICC
Glucose 100 mg/dL 70 - 105
Urea Nitrogen 24* mg/dL 6 - 20
Creatinine 1.0 mg/dL 0.5 - 1.2
Sodium 139 mEq/L 133 - 145
Potassium 4.0 mEq/L 3.3 - 5.1
Chloride 106 mEq/L 96 - 108
Bicarbonate 28 mEq/L 22 - 32
Anion Gap 9 mEq/L 8 - 20
Calcium, Total 7.4* mg/dL 8.4 - 10.2
Phosphate 2.4* mg/dL 2.7 - 4.5
Magnesium 2.8* mg/dL 1.6 - 2.6
.
[**2133-10-5**] 05:13AM
Report Comment:
Source: Line-PICC
BASIC COAGULATION (PT, PTT, PLT, INR)
PT 15.3* sec 10.4 - 13.1
PTT 95.1* sec 22.0 - 35.0
INR(PT) 1.4*
.
PATIENT/TEST INFORMATION:
Indication: Left ventricular function.
Height: (in) 69
Weight (lb): 158
BSA (m2): 1.87 m2
BP (mm Hg): 107/47
HR (bpm): 68
Status: Inpatient
Date/Time: [**2133-9-14**] at 12:06
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007W041-0:52
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.3 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 5.1 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.5 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 3.6 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.3 cm
Left Ventricle - Fractional Shortening: 0.36 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 60% (nl >=55%)
Aorta - Valve Level: 3.5 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.4 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.5 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Pressure Half Time: 500 ms
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - E Wave Deceleration Time: 215 msec
TR Gradient (+ RA = PASP): *36 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A
catheter or pacing
wire is seen in the RA and extending into the RV. Normal IVC
diameter
(1.5-2.5cm) with <50% decrease during respiration (estimated RAP
11-15mmHg).
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global
systolic function (LVEF>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Moderately dilated RV cavity. Focal basal
hypokinesis of RV
free wall. [Intrinsic RV systolic function likely more depressed
given the
severity of TR]. Abnormal diastolic septal motion/position
consistent with RV
volume overload.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in
aortic root. Normal ascending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Mild to moderate ([**1-6**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate to
severe [3+] TR.
Moderate PA systolic hypertension.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: The rhythm appears to be atrial fibrillation.
Left pleural
effusion.
Conclusions:
The left atrium is mildly dilated. The right atrium is
moderately dilated.
There is mild symmetric left ventricular hypertrophy with normal
cavity size
and regional/global systolic function (LVEF>55%). The right
ventricular cavity
is moderately dilated with focal hypokinesis of the midportion
of the right
ventricular free wall. [Intrinsic right ventricular systolic
function is
likely more depressed given the severity of tricuspid
regurgitation.] There is
abnormal diastolic septal motion/position consistent with right
ventricular
volume overload. The aortic valve leaflets (3) are mildly
thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral
valve leaflets are mildly thickened. Mild to moderate ([**1-6**]+)
mitral
regurgitation is seen. At least moderate to severe [3+]
tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Right ventricular cavity enlargement with regional
systolic
dysfunction primary pulmonary process (pulmonry embolism,
bronchospasm, etc.)
or primary ischemic process (acute marginal branch) or both
processes.
Pulmonary artery systolic hypertension. At least moderate to
severe tricuspid
regurgitation.
CLINICAL IMPLICATIONS:
Based on [**2133**] AHA endocarditis prophylaxis recommendations, the
echo findings
indicate prophylaxis is NOT recommended. Clinical decisions
regarding the need
for prophylaxis should be based on clinical and
echocardiographic data.
Brief Hospital Course:
# Left femoral fracture: s/p L hemiarthroplasty. [**2133-9-15**] hip
films stable. Prophylaxis with Lovenox 30 mg [**Hospital1 **] which will be
discontinued once INR is therapeutic with Coumadin. Will need
f/u with Dr. [**Last Name (STitle) 7376**] from [**Hospital1 18**] ([**Doctor First Name **] [**Doctor Last Name 7376**] ([**Telephone/Fax (1) 2007**]
[**Hospital Ward Name 23**] 2 ([**Telephone/Fax (1) 2007**])
.
# Retroperitoneal bleed: Patient found to have retroperitoneal
bleed on pelvic CT. HCT dropped over past several days. Pt had
retroperitoneal bleed in the past (more severe). Unclear
etiology, most likely spontaneous bleed due to anticoagulation.
pt received a total of 3 units RBC on consecutive days. Held
anticoagulation gave Vit K and stopped anticoagulation. Pt HCT
remained stable over several days and anticoagulation was
restarted. Pt will need Lovenox/Coumadin bridge. Will need daily
HCT checks.
.
# CHF/ systolic dysfunction: Pt remains fluid overloaded however
with good respiratory status. Diuresed with furosemide 40 mg PO.
On occasions furosemide needed to be held due to intravascular
volume contraction and decreased renal function. Plan is to
continue diuresis as renal function allows. During episodes of
fever and hypotension lisinopril and Metoprolol were held as
well. Metoprolol succinate 25 mg daily and digoxin 0.125 mg is
pts current regiment, and lisinopril 5 mg will need to be
restarted in rehab.
# Delirium/aphasia: delirium resolved, although pt daughter can
not exactly recall what pts baseline status was prior to
hospitalization. Pt cooperative in past days and responds and
follows commands. Not oriented to place and time. Can not give
history. Head CT w/o contrast on [**9-23**] without evidence for acute
event. During the course pt received Haldol 1 mg QHS PRN for
agitation.
.
#Fever/Leukocytosis: afebrile for one week now, still
leucocytosis. Extensive workup could not reveal a source of
infection. Antibiotics were stopped as no source of infection.
could be [**2-6**] sterile retroperitoneal bleed. Blood CX remained
negative although pt had enterococci positive culture earlier
during admission. C-Diff negative and no diarrhea any more. Pt
was empirically treated with Vanco and Zosyn however developed
rash and antibiotics were discontinued. Patient remained
afebrile and without symptoms. Chest CT showing pleural effusion
however doubt this to be an empyema. No tap by IR, followed
clinical picture, which remained asymptomatic.
.
# R hand hematoma/wound: Pt developed R hand hematoma on [**9-25**],
likely [**2-6**] trauma from hitting hand against bed rail in the
setting of anticoagulation with Lovenox and Coumadin. Plastics
followed the patient and wound was debrided with daily dressing
changes. no signs and symptoms of infection. Specific wound care
recs are written in the discharge summery. pt was followed by
plastic surgery. Elevate RUE as possible with daily wet to dry
dressing changes (see discharge summery)
.
#) Hypoxia: most likely due to acute CHF exacerbation. Resolved
completely and pt stable on RA.
.
#Transaminitis/RUQ tenderness: Patient with acutely elevated
AST/ALT/LDH a.m. of [**2133-9-14**] likely secondary to acute
hypoperfusion of liver parenchyma. LFTs mostly trending
downwards, though mild increase in [**Doctor First Name **]/lip and alk phos which
also is trending down. RUQ ultrasound unremarkable. Continued to
trend LFTs q3 days and limit all potentially hepatotoxic
medications (Tylenol, etc.)
.
# Shock: Now resolved and not an active issue. This occurred
post op. and was managed in the ICU. most likely due to volume
depletion in setting of diuresis and patient had low UOP prior
to surgery. At reintubation [**2133-9-16**] patients BP dropped
requiring pressors.
.
# ARF: Resolving. Patient anuric for 5 hours post op. Renal US
showed no hydronephrosis. [**2133-9-13**] UA with moderately +
eosinophils c/w AIN or atheroembolic emboli. Urine lytes with
FENa indicating prerenal etiology of ARF. Peak Cr of 1.8 on
[**9-14**], trending down now--stable at 1.0. Monitor UOP and check Cr
daily specially in the setting of continues diuresis. Monitor
I/Os with a goal negative 500cc daily as renal function allows,
and till sacral edema has been mobilized (lasix 40 po)
.
# Anticoagulation s/p hip surgery and in afib: resumed
anticoagulation as no bleed any more. Started with lovenox 30 mg
[**Hospital1 **] and will also resume coumdin 5 mg. Stop lovenox once INR
therapeutic.
.
#Chronic afib: Paced rhythm in 70s. BP well controlled with
metoprolol succinate 25mg. Continue anticoagulation with lovenox
and coumadin as above. Monitor for bleed, HCT [**Hospital1 **].
.
# CAD: also history of PVD, CVA. Continue ASA 81 mg and
metoprolol succinate (TOPROL XL) 25mg. Also resuming low dose
Statin. LFTs need to be followed up as pt had acute hepatitis
unclear etiology in the past.
.
#) FEN: Pt was cleared by speech and swallow for oral intake
(pureed)(see diet order in discharge paper). Pt has good PO
intake in recent days
.
#) Access: R arm double-lumen PICC. Looks clean, no erythema and
no sign of infection
.
#) Code: Patient DNR but not DNI per daughter (HCP)
.
#) Contact: [**Name (NI) 14841**] [**First Name8 (NamePattern2) **] [**Known lastname **] [**Telephone/Fax (1) 26843**] (h), [**Telephone/Fax (1) 26844**]
(c), [**Telephone/Fax (1) 26845**] (w); Daughter- [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 26846**] (c),
[**Telephone/Fax (1) 26847**] (until [**10-1**]), [**Telephone/Fax (1) 26848**] ([**State **])
Medications on Admission:
Medications on admission (per ED note)
Coumadin 3 mg PO QHS
Lunesta 3 mg PO QHS
Lasix 40 mg PO daily
ASA 81mg PO daily
Folic Acid 1 mg PO daily
MVI PO daily
Proscar 5 mg PO daily
Captopril 75 mg PO TID
Ativan 0.5 mg PO Daily
Digoxin 0.125 mg PO daily
Celexa 5 mg PO daily
Lovastatin 20 mg PO QHS
Metamucil PO daily
VIt b12 1000 sc monthy
Flonase
2 sprays MDI daily
Tramadol 50mg PO TID
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable [**State **]: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Folic Acid 1 mg Tablet [**State **]: One (1) Tablet PO DAILY (Daily).
3. Therapeutic Multivitamin Liquid [**State **]: One (1) Cap PO DAILY
(Daily).
4. Finasteride 5 mg Tablet [**State **]: One (1) Tablet PO DAILY (Daily).
5. Citalopram 20 mg Tablet [**State **]: 0.25 Tablet PO DAILY (Daily).
6. Fluticasone 50 mcg/Actuation Aerosol, Spray [**State **]: Two (2)
Spray Nasal DAILY (Daily).
7. Docusate Sodium 100 mg Capsule [**State **]: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet [**State **]: One (1) Tablet PO BID (2 times a
day) as needed.
9. Tramadol 50 mg Tablet [**State **]: One (1) Tablet PO BID (2 times a
day).
10. Bisacodyl 10 mg Suppository [**State **]: One (1) Suppository Rectal
DAILY (Daily) as needed.
11. Acetaminophen 325 mg Tablet [**State **]: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever.
12. Calcium Carbonate 500 mg Tablet, Chewable [**State **]: One (1)
Tablet, Chewable PO BID (2 times a day).
13. Digoxin 125 mcg Tablet [**State **]: One (1) Tablet PO DAILY (Daily).
14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
15. Haloperidol 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime) as needed.
16. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: Two (2)
Tablet PO DAILY (Daily).
17. Simvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
18. Warfarin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
19. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
[**Last Name (STitle) **]: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
20. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
21. Lovenox 60 mg/0.6 mL Syringe [**Last Name (STitle) **]: Seventy (70) mg
Subcutaneous every twelve (12) hours.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] - [**Location (un) 620**]
Discharge Diagnosis:
Primary:
1. Left Hip Fracture.
2. Hypovolemic Shock.
3. Acute Renal Failure.
4. Ischemic Hepatitis.
5. Enterococcal Bacteremia.
6. Ventilator Associated Pneumonia.
7. Right Retroperitoneal Bleed.
8. Blood Loss Anemia.
9. Delirium.
10. Acute on Chronic Systolic Heart Failure.
11. Dysphagia.
12. Right Hand Hematoma
13. Rash NOS.
14. VRE
Secondary:
1. Systolic Heart Failure (EF~40%)
2. CAD s/p IMI and RCA stent, [**2125**]
3 PPM placment for bradycardia, [**2125**]
4. Embolic Left MCA Stroke - expressive aphasis/right
hemiparesis.
5. Anemia of Chronic Disease.
6. Atrial fibrillation
7. MRSA PM wire infection, [**2131**].
8. Hyperlipidemia
9. S/P left retinal detachment
10. S/P left carotid endarterectomy
11. S/P appendectomy
Discharge Condition:
Good.
Patient hematocrit is stable.
Afebrile for more than one week.
Delirium resolved with baseline aphasia
Discharge Instructions:
Patient needs monitoring of his INR as he is anticoagulated with
coumadin for atrial fibrillation and for his femoral fracture.
.
Lovenox can be stoped once patient is adequately anticoagulated
with coumadin.
.
Pleasee follow daily INR checks and adjust coumadin accordingly.
.
Patient has systolic congestive heart failure. Please diures,
and start lisinopril 5 mg daily if renal function stable.
.
Please titrate Metoprolol succinate (ToprolXL) based on BP and
HR
.
Please titrate lasix based on renal function
.
Patient had spontaneouse retroperitoneal bleed on
anticoagulation. This is stable and anticoagulation has been
resumed. Please continue to monitor for bleed (hematocrit
checks)
Followup Instructions:
Please follow up with primary care doctor [**Last Name (Titles) 26849**],[**First Name3 (LF) **] J.
[**Telephone/Fax (1) 26850**].
Dr. [**Last Name (STitle) **] has been notified about patients disposition to a
rehab.
|
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"428.0",
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icd9cm
|
[
[
[]
]
] |
[
"96.72",
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icd9pcs
|
[
[
[]
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1628, 1990
|
2022, 2258
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,391
| 126,658
|
20515
|
Discharge summary
|
report
|
Admission Date: [**2142-7-24**] Discharge Date: [**2142-8-3**]
Date of Birth: [**2076-8-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
IR guided embolization
History of Present Illness:
Mr [**Known lastname 17029**] is a 65 year old man with past medical history
significant for hypertension, hyperlipidemia, coronary artery
disease s/p CABG and recent PTCA with BMS to D1 [**2142-3-19**], CHF
(EF 40%), as well as difficult crossmatch, recently discharged
from vascular surgery [**7-13**] with C diff colitis transferred from
OSH with syncope and BRBPR. At 2am on [**7-23**], pt had episode of
syncope while on toilet and noted to have large bloody BM. 911
was called and he was sent to [**Hospital6 33**] ED where HCT
initially 29->27 despite transfusion 3-4 units PRBC. After 7
units PRBCs and 2 units FFP as well as vitamin K, HCT 25 and INR
2.1 from 6. ([**7-23**] 1700 HCT 25 INR 3.4 [**7-24**] 0400 27.2 INR 2.1 [**7-24**]
1500 HCT 25.5). NG lavage was reportedly negative. He remained
HD stable but had ongoing BRBPR, last BM 8pm on night of
transfer. He was also given insulin, D50, alcium and kayexalate
for K 6.1. He was transferred given usual care at [**Hospital1 18**].
.
On the floor, he is awake and conversant and had repeat episode
of BRBPR with passing approx 1 cup clot. Pt denies h/o GIB and
also reports R sided abdominal pain [**2142-6-21**] which he has had
intermittently over several years. Also reports lightheadedness
and dizziness which have improved with trasnfusions. Denies N/V,
hematemesis, recent fever or chills.
.
Review of systems:
(+) Per HPI
(-) Denies 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. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
CAD s/p 4 MI's ([**2125**], [**2134**], [**2142**]), s/p 3 vessel CABG
Diabetes mellitus type II
Neuropathy
Retinopathy
diabetic foot ulcer
PVD
Hypertension
Hyperlipidemia
GERD
Depression
h/o alcoholism- stopped drinking 25 years ago
Ischemic colitis
PAST SURGICAL HISTORY: L 2nd toe amp, R TMA, R colectomy for
ischemic colitis, 3 vessel CABG, R fem-DP, l fem-[**Doctor Last Name **] with stent
bilaterally, s/p aortoiliac stenting
History of partial colectomy from ischemic colitis of cecum
s/p amputation of 2nd left toe
Social History:
Retired automechanic. No current alcohol or tobacco. Prior
smoker: 80 pack-years, quit in [**2125**] after first MI per OMR.
Previous alcoholism- no alcohol for 25+ years
Family History:
Mother with breast cancer at 54. Father with alcohol abuse,
multisystem organ failure at 77. No FH IBD, [**Last Name (un) 43922**] CA, Gi
malignancy.
Physical Exam:
General: Alert, oriented x 3, appears fatigued, pale but
conversant and interactive
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally with faint bibasilar
rales, no wheezes or rhonchi
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic murmur
LLSB
Abdomen: soft, mildly distended, TTP RUQ and R mid quadrant.
Multiple scars. No hernia appreciated. Bowel sounds present, no
rebound tenderness or guarding, no organomegaly. - [**Doctor Last Name **] sign
GU: foley in place
Ext: s/p R TMA. [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **], 1+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs
[**2142-7-24**] 11:29PM BLOOD WBC-11.9* RBC-2.84*# Hgb-8.6* Hct-24.9*#
MCV-88 MCH-30.2 MCHC-34.5 RDW-16.6* Plt Ct-252
[**2142-7-24**] 11:29PM BLOOD Neuts-84.5* Lymphs-9.3* Monos-4.9 Eos-1.2
Baso-0.1
[**2142-7-24**] 11:29PM BLOOD PT-22.4* PTT-37.9* INR(PT)-2.1*
[**2142-7-24**] 11:29PM BLOOD Glucose-66* UreaN-13 Creat-1.2 Na-138
K-4.5 Cl-106 HCO3-26 AnGap-11
[**2142-7-24**] 11:29PM BLOOD ALT-13 AST-12 LD(LDH)-146 CK(CPK)-43*
AlkPhos-49 TotBili-0.9
[**2142-7-24**] 11:29PM BLOOD Calcium-7.7* Phos-4.0 Mg-1.7
[**2142-7-24**] 11:50PM BLOOD Lactate-0.9
Lab trends
[**2142-7-25**] 08:23AM BLOOD freeCa-1.06*
[**2142-7-25**] 03:38AM BLOOD CK-MB-2 cTropnT-0.06*
[**2142-7-25**] 02:05PM BLOOD CK-MB-2 cTropnT-0.05*
[**2142-7-27**] 05:18AM BLOOD CK-MB-2 cTropnT-0.06*
[**2142-7-25**] 03:38AM BLOOD LD(LDH)-174 CK(CPK)-40*
[**2142-7-26**] 10:01PM BLOOD CK(CPK)-21*
[**2142-7-27**] 05:18AM BLOOD CK(CPK)-24*
[**2142-7-28**] 03:37AM BLOOD Glucose-150* UreaN-8 Creat-1.0 Na-137
K-3.8 Cl-104 HCO3-28 AnGap-9
[**2142-7-25**] 03:38AM BLOOD PT-20.1* PTT-37.5* INR(PT)-1.9*
[**2142-7-26**] 04:41AM BLOOD PT-16.3* PTT-33.0 INR(PT)-1.4*
[**2142-7-27**] 05:18AM BLOOD PT-13.8* PTT-32.5 INR(PT)-1.2*
[**2142-7-28**] 03:37AM BLOOD PT-13.4 PTT-28.5 INR(PT)-1.1
[**2142-7-25**] 03:38AM BLOOD WBC-10.4 RBC-3.30* Hgb-9.9* Hct-28.2*
MCV-85 MCH-29.9 MCHC-35.0 RDW-16.0* Plt Ct-229
[**2142-7-25**] 08:10AM BLOOD Hct-28.5*
[**2142-7-25**] 10:59PM BLOOD Hct-30.0*
[**2142-7-26**] 04:00PM BLOOD Hct-28.1*
[**2142-7-26**] 10:01PM BLOOD Hct-25.4* Plt Ct-170
[**2142-7-28**] 03:37AM BLOOD WBC-8.4 RBC-3.55* Hgb-10.7* Hct-30.0*
MCV-85 MCH-30.2 MCHC-35.8* RDW-16.6* Plt Ct-161
CTA:1. Active bleeding seen into the right colon as described.
The right colon is diffusely thickenend, which is likely due to
colitis, probably ischemic given the stenosis at the orogin of
the SMA. The patient underwent mesenteric embolization
subsequently on [**2142-7-26**].
2. Medially in both pleural effusions there is increased
density, which
demonstrates no enhancement, and likely represents pleural
thickening or the sequela of prevoious hemothorax. This,
however, is not significantly changed since the CT [**2139-6-10**].
Brief Hospital Course:
65 year old man with CAD s/p CABG, recent BMS to D1 [**3-/2142**], PVD,
AF on coumadin, recent C diff infection on flagyl transferred
from OSH in setting of LGIB with supratherapeutic INR
.
# GIB: Patient admitted with BRBPR, had negative NG lavage at
OSH. LGIB most likely triggered by supratherapeutic INR in the
setting of coadministration of flagyl and coumadin. On [**7-26**],
underwent EGD and [**Last Name (un) **] with bright red blood proximal to
descending colon seen on [**Last Name (un) **]. He subsequently developed ongoing
bleeding and underwent CTA which revealed colitis and bleeding
from right side colon. He underwent IR guided mesenteric
embolization [**7-26**]. After this procedure, he had one isolated
episode of hypotension, and 2 episodes of recurrent BRBPR so
underwent repeat GI bleed nuclear medicine studies which were
negative. HCT remained stable at 30 (above baseline) prior to
transfer to floor. Last unit transfused was [**7-27**] at 1215am. Goal
HCT now 24 given no active bleed or ischemia. He was continued
on his PPI and diet advanced [**7-29**] without difficulty. Exact
etiology of LGIB remained unclear; thought likely secondary to
mesenteric ischemia. Patient will have GI f/u as outpatient on
[**8-28**] with repeat colonoscopy soon after that appointment for
further evaluation. Based on the results of the colonoscopy,
decision will be made whether to restart plavix and coumadin.
.
# C diff: Diagnosed prior to this admission. Received 13 day
course flagyl with resolution of diarrhea and no leukocytosis.
Two days prior to discharge, patient began having recurrence of
multiple episodes of watery diarrhea. Cdiff sent and was
positive. Patient started on po vancomycin on [**2142-7-31**]. He will
continue this medication as an outpatient to complete a 14 day
course.
.
# CAD s/p CABG s/p BMS D1 [**3-/2142**]: Continued statin, ASA (dose
decreased to 81mg). Not on BB or ACE for unclear reasons.
.
# AF: on ASA 81. Held coumadin. Not on BB at home.
.
# DM2: Blood sugars well controlled on HISS.
.
# Depression/Anxiety: Continued sertraline.
.
The patient was discharged to home with close PCP and GI
[**Name9 (PRE) 702**].
Medications on Admission:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
5. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 11 days.
9. Hydrocodone-Acetaminophen 5-500 mg Capsule Sig: One (1)
Capsule PO every six (6) hours as needed for pain for 7 days: do
not drive while taking narcotics.
10. Insulin Sliding Scale & Fixed Dose
Discharge Medications:
1. Insulin Lispro 100 unit/mL Solution Sig: One (1) injection
Subcutaneous ASDIR (AS DIRECTED).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
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. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
7. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 12 days.
Disp:*48 Capsule(s)* Refills:*0*
8. Outpatient Lab Work
Please obtain CBC and Chem 7 by [**2142-8-12**]. Please fax
results to new PCP, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]: [**Telephone/Fax (1) 3382**]. Thank you.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Gastritis
Mesenteric ischemia
Clostridium difficile colitis (1st recurrence)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane), out of bed with assistance to chair or wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 17029**], you were admitted to the hospital because of
bleeding from your intestinal tract. This was because of an
underlying condition you have called mesenteric ischemia and
also because you were on multiple medications that thinned your
blood. You received blood transfusions, and had a procedure to
stop the bleeding and your condition improved. You are now
deemed medically stable for discharge to home with services.
.
The following changes have been made to your medications:
1. STOP PLAVIX (CLOPIDOGREL).
2. STOP COUMADIN (WARFARIN).
3. STOP FLAGYL (METRONIDAZOLE).
4. STOP VICODIN (Hydrocodone-Acetaminophen 5-500 mg).
5. START VANCOMYCIN 125 mg capsule by mouth every 6 hours for 12
days for diarrhea. It is EXTREMELY important that you take all
of this medication exactly as prescribed.
.
You have follow-up appointments as outlined below. Please be
certain to have your blood drawn within one week of discharge
from the hospital. Please also weigh yourself every morning, and
call your primary care doctor if your weight goes up more than 3
lbs. It was a pleasure to care for you during this hospital
stay.
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2142-8-24**] at 2:35 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 54892**], MD [**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: GASTROENTEROLOGY
.
When: TUESDAY [**2142-8-28**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1983**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2142-8-3**]
|
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icd9cm
|
[
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[]
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[
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icd9pcs
|
[
[
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9860, 9917
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,198
| 174,649
|
1124
|
Discharge summary
|
report
|
Admission Date: [**2182-2-1**] Discharge Date: [**2182-2-13**]
Service: MEDICINE
Allergies:
Gentamicin
Attending:[**First Name3 (LF) 5827**]
Chief Complaint:
Aspiration
Major Surgical or Invasive Procedure:
Endotracheal intubation
IJ central line
PICC line placement
Blood transfusion x 2
History of Present Illness:
83 year old male with end stage parkinson's disease on 2L O2 at
baseline admitted with aspiration PNA. At the time of admission
the patient was a DNR/DNI. The plan was discussed with the
family, and the decision was made for intubation and full
treatment, everything short of CPR and shocks. He was
subsequently intubated. Sputum subsequently grew proteus and he
is being treated with a 10 day course of Zosyn (last day
[**2182-2-13**]). He was also diuresed while in the ICU. On the day of
transfer out of the ICU he was felt to be at well diuresed (and
bicarb rising) and his lasix was stopped. Of note, while in the
ICU he was noted to have bilateral red legs and LENI's were
performed. He was found to have a left DVT. A heparin drip was
started. He got his first dose of coumadin on [**2182-2-7**]. His
hemotocrit slowly trended down and he required 2 transfusions
during his ICU stay. His hct was stable at the time of transfer
to the medical floor.
Past Medical History:
Parkinson's disease/multisystem atrophy
Contracture of multiple joints
h/o blood clots
Mild heart arrhythmia
Dementia, likely Alzheimer
Depression
Bilateral heel ulcers
Benign prostatic hypertrophy
Social History:
He formally worked as an engineer and has a Master's Degree. He
has never smoked and rarely drinks alcohol. Lives in a NH at
baseline non-verbal and bed ridden.
Family History:
His parents died in their 80's of "natural
causes". His son has factor 5 mutations and a history of blood
clots.
Physical Exam:
GEN: NAD, lying in bed, non-verbal, appears chronically illl
HEENT: PERRL, anicteric, dry MM, op without lesions, poor
dentition
NECK: no LAD, no jvd
RESP: bronchial breathsounds throughout
CV: distant heart sounds difficult, no murmur appreciated
ABD: nd, +b/s, soft, G tube in place
EXT: pitting edema bilaterally, lower extremities wrapped in
bandages
SKIN: Stage 4 decubitus on sacrum
NEURO: severe contractions in all joints. non-verbal
Pertinent Results:
[**2182-2-1**] 09:10AM BLOOD WBC-5.7 RBC-2.78* Hgb-9.2* Hct-28.9*
MCV-104* MCH-33.2* MCHC-31.9 RDW-14.5 Plt Ct-283
[**2182-2-1**] 02:44PM BLOOD WBC-12.3*# RBC-2.84* Hgb-9.4* Hct-29.1*
MCV-103* MCH-33.2* MCHC-32.4 RDW-15.0 Plt Ct-327
[**2182-2-1**] 11:08PM BLOOD WBC-8.7 RBC-2.63* Hgb-8.5* Hct-26.1*
MCV-99* MCH-32.4* MCHC-32.6 RDW-15.9* Plt Ct-231
[**2182-2-11**] 06:14AM BLOOD WBC-10.6 RBC-2.86*# Hgb-9.2*# Hct-27.3*
MCV-96 MCH-32.3* MCHC-33.9 RDW-15.4 Plt Ct-294
[**2182-2-12**] 07:10AM BLOOD WBC-11.3* RBC-2.88* Hgb-9.7* Hct-28.0*
MCV-97 MCH-33.7* MCHC-34.7 RDW-16.0* Plt Ct-334
[**2182-2-1**] 11:08PM BLOOD Neuts-64 Bands-20* Lymphs-7* Monos-8
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2182-2-12**] 02:56PM BLOOD PT-15.0* PTT-63.9* INR(PT)-1.3*
[**2182-2-1**] 02:44PM BLOOD Glucose-125* UreaN-88* Creat-2.3* Na-139
K-4.5 Cl-103 HCO3-20* AnGap-21*
[**2182-2-2**] 04:57AM BLOOD Glucose-105 UreaN-80* Creat-1.7* Na-139
K-3.9 Cl-108 HCO3-23 AnGap-12
[**2182-2-2**] 06:36PM BLOOD Glucose-130* UreaN-77* Creat-1.4* Na-140
K-3.8 Cl-111* HCO3-22 AnGap-11
[**2182-2-9**] 05:35AM BLOOD Glucose-118* UreaN-27* Creat-1.0 Na-141
K-4.4 Cl-103 HCO3-31 AnGap-11
[**2182-2-10**] 06:47AM BLOOD Glucose-91 UreaN-26* Creat-1.2 Na-139
K-4.3 Cl-102 HCO3-34* AnGap-7*
[**2182-2-11**] 06:14AM BLOOD Glucose-179* UreaN-24* Creat-1.1 Na-134
K-3.8 Cl-96 HCO3-32 AnGap-10
[**2182-2-12**] 07:10AM BLOOD Glucose-115* UreaN-28* Creat-1.3* Na-138
K-3.9 Cl-100 HCO3-32 AnGap-10
[**2182-2-1**] 02:44PM BLOOD ALT-11 AST-25 LD(LDH)-153 AlkPhos-57
Amylase-53 TotBili-0.7
[**2182-2-12**] 07:10AM BLOOD Calcium-8.3* Phos-4.2 Mg-2.2
[**2182-2-2**] 06:36PM BLOOD Ferritn-556*
[**2182-2-1**] 09:10AM BLOOD Cortsol-76.1*
[**2182-2-1**] 09:10AM BLOOD CRP-GREATER TH
[**2182-2-4**] 07:08PM BLOOD Vanco-12.5
[**2182-2-1**] 09:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2182-2-7**] 02:03PM BLOOD Lactate-2.0
.
CXR 1/18:1. Airspace opacities in the mid- and lower lungs,
bilaterally, likely represent pneumonic consolidation, possibly
due to aspiration.
2. Tip of endotracheal tube is 5 cm from the carina, in standard
position.
.
GTube check: There is a gastrojejunostomy tube seen projecting
over the mid lower abdomen with contrast being injected into the
jejunal loop.
.
CXR [**2-3**]: The ETT and CVL remain in place. There is no
pneumothorax. Stable appearance of bilateral infiltrates with no
significant interval change.
.
CXR [**2-7**]: In comparison to previous radiograph, the central
venous access line right has been removed. Both lungs show
slightly better transparency than yesterday, this is more
obvious on the right than on the left side. No evidence of newly
appeared pneumonia. No signs of cardiac decompensation. No newly
appeared opacities.
IMPRESSION: Status post removal of the central venous access
line right. Slight improvement of parenchymal consolidations.
.
CXR [**2-8**]: Compared to [**2182-2-7**]. Left-sided central venous line
tip remains in the proximal SVC without evidence of
pneumothorax. No significant change in bilateral parenchymal
opacities and likely left pleural effusion.
.
Sputum culture [**2-2**]
PROTEUS MIRABILIS. MODERATE GROWTH. PRESUMPTIVE
IDENTIFICATION.
YEAST. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ <=1 S
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
MRSA nasal swab screen: pending at discharge
Urnialysis + for blood, but no infection. Culture pending.
Brief Hospital Course:
83M h/o end-stage Parkinson's presenting with sepsis likely from
aspiration PNA. He was admitted to the MICU. He was treated
with broad spectrum antibiotics, intubated, and given aggressive
IVF resuscitation. He improved on that treatment in the MICU,
and was extubated [**2182-2-8**]. He had sputum cultures that grew
P.mirabilis, that was sensitive to zosyn. He was transferred to
the medical [**Hospital1 **] that day after extubation. He was continued on
antibiotics and intermittent nasal and then oral suctioning.
Details are as follows:
# Respiratory failure. This was felt to be due to aspiration
pneumonia. As mentioned, he was treated with broad spectrum
antibiotics, and then narrowed to zosyn when culture were
positive, and he completed a 10 day course. He was treated
with as well while in the MICU with furosemide drip, and then
transitioned to PO oral lasix while on the medical [**Hospital1 **]. He was
given a face mask with humidified oxygen. He will need a follow
up xray in one month to assess interval change. He was
continued on his nebulizers.
# Anemia. His hematocrit was drifting down during his ICU stay,
with no clear cause. He was hemoccult negative. He had no
imaging studies consistent with a new bleed. There was concern
of bleeding while on the heparin gtt, but none was found. He
received two transfusions of PRBC without complications. His
hemolysis workup was negative. His hematocrit was stable upon
discharge.
# DVT: He was found to have a left sided LE DVT, and started on
heparin gtt with transition to warfarin. At the time of
discharge, he was trandsitioned to lovenox [**Hospital1 **] while continuing
the warfarin. His goal INR is [**2-17**], and he should be treated for
6 months.
# Rash: He developed a diffuse macular erythematous rash ,
blanching, by the time he was leaving the MICU. It was
suspected to be a drug rash, with Zosyn as the likely offender.
His Abx were scheduled to stop that day, and the rash started to
improve after that.
# Pressure ulcers: This was a CHRONIC problem. Wound care
consulted, Kinair bed was supplied, ensure adequate nutrition.
Zinc and ascorbic acid were given.
# Dementia: CHRONIC. Continue home dose of memantine 10mg daily
. He appeared to be back at his baseline by discharge.
# Parkinson: CHRONIC. Continuee home dose of Carbidopa-Levodopa
(Sinemet) and baclofen (to avoid baclofen withdrawal)
#FEN: He was fed via GJ tube. He had two studies done to ensure
proper placement.
#Prophylaxis: Bowel regimen, pantoprazole, heparin gtt until
therpeautic on coumadin.
#Access: Left PICC line.
#Code Status: DNR not DNI. Family would like to continue
intubation/treatment for two weeks, then reassess status. Son
confirms that if pt is extubated and needs reintubated (as long
as in two week period) would re-intubate. He does not want to
be shocked.
#Communication: Son [**Name (NI) 429**] [**Name (NI) 7229**], cell [**Telephone/Fax (1) 7230**], home
[**Telephone/Fax (1) 7231**]. [**Hospital3 2558**] 4floor nurses [**Doctor First Name 2013**] and [**Doctor First Name 7232**],
[**Telephone/Fax (1) 7233**].
Medications on Admission:
Polysporin powder topical
Hyoscamine prn for secretions
Morphine SL prn for pain
Acetaminophen prn
BIsacodyl 10mg pr prn
Mild of magnesia 30ml on Saturday
Namenda 10mg Daily
Prilosec 20mg Qdaily
Calcium carbonate 500mg Qdaily
Vitamin C
Baclofen 5mg TID
Carbidopa/Levodopa 25/100mg 2 tables TID
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Telephone/Fax (1) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Docusate Sodium 50 mg/5 mL Liquid [**Telephone/Fax (1) **]: One (1) PO BID (2
times a day).
3. Thiamine HCl 100 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily).
5. Carbidopa-Levodopa 25-100 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO
TID (3 times a day).
6. Baclofen 10 mg Tablet [**Telephone/Fax (1) **]: 0.5 Tablet PO TID (3 times a day).
7. Memantine 5 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO daily ().
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Senna 8.8 mg/5 mL Syrup [**Last Name (STitle) **]: 8.8 MLs PO BID (2 times a day)
as needed for constipation.
10. Ascorbic Acid 90 mg/mL Drops [**Last Name (STitle) **]: Five (5) ml PO BID (2
times a day) for 5 days.
11. Zinc Sulfate 220 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
(Daily) for 5 days.
12. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]:
One (1) neb Inhalation Q6H (every 6 hours) as needed.
13. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb
Inhalation Q6H (every 6 hours).
14. Warfarin 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY16 (Once
Daily at 16): Please titrate to INR [**2-17**].
15. Furosemide 20 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY
(Daily): Please hold if SBP < 100.
16. Enoxaparin 80 mg/0.8 mL Syringe [**Month/Day (3) **]: One (1) injection
Subcutaneous Q12H (every 12 hours): Please continue while
transitioning to warfarin; overlap three days with therapeutic
INR.
17. Heparin Flush PICC (100 units/ml) 2 mL IV DAILY:PRN
10 ml NS followed by 2 mL of 100 Units/mL heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Aspiration pneumonia
Respiratory failure
Sepsis
Acute renal failure
Drug rash (? zosyn)
Parkinson's disase
DVT
Discharge Condition:
Stable, requiring less suctioning, afebrile
Discharge Instructions:
You were admitted with aspiration pneumonia. You had a central
line placed, were intubated, and started on broad antibiotics.
You have recovered from the pneumonia. You were also found to
have a LE DVT (blood clot) and were started on coumadin and
heparin.
You should seek immediate medical attention if you experience
any concering symptom, such as shortness of breath, high fever,
chest pain.
You should continue the lovenox injections twice daily until
your INR is [**2-17**] for three days.
Followup Instructions:
Please follow up with the doctors at your rehab. You should
also see your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5351**] and [**Doctor Last Name **], as soon as possible
while at [**Hospital3 2558**].
|
[
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"331.0",
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"584.9",
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"294.10",
"285.9",
"332.0",
"707.03",
"453.41",
"785.52",
"600.00",
"038.9",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"38.91",
"96.04",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11854, 11924
|
6320, 9452
|
228, 311
|
12079, 12125
|
2303, 6297
|
12673, 12899
|
1712, 1826
|
9796, 11831
|
11945, 12058
|
9478, 9773
|
12149, 12650
|
1841, 2284
|
178, 190
|
339, 1297
|
1319, 1518
|
1534, 1696
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,040
| 152,635
|
22346
|
Discharge summary
|
report
|
Admission Date: [**2115-10-17**] Discharge Date: [**2115-11-1**]
Date of Birth: [**2074-6-2**] Sex: F
Service: MEDICINE
Allergies:
Tegretol / Haldol / Risperidone
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Acute renal failure secondary to antibiotics
Major Surgical or Invasive Procedure:
None
History of Present Illness:
41yo female with bipolar d/o, heroin use in past, h/o mrsa,
recent Hep C, recent history of septic joint s/p debridment p/w
acute renal failure. PT first presented to [**Hospital1 18**] on [**9-20**] with
question of septic arthritis of R ankle. Pt underwent R.
calcaneus irrigation and debridement, removal of hardware, bone
biopsy of R. calcaneus, and arthrotomy right ankle, irrigation
and debridement. Cultures from this procedure with + MRSA and
enterobacter cloacae. On [**9-26**], pt was started on IV vancomycin.
On [**9-30**], pt had PICC line placed and when advised that she would
need to go to a rehab for 4-6 weeks of IV antibiotics, refused
to be discharged to a rehab. After lengthy discussion, pt was
discharged on oral cipro 750 mg po bid and oral linezolid 600 mg
po bid. She was seen for f/u on [**10-15**] with Dr. [**Last Name (STitle) **]. Mitty and had
safety labs drawn at that time. Her discharge Bun/cr on [**9-26**] was
16/0.7 and repeat labs from yesterday with Bun/Cr: 33/4.5,
platelets also slightly low at 116. PT was contact[**Name (NI) **] but did
not want to come to hospital initially. She was seen in [**Hospital 1957**]
clinic today, foot okay from ortho perspective, sent to ED for
ARF. Patient knew that her renal function was worsening,
although didn't know progression rate. Cr 3.6 today. Patient
reports tired. PT also reports diarrhea with soft stool since
discharge, stool moved from [**Location (un) 2452**] to brown color, the episode
occurs in the morning, reports no odor/blood. Report positive
cough since last admission, productive with rare brownish
sputum, endorses 25 ppy history of smoking. Patient also report
rashes on the elbows b/l, believes that the rash is from
crawling on the floor to the bathroom (goes to bathroom to
urinate 3-4x per night). No change in urine amount, color,
frequency from baseline.
.
In the ED, initial vs were: T98.1 P72 BP108/82 R18 O2 sat97% RA.
Patient was given IVF.
.
On the floor, PTs vital signs were stable. Tired and sleepy from
the day.
.
Review of sytems:
.
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied 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:
mva in [**4-12**] with resultant R. calcaneal fracture, R. femur
fracture, r. femoral neck fracture with rod implantation and L.
radius fracture
bipolar
Substance Abuse (Heroine - 5-6yrs use, quit 2 years ago on
suboxone)
+ MRSA screen in [**4-12**]
HEP C
Social History:
Social History:
+ IVDU (heroin), + THC, + smoking, denies etoh, no travel
lives in urban area, no insect bites, 1 cat, 10 lifetime sexual
partners, denies HIV but notes "Hep B exposure".
Family History:
mo- emphysema
Fa - etoh and drug abuse
Physical Exam:
Physical Exam:
Vitals: T:97.8 BP:98/56 P:60 R: 18 O2:100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL, EOMI,
skin scratchs on chin and forhead
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, + suture, well healed posteriorly to the lateral ankle
and anterior-medially on the right ankle, without any signs of
infection/bleed, R foot is mildly edematous 1+ to the ankle.
Neuro: a/ox3, CNs [**3-21**] intact, strength and sensation intact
throughout, 2+ DTRs, [**Name (NI) 14451**] [**Name2 (NI) **]
.
Pertinent Results:
[**2115-10-17**] 12:50PM BLOOD WBC-5.9 RBC-3.34* Hgb-11.4* Hct-34.2*
MCV-102* MCH-34.1* MCHC-33.4 RDW-14.2 Plt Ct-104*
[**2115-10-17**] 12:50PM BLOOD Neuts-62.6 Lymphs-29.2 Monos-4.6 Eos-3.0
Baso-0.6
[**2115-10-28**] 07:10AM BLOOD WBC-4.7 RBC-2.54* Hgb-8.5* Hct-25.5*
MCV-100* MCH-33.5* MCHC-33.4 RDW-15.9* Plt Ct-161
[**2115-10-28**] 07:10AM BLOOD Plt Ct-161
[**2115-10-19**] 05:43PM BLOOD Hypochr-NORMAL Anisocy-1+
Poiklo-OCCASIONAL Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Tear
Dr[**Last Name (STitle) 833**]
[**2115-10-17**] 12:50PM BLOOD Plt Ct-104*
[**2115-10-21**] 01:10PM BLOOD ESR-85*
[**2115-10-21**] 01:10PM BLOOD Ret Aut-0.6*
[**2115-10-19**] 07:40AM BLOOD VitB12-312 Folate-6.5 Hapto-112
[**2115-10-22**] 06:05AM BLOOD TSH-0.42
[**2115-10-21**] 01:10PM BLOOD CRP-4.6
[**2115-10-18**] 12:40PM BLOOD C3-137 C4-32
[**2115-10-25**] 06:18AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2115-10-17**] 12:50PM BLOOD Lipase-28
[**2115-10-17**] 12:50PM BLOOD ALT-24 AST-30 AlkPhos-61 TotBili-0.3
[**2115-10-18**] 12:40PM BLOOD CK(CPK)-22*
[**2115-10-19**] 07:40AM BLOOD LD(LDH)-182
[**2115-10-17**] 12:50PM BLOOD Glucose-81 UreaN-31* Creat-3.6* Na-137
K-5.5* Cl-103 HCO3-26 AnGap-14
[**2115-10-28**] 07:10AM BLOOD Glucose-114* UreaN-10 Creat-1.2* Na-138
K-3.7 Cl-103 HCO3-28 AnGap-11
[**2115-10-24**] 08:21PM URINE bnzodzp-POS barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
[**2115-10-19**] 09:11PM URINE Hours-RANDOM UreaN-252 Creat-46 Na-65
TotProt-LESS THAN
[**2115-10-19**] 09:11PM URINE Eos-NEGATIVE
[**2115-10-17**] 02:25PM URINE RBC-[**4-11**]* WBC-0-2 Bacteri-FEW Yeast-OCC
Epi-0-2
HCV GENOTYPE (Final [**2115-10-24**]):
Hepatitis C genotype, 1.
Performed by Invader assay.
This assay detects the six major HCV genotypes 1, 2, 3, 4,
5, & 6..
This test was developed and its performance
characteristics were
determined by the [**Hospital1 18**] Clinical Microbiology Laboratory.
It has not
been cleared or approved by the U.S. Food and Drug
Administration.
The FDA has determined that such clearance or approval is
not
necessary. This test is used for clinical purposes. It
should not be
regarded as investigational or for research.
HCV VIRAL LOAD (Final [**2115-10-22**]):
17,900,000 IU/mL.
Performed using the Cobas Ampliprep / Cobas Taqman HCV
Test.
Detection Range 43 - 69,000,000 IU/mL.
As of [**2115-6-9**], HCV viral load is performed by the
FDA-approved,
Cobas Ampliprep-Taqman assay, replacing the HCV ASR assay
previously
developed and validated by the [**Hospital1 18**] Microbiology
Laboratory.
URINE CULTURE (Final [**2115-10-18**]):
YEAST. <10,000 organisms/ml.
CHEST (PA & LAT)
IMPRESSION: Mild interstitial edema. No radiographic evidence of
pneumonia.
RENAL U.S.
IMPRESSION: Normal renal ultrasound.
LIVER OR GALLBLADDER US (SINGLE ORGAN)
IMPRESSION:
1) No focal parenchymal abnormality is identified in the liver.
No imaging findings to suggest hepatic cirrhosis.
2) Borderline enlargement of the spleen.
Brief Hospital Course:
Assessment and Plan: This is a 41yo female with bipolar d/o,
heroin use in past, h/o mrsa, recent Hep C, recent history of
septic joint s/p debridment p/w acute renal failure.
.
# ARF: This is due to her PO antibiotic for her septic joint,
likely due to the prolong course of ciprofloxacin and linezolid.
Renal US showed within normal limits. After IV hydration, her
creatinine plateaued around 1.2 - 1.3. Infectious disease
recommended IV vancomycin and ceftriaxone renally dosed for the
patient (roughly 4 wks). Paitent had a PICC placed on [**10-29**] in
anticipation for discharge to rehab. She will have to follow up
with her infectious disease doctor on the [**6-11**], at
which time the duration of her IV antibiotic treatment will be
reassessed. If she leaves AMA from her rehab, PICC should be
discontinued. She will not be able to get any PO antibiotics
but she should follow up with infectious disease doctors.
.
# R. ankle s/p drainage: Her wound was well healed. Orthopedics
followed and evaluated her ankle. They removed the sutures and
will follow her as on outpatient on [**11-21**]. Her pain was
well controlled on oxycodone 5mg Q4H prn.
.
# respiratory depression due to Heroin use: Patient had an
episode of respiratory depression secondary to heroin use. This
event was due to patient's inability to cope with her diagnosis
of hep C and her other medical issues. After this episode she
had a short stay in the MICU(see MICU course). Patient was
stable after transferring back to the floor. Her neurotin and
valium were titrated up to alleviate anxiety with a good
response. She saturated well on room air. She was maintained
on no visitors for the stay of her hospitalization.
.
#MICU Course:
On [**2115-10-24**], patient had an associate inject heroin into her, and
became cyanotic and apnic for one minute. She was bagged and
resumed spontaneous breathing, but remained lethargic throughout
the night. She was transferred to the MICU overnight for
observation. She remained stable from a respiratory standpoint.
Oxycodone was held and she was given tylenol for pain. Addiction
services and social work were consulted. - continue seroquel,
valium, and oxycodone
.
# Bipolar: Her symptoms are currently stable. She should
continue home medications renally dosed - on Gabapentin,
Aripiprazole, Quetiapine.
.
# anxiety/muscle spasm: She is stable on Diazepam 10mg.
.
# Hep C infection: She is very distressed by her recent
diagnosis of hep C infection (viral load 18 million, type 1).
RUS showed normal liver anatomy and no LFT changes. PT did not
follow up with liver clinic since last admission. She will need
an outpatient follow up with the liver clinic.
.
# macrocytic anemia: She had macrocytic anemia with elevated mcv
is elevated, appears to be baseline to [**2112**]. B12 and folate are
within normal range. Her blood smear showed occasional tear drop
cells, with expected macrocytes of unequal shape and size.
Retic count was inappropriately low. TSH level was wnl. She
was given empirical Vit B12 repletion. She should follow up as
outpatient with hematology (B12 is 312, likely will benefit from
MMA testing).
.
# FEN: No IVF, replete electrolytes, renal diet
.
# Prophylaxis: Subcutaneous heparin, ambulate
.
# Access: PICC, peripherals
.
# Code: full
.
# Communication: Patient
Medications on Admission:
MEDICATIONS (d/c summary from [**2115-10-2**]):
1. Aripiprazole 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
3. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*175 Tablet(s)* Refills:*0*
4. Diazepam 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for spasm and anxiety.
Disp:*56 Tablet(s)* Refills:*0*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
6. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*28 Tablet Sustained Release 12 hr(s)* Refills:*0*
7. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
8. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H
(every 12 hours) for 2 weeks.
Disp:*84 Tablet(s)* Refills:*0*
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aripiprazole 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
7. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QAM (once a day
(in the morning)).
8. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
10. Diazepam 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for anxiety.
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours).
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain fever.
13. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
every twelve (12) hours for 2 weeks.
14. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
One (1) Intravenous once a day for 2 weeks.
15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
16. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
17. Outpatient Lab Work
WEEKLY CBC with diff, BUN, creatinine, and vancomycin troughs
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 6313**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary Diagnosis:
1. Acute renal failure, now resolved
2. Septic joint
Secondary:
1. Bipolar disorder
2. Anxiety
3. Macrocytic anemia
4. Thrombocytopenia, now resolved
Discharge Condition:
Hemodynamically stable; ambulatory with crutches
Discharge Instructions:
You were admitted to the hospital for acute renal failure in the
setting of being on long term antibiotics. It was likely the
ciprofloxacin that caused this renal failure. We stopped this
medicine and changed your treatment to vancomycin and
ceftriaxone. Your kidney function returned to [**Location 213**]. We found
that you also had anemia with borderline normal vitamin B12. We
provided you with Vitamin B12. You had an episode of apnea
during the hospitalization secondary to using heroin; for this
you required a short stay in the intensive care unit. You
remained without a fever and with stable blood pressure
throughout your hospitalization. In addition, the infection in
your ankle continues to improve.
While you were in the hospital, your kidney function continued
to improve. We were able to control your pain and cramps with
oxycodone and valium.
Aside from the antibiotics, there were no other changes to your
medications.
Please return to the hospital for any worsening leg pain,
fevers, chills, chest pain, shortness of breath, nausea,
vomitting, worsening diarrhea, decreased amount of urination,
pain with urination or any other concerns.
Followup Instructions:
1. Please call your primary care doctor, Dr. [**First Name (STitle) **], to make a
follow up appointment. Call [**Telephone/Fax (1) 58182**] on Monday to make this
appointment.
2. Please call the [**Hospital1 18**] liver clinic at ([**Telephone/Fax (1) 16687**] to make
an appointment for further care of hepatitis C.
3. Infectious Disease. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 16976**], MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2115-11-11**] 9:00
4. [**Hospital **] Clinic. Provider: [**Name10 (NameIs) 13978**] [**Name11 (NameIs) **], MD
Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2115-11-21**] 2:45
|
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[
[
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,677
| 135,986
|
36161
|
Discharge summary
|
report
|
Admission Date: [**2194-1-7**] Discharge Date: [**2194-1-16**]
Service: MEDICINE
Allergies:
Latex / Penicillins / Sulfa (Sulfonamide Antibiotics) / Levaquin
/ Ciprofloxacin
Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
s/p percutaneous cholecystostomy inserted via Interventional
Radiology.
History of Present Illness:
This is a 88 year-old female with a history of HTN, IHSS,
hydrocephalus s/p VP shunt who underwent percutaneous cystostomy
on [**1-7**] for acute cholecystitis and is now transferred to the
[**Hospital Unit Name 153**] for epigastric/sub-xyphoid pain.
Pt was in her USOH until the night of [**1-5**] when she developed
acute onset RUQ pain with radiation down her R leg. She
initially presented to [**Hospital 1562**] hospital where she was diagnosed
with acute cholecystitis. Plan was for cholecystectomy, however
given her complicated PMH including recent VP shunt, it was felt
that she should be transferred to a tertiary care center and
thus she was transferred to [**Hospital1 18**]. On [**1-7**], she underwent
percutaneous cholecystostomy. Post-operatively the patient
developed hypertension to SBP of 220s with left-sided chest pain
radiating to her L arm. EKG was unremarkable and cardiac enzymes
were negative. Had been doing well on the surgery floor
yesterday with plans to discharge on the morning of [**1-9**].
However, she was not feeling well all afternoon at 6pm a trigger
was called for chest pain. Pt had awoken from sleep complaining
of chest pain/chest heaviness and SOB. BP was markedly elevated
to 220/80. She was afebrile and satting well on RA. She received
SLN x 3, morphine but pain persisted. Hydralazine 10mg IV was
given with good response and drop in BP to 180-190s. Pt was
transferred to the [**Hospital Unit Name 153**] for closer cardiac monitoring.
On arrival to the [**Name (NI) 153**], pt was complaining of [**7-16**]
epigastric/sub-xyphoid pain. Also SOB. No nausea. Received
morphine IV 1mg x 2, followed by 2mg x 1 with eventual
improvement. Also received SLN x 1. Cardiology consult arrived
promptly and felt that the lateral ST depressions were
representative of her severe LVH and unlikely to represent ACS.
Past Medical History:
Hydrocephalus s/p VP shunt [**9-13**]
[**Month/Year (2) **] DVT s/p IVC filter on coumadin- dx [**8-13**]
HTN
IHSS
Mitral regurgitation
OA
GERD
Osteoporosis
R total hip replacement
Social History:
Lives at home with daughter. Denies smoking/etoh/drugs.
Family History:
non-contributory
Physical Exam:
Vitals: T: BP: HR: RR: O2Sat:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: distended, diffusely TTP but mainly at epigastrium and
sub-xyphoid, no rebound or guarding
EXT: 1+ bilateral ankle edema
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Chemistries:
[**2194-1-6**] 09:25PM GLUCOSE-100 UREA N-19 CREAT-1.0 SODIUM-132*
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-23 ANION GAP-11
[**2194-1-6**] 09:25PM ALT(SGPT)-16 AST(SGOT)-22 ALK PHOS-80 TOT
BILI-1.4
[**2194-1-6**] 09:25PM LIPASE-30
[**2194-1-6**] 09:25PM ALBUMIN-3.5
Hematology:
[**2194-1-6**] 09:25PM WBC-9.3 RBC-3.74* HGB-11.1* HCT-31.5* MCV-84
MCH-29.6 MCHC-35.2* RDW-15.6*
[**2194-1-6**] 09:25PM NEUTS-80.1* LYMPHS-13.1* MONOS-5.7 EOS-0.8
BASOS-0.3
[**2194-1-6**] 09:25PM PLT COUNT-212
[**2194-1-6**] 09:25PM PT-24.1* PTT-38.3* INR(PT)-2.3*
Urinalysis:
[**2194-1-7**] 03:40AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2194-1-7**] 03:40AM URINE RBC-[**4-10**]* WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
EKG: Sinus tach at 102 bpm, nl axis, normal intervals, LVH, ST
depression in I, II, V3-V6.
CXR [**2194-1-7**]: A catheter overlies the right hemithorax coursing
into the abdomen, likely representing a ventriculoperitoneal
shunt. A second catheter overlies the right abdomen. The
cardiomediastinal silhouette is stable. The aorta is calcified
and mildly tortuous. The lung volumes are low resulting in mild
vascular plethora. A patchy opacity at the right lung base is
new and may represent atelectasis. Thoracolumbar scoliosis is
severe.
CT Abdomen with contrast [**2194-1-9**]:
1. No radiographic evidence of pulmonary embolism.
2. RUQ location of VP shunt, changed significantly from previous
study.
3. Bilateral pleural effusions and atelectasis.
3. No radiographic evidence of cholecystostomy tube
complication.
4. Extensive diverticulosis in the absence of diverticulitis.
Echocardiogram [**2194-1-10**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is a severe resting left ventricular
outflow tract obstruction. 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. There is mild
functional mitral stenosis (mean gradient 5 mmHg) due to mitral
annular calcification. Mild (1+) mitral regurgitation is seen.
The left ventricular inflow pattern suggests impaired
relaxation. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
RUQ ultrasound [**2194-1-10**]: The pigtail of a cholecystostomy tube
lies in a collapsed gallbladder. There is no intra- or
extra-hepatic biliary ductal dilatation. The liver parenchyma is
within normal limits. The flow in the main portal vein is
hepatopetal.
Brief Hospital Course:
Ms [**Known lastname 49957**] is an 88 year old woman with acute cholecystitis
transferred from an outside hospital given her multiple
comorbidities. Initially she underwent cholecystostomy tube
placement by IR and defervesced. Bile drained grew
pan-sensitive Klebsiella and she was continued on ceftriaxone.
On the day of anticipated discharge ([**1-9**]) from Surgery service,
Ms. [**Known lastname 49957**] developed epigastric and chest pain and severe
hypertension necessitating transfer to the medical ICU. CT scan
showed no evidence for a significant pulmonary embolism, she
ruled out by cardiac biomarkers for acute myocardial injury, her
EKG was without ischemic changes and there was no evidence
radiographically or clinically of an acute abdominal event. She
was treated with antihypertensive medications, analgesia and was
transferred to the General Medical floor/hospitalist service on
[**1-11**]. On transfer she was noted to have acute delirium
attributed to her complicated hospital course, acute prerenal
azotemia and multiple cormorbidities. On [**1-13**], IVF were
discontinued and the ceftriaxone was stopped. Cefpodoxime was
started. She passed her speech and swallow evaluation and her
mental status gradually improved.
## Acute Cholecystitis. Biliary culture with pan-sensitive
Klebsiella
--s/p percutaneous cholecystostomy tube with 60 cc purulent
material removed/drained on [**2194-1-7**]
--initially treated with ceftriaxone, changed to cefpodoxime
[**2194-1-14**]. Needs to complete a 14 day course. (Day #1 [**2194-1-6**]
Day #14 [**2194-1-19**]).
--f/u with Dr. [**Last Name (STitle) **] for consideration of cholecystectomy
(phone number provided to family and they will arrange follow up
if they so desire).
--f/u with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from IR for tube study and planned
tube removal in 6 weeks [**2194-2-18**] 10:30a XDI LOWER GI (TCC) [**Hospital 4054**], [**Location (un) **] RADIOLOGY
.
## Poorly controlled hypertension: her BP was elevated on the
floor (SBP mostly in the 140s-150s with occasional spikes to
180s-200s, asymptomatic, that resulted in extra verapamil doses
being given on two separate occasions), although her family
reported that her BP is usually better controlled at home (she
does have these occasional episodes of asymptomatic hypertensive
urgency at home). Per cardiology consult, labile BP is often
seen with HOCM and is very volume sensitive and HR sensitive.
Chest pain can also occur with HOCM with increased afterload
with HTN and is best treated with lowering the BP.
--Verapamil 40 mg PO Q24H was continued, then increased to [**Hospital1 **]
(per family, this dose has been slowly decreased by her
cardiologist over the past several months to 40mg qd even though
it is not usually a daily dosed drug)
--needs continued monitoring at rehab and followup with her
cardiologist
--furosemide continued at 4x/week, this may be increased
cautiously if necessary
.
## Delirium/Encephalopathy - Likely multifactorial including
infection, change in environment, medication side effects,
multiple intercurrent illness(es). Her delirium improved with
her medical conditions until she was back to baseline. As
delirium improved, dysphagia did as well.
.
## Possible THRUSH
--Treated with oral fluconazole x several days, no further
complaints for dysphagia, or evidence of Thrush on physical exam
so d/c'd, particularly given interaction with warfarin.
.
## History of [**Hospital1 **] DVT, Diagnosed in [**8-/2193**] with IVC filter in
place, maintained chronically on wafarin.
--Continued warfarin with goal INR [**3-10**], will need frequent INR
monitoring given concomitant use of antibiotics as well as
irregular eating pattern of last 10 days.
--Question if baseline cancer screening has been undertaken. If
not, would consider mammography and colonoscopy as outpatient
--on [**2194-1-15**], patient's daughter felt [**Name (NI) **] was slightly larger
than RLE but this was very subtle (if at all present). INR 3.1
on this day, so doubt recurrent thromboembolic phenomenon.
Discussed with daughter and agreed to monitor clinically.
.
## Acute prerenal azotemia vs contrast induced nephropathy.
Improved with fluids. Foley d/c'd with transient urinary
retention requiring intermittent catheterization, now voiding
spontaneously.
.
## Anemia of inflammation with possible B12 deficiency (255
pg/mL)
--consider outpatient evaluation for anemia
--consider checking a methylmalonic acid level as an outpatient
vs. empiric treatment with supplemental B12
--TSH within normal limits
.
## HCP = [**Name (NI) 4457**] (daughter) [**Telephone/Fax (1) 82033**]
Medications on Admission:
Verapamil 40mg PO daily
Nexium 40mg PO daily
Colace 100mg PO BID
Coumadin 1mg PO qM/W/Th/F/S/S, 2mg PO qTu
Furosemide 20mg PO every Monday/Wed/Fri and either Sat or Sunday
Fosamax weekly
Discharge Medications:
1. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain for 2 weeks: Do not exceed
4000mg in 24hrs.
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
4. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day:
Except Tuesday.
5. Coumadin 2 mg Tablet Sig: One (1) Tablet PO On Tuesday only.
6. Verapamil 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO MONDAY,
WEDNESDAY, FRIDAY AND SATURDAY ().
8. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 4 days.
9. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**First Name5 (NamePattern1) 4542**] [**Last Name (NamePattern1) 6252**] Nursing & Rehab
Discharge Diagnosis:
Primary:
1) acute cholecystitis with pan-sensitive Klebsiella s/p
cholecystostomy tube placement [**2194-1-7**]
2) Hypertrophic Cardiomyopathy with sensitive volume status
3) Hypertension
.
Secondary:
1) hydrocephalus s/p VP shunt [**9-13**]
2) [**Month/Year (2) **] DVT, s/p IVC filter on coumadin
3) Osteoporosis s/p hip fracture
4) GERD
.
INCIDENTAL FINDINGS ON IMAGING HERE:
--Right inguinal and retroperitoneal lymphadenopathy 1.3 cm
(unclear significance)
--[**Name (NI) 82034**] hypodensity in right kidney (uncertain
significance)
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* Changes in mental status or losing control of your bowel or
bladder.
* 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.
* Call or return immediately if your pain is getting worse or is
changing location or moving to your chest or back.
*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.
.
Chole Drain Care:
-Flush with 10cc of Normal Saline once a day to prevent
clogging.
-Please look at the site every day for signs of infection
(increased redness, swelling, odor, yellow or bloody discharge,
fever).
-Maintain the bulb deflated to provide adequate suction.
-Note color, consistency, and amount of fluid in drain. Call
doctor if amount increases significantly or changes in
character.
-Be sure to empty the drain frequently.
-You may shower, wash area gently with warm, soapy water.
-Maintain the site clean, dry, and intact.
-Avoid swimming, baths, hot tubs-do not submerge yourself in
water.
-Keep drain attached safely to body to prevent pulling
Followup Instructions:
--Please report to the [**Hospital Ward Name 23**] Building, [**Location (un) 861**] at [**Location (un) **] at 10:15 am for a 10:30 am appoinment on
[**2194-2-18**]. This appointment is to study the
cholecystostomy tube in your abdomen. You should only eat clear
liquids the morning of the exam. You should take your regularly
prescribed medications but please do so before 9:30 am that day.
XDI LOWER GI (TCC) RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2194-2-18**] 10:30
.
--Please call to schedule a follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (3) **] in [**2-6**] weeks. This is for considering having your
gallbladder removed (surgery).
.
--Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 41632**] (Cardiology)
[**Telephone/Fax (1) 19666**].
.
--Please follow-up with your PCP, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 41632**] after you are
discharged from rehab. Please call his office to schedule an
appointment within one week of discharge. As your discharge
date from rehab is not set, this appointment was not made for
you. Dr. [**Last Name (STitle) 41632**] said he will rearrange his schedule if need be
to see you within one week of discharge from the rehab or as
needed.
.
If you wish to see a PCP here at the [**Hospital1 18**], please call the
Gerontology office at [**Telephone/Fax (1) 719**].
|
[
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] |
icd9cm
|
[
[
[]
]
] |
[
"57.17"
] |
icd9pcs
|
[
[
[]
]
] |
11905, 12021
|
6130, 10807
|
296, 370
|
12604, 12682
|
3238, 6107
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10833, 11022
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12706, 14427
|
2582, 3219
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248, 258
|
398, 2255
|
2277, 2460
|
2476, 2533
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,154
| 102,807
|
7821
|
Discharge summary
|
report
|
Admission Date: [**2184-10-13**] Discharge Date: [**2184-10-19**]
Date of Birth: [**2115-11-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Airway obstruction
Major Surgical or Invasive Procedure:
tracheotomy change [**2184-10-13**], [**2184-10-14**]
chest tube placement [**2184-10-14**]
flexible bronchoscopy [**2184-10-15**]
History of Present Illness:
68-year-old male who is status post chemo XRT for a T2 N2B right
tonsillar squamous cell carcinoma who was recently admmitted for
a pneumonia. Due to respiratory distress received a tracheotomy
on [**2184-10-2**] per the ORL service. The patient did well post-op and
was discharge to rehab. On the day of admission, nursing at
rehabilitation noted difficulty with suctioning and on deep
suctioning some tracheal bleeding. He was transferred to [**Hospital1 18**]
for evaluation. Of note, the patient has a 7 portex cuffed trach
tube, a different
tube than at discharge.
While in the ED, complete clogging of the trach tube was noted
on ORL evaluation with clots coming from the trach. Respiratory
was unable to pass a suction. The ORL service was consulted for
evaluation.
Outside records from [**Location **] indicate that the patient was 2
receive 2 unit PRBCs for a HCT of 22 today. Also, is WBC count
was 25 with C.diff results pending from rehab and was
emperically started on flagyl. He was currently receiving
vancomycin for MRSA pneumonia.
Past Medical History:
Hypertension
CVA- "small strokes,"
Exploratory laparatomy about 20 yrs ago for incarcerated hernia
Social History:
Previous gas station maintenance worker, 40 pack-yr history of
smoking and current smoker, drank 2-3 beers a day before the
dysphagia started.
Family History:
Noncontributory.
Physical Exam:
VS: HR 110s BP 161/72 T 101 97% on trach mask
General: NAD, lying in bed
HEENT: tongue slightly protruding, firm mass right jaw and
superior
NECK: radiation changes anterior/right neck. Tracheostomy.
Gurgling sounds with breathing.
HEART: Regular rhythm, tachycardic without murmurs.
LUNGS: Diffuse rhonchorous sounds anterior and posterior chest
ABD: Soft, nondistended, PEG-tube site is clean dry and intact.
SKIN: Warm and dry without rashes.
EXTREMITIES: Warm, no edema.
Psych: Alert and oriented with normal affect.
Pertinent Results:
Admission Labs:
[**2184-10-13**] 07:47PM LACTATE-1.7
[**2184-10-13**] 07:00PM GLUCOSE-169* UREA N-24* CREAT-0.7 SODIUM-132*
POTASSIUM-3.8 CHLORIDE-89* TOTAL CO2-36* ANION GAP-11
[**2184-10-13**] 07:00PM CK(CPK)-28*
[**2184-10-13**] 07:00PM cTropnT-0.04*
[**2184-10-13**] 07:00PM CK-MB-NotDone
[**2184-10-13**] 07:00PM WBC-23.0*# RBC-3.04* HGB-8.2* HCT-25.3*
MCV-83# MCH-27.1 MCHC-32.6 RDW-15.4
Discharge Labs:
[**2184-10-19**] 03:43AM BLOOD WBC-23.5* RBC-3.39* Hgb-9.3* Hct-29.3*
MCV-86 MCH-27.6 MCHC-32.0 RDW-14.3 Plt Ct-594*
[**2184-10-19**] 03:43AM BLOOD Glucose-154* UreaN-14 Creat-0.6 Na-132*
K-4.0 Cl-97 HCO3-26 AnGap-13
[**2184-10-19**] 03:43AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.1
Brief Hospital Course:
68yo M squamous cell throat cancer w recent hx of pneumonia and
ICU stay, s/p Trach/PEG, presented w tracheostomy tube in false
lumen.
#) Tracheostomy Replacement: on presentation patient initially
had bleeding around his trach site, and his ET tube was found to
be full of clots, in the ED, his tracheotomy tube replaced.
While changing the tube, a false passage was noted. This passage
was not present at discharge. On HD 2, the tracheotomy tube
migrated into the false passage and required a second procedure
to secure the airway. Which was complicated by a left
pneumothorax seen on follow-up chest xray, and a chest tube was
placed by the SICU team. The chest tube was removed [**10-17**] with
small residual apical pneumothorax, patient will need repeat
chest x-ray in [**2-3**] days after discharge to make sure the
pneumothorax has not worsened.
#) Leukocytosis: patient with persistent leukocytosis with white
blood cell counts over 20, and he continued to have low grade
temps. He was recultured, C.diff was sent, and his repeat
sputum culture also showed MRSA, which was thought to be
colonization rather then infection. His chest x-ray on the day
of discharge showed improvement in LLL.
#) Nutrition: Continuous tube feeds were transitioned to bolus
tube feeds and the patient appeared to tolerate well with low
residuals.
#) Hypertension: overall his BP was well controlled but he was
hypertensive in the morning, so he may need his medications
split to morning and evening meds.
Medications on Admission:
1. Insulin Sliding scale
2. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze
3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
6. Magnesium Sulfate IV Sliding Scale
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
8. MetRONIDAZOLE (FLagyl) 250 mg PO TID
9. Atenolol 100 mg PO DAILY
10. OxycoDONE Liquid 5 mg PO Q4H:PRN pain
11. Calcium Gluconate IV Sliding Scale
12. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN mouth pain
13. Senna 1 TAB PO BID:PRN
14. Docusate Sodium (Liquid) 100 mg PO BID
15. Ferrous Sulfate 325 mg PO/NG DAILY
16. Sodium Chloride Nasal [**1-2**] SPRY NU QID
17. Furosemide 20 mg PO BID
18. Heparin 5000 UNIT SC TID
19. Vancomycin 1000 mg IV Q 24H
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (2) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
2. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Month/Day (2) **]: Five (5)
mL PO DAILY (Daily): please give via g-tube.
3. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1) Inhalation
Q6H (every 6 hours) as needed for wheeze.
4. Aspirin 81 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Insulin Regular Human 100 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection ASDIR (AS DIRECTED).
6. Lisinopril 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
7. Atenolol 50 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY (Daily).
8. Oxycodone 5 mg/5 mL Solution [**Month/Day (2) **]: Five (5) ml PO Q4H (every 4
hours) as needed for pain.
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Sodium Chloride 0.65 % Aerosol, Spray [**Last Name (STitle) **]: [**1-2**] Sprays Nasal
QID (4 times a day).
11. Acetaminophen 160 mg/5 mL Solution [**Month/Day (2) **]: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain.
12. Phenol 1.4 % Aerosol, Spray [**Age over 90 **]: One (1) Spray Mucous
membrane Q4H (every 4 hours) as needed for mouth pain.
13. Docusate Sodium 50 mg/5 mL Liquid [**Age over 90 **]: One Hundred (100) mg
PO BID (2 times a day).
14. Senna 8.8 mg/5 mL Syrup [**Age over 90 **]: Five (5) ML PO BID (2 times a
day) as needed for constipation: Please give via PEG .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Respiratory Distress
Discharge Condition:
At the time of discharge patient had a stable white blood cell
count, had been having low grade temps but was not febrile,
tolerating his tube feeds, and considered medically stable for
discharge to rehab.
Discharge Instructions:
*Do not change trach tube until [**2184-11-12**]. This time is required
for maturation of the tracheal tract.
Dear Mr. [**Known lastname 28253**],
You were admitted to the hospital because you were having
difficulty breathing. The Otolaryngology Surgeons and
Interventional Pulmonology doctors helped replace your
tracheostomy tube so that you should be able to breathe better.
Your tracheostomy tube was replaced with a longer tube to help
prevent this from happening again in the future. During the
replacement of your tracheostomy, the procedure was complicated
by a pneumothorax (left lung collapse) and you had a chest tube
placed. After the lung reinflated you were able to have the
chest tube removed.
During your time in the hospital you completed your course of
vancomycin for your prior pneumonia and PICC line was taken out.
No other changes were made to your medication regimen.
Please call your doctor or return to the hospital if you
experience any shortness of breath, difficulty breathing, chest
pain, worsening cough or sputum production, blood from around
your trach site or any other concerning symptoms.
Followup Instructions:
Please be sure to keep your scheduled appointments:
Provider: [**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2184-10-22**] 10:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2184-11-5**] 11:00
|
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"482.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.23",
"34.04"
] |
icd9pcs
|
[
[
[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,089
| 132,282
|
10112
|
Discharge summary
|
report
|
Admission Date: [**2157-2-24**] Discharge Date: [**2157-3-9**]
Date of Birth: [**2117-6-4**] Sex: M
Service: NEUROLOGY
Allergies:
Lipitor
Attending:[**First Name3 (LF) 4583**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
VP shunt placement [**2157-2-26**]
History of Present Illness:
Mr. [**Known lastname 3234**] is a 39 year old with a history of hyperlipidemia,
hypothyroidism, and chronic low back pain who presents with one
week of headache and nausea.
The headache began on Thursday of last week when he returned
from work. He got out of his car and had the acute onset of a
severe ([**9-9**]) throbbing midline headache radiating from his
forehead to his occiput which worsened over the course of 30
minutes. He also felt very nauseas at that time and retched
although he did not vomit. Prior to onset of the HA he had
worked from 2am-8am
shoveling snow. After the HA began he went to sleep and
subseuqently had partial resolution of his symptoms when he
awoke. Over the course of the past week the headaches have been
intermittent, and occur with movement of his head or neck,
straining to defecate, or bending over to tie his shoes. He does
not have the headache when he does not move regardless of
whether he is lying down, sitting, or standing. The headaches
are similar in quality and location to his original epsiode,
last 3-5 minutes and are rated as a [**7-10**]. They occur 15-20 times
throughout the day. These episodes are occasionally accompanied
by iziness and occasionally nausea although he has not vomited.
He describes the
diziness as feeling like the room is spinning, and feels he
occasionally has to catch himself. Most of the time the vertigo
is brought up when lying in bed and turning his head. He states
that a few years ago he had a similar episode of vertigo that
lasted several days, at that time he had no HA.
On review of systems Mr. [**Known lastname 3234**] notes that he believes he hears
sounds around him as mor pronounced when he has his headaches.
he says occasionally they will be accompanied by very transient
blurry vision. he denies any diplopia, has not fallen, and
denies phophobia or photophobia during these episodes. Notably
history includes epidural steroid injections for chronic low
back pain (last [**2157-1-25**]).He also reports a similar sort of
diziness related to Lipitor use some time ago. He says he had
been taking the lipitor for several years, and subsequently
developed some muscle weakness and diziness which resolved when
he stopped the medication. This was not accompanied by headache.
Mr. [**Known lastname 3234**] was recently transitioned from a fibrate to
pravastatin on [**2157-1-28**].
Past Medical History:
hyperlipidemia
Chronic low back pain- receives epidural steroid injections last
[**2157-1-25**]
Elevated Ck in setting of alcohol binge and hypothyroidism
Hypothyroidism
Depression
Vitamin d deficiency
Carpal Tunnel
Social History:
He lives with his wife and two children. Alcohol on holidays. no
smoking, no illicit drugs. He is a landscaper. He immigrated
from [**Country 7192**] 20 years ago and last trip back was 3 years ago.
Family History:
Mom is age 59 with hypertension and diabetes. Dad is age 60 with
headaches. He has three brothers and eight sisters. One brother
has kidney problems, patient is unsure what.
Physical Exam:
VS: 96.5 67 141/75 16 100
Gen: NAD, spanish speaking man lying comfortable on stretcher
HEENT: NC/AT, no scleral icterus noted, no lesions noted in
oropharynx. No pain to plapation over face, neck, or scalp. Able
to elicit headache and diziness with movement of the head to the
right or left. no nystagmus noted when this occurs.
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to place and date. Able to
relate history without difficulty. Attentive, able to name DOW
and [**Doctor Last Name 1841**] backward without difficulty. Language is fluent with
intact comprehension. Normal prosody. There were no paraphasic
errors.Speech was not dysarthric. Able to follow both midline
and appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation. Right disk
margin is blurry, difficult to see the left
III, IV and VI: EOM are intact and full, no nystagmus b/l.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, vibration or
proprioception throughout.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response: flexor bilaterally
-Coordination: No intention tremor. No dysmetria on FNF, finger
tapping bilaterally.
-Gait: Good initiation. Normal casual and tandem gait. Stride
length is short, apparently due to fatigue. Brudzinki is
negative
+++++++++++++++++++++++++++++
DISCHARGE EXAM:
Afebrile BP 104/60, HR 60s, RR 18, O2 98%RA
General physical unremarkable, CV- RRR, Resp- CTAB, Abd-
s/ND/NT, no peritoneal signs. VP shunt runs down right scalp,
overlying skin intact with no erythema
Neurologic: no focal deficits, alert, oriented, speech fluent,
CNII-XII intact, motor- normal tone/bulk with full strength
throughout. Sensation intact to light touch throughout. FNF and
fingertapping intact. Gait steady.
Pertinent Results:
[**2157-3-1**] 04:35AM BLOOD WBC-5.6 RBC-4.33* Hgb-12.7* Hct-36.8*
MCV-85 MCH-29.3 MCHC-34.6 RDW-12.6 Plt Ct-243
[**2157-2-24**] 01:35PM BLOOD Neuts-62.0 Lymphs-32.1 Monos-4.2 Eos-0.6
Baso-1.2
[**2157-3-1**] 04:35AM BLOOD Glucose-110* UreaN-8 Creat-1.0 Na-141
K-3.9 Cl-103 HCO3-32 AnGap-10
[**2157-3-3**] 12:37AM BLOOD CK(CPK)-58
[**2157-2-27**] 08:04AM BLOOD CYSTICERCUS IGG AB, WESTERN BLOT-PND
[**2157-2-27**] 08:02AM BLOOD CYSTICERCOSIS ANTIBODY-PND
NCHCT [**2157-2-24**]: IMPRESSION: 1. Enlarged ventricles compatible
with communicating hydrocephalus with a small amount of
transependymal flow of CSF. 2. Scattered calcifications in the
white matter may relate to prior infection or inflammation. 3.
No acute hemorrhage.
MR brain [**2157-2-25**]: There is a 1.3 cm cystic lesion in the 4th
ventricle causing obstructing hydrocephalus. These findings in
combination with the bilateral calcification seen on CT are
highly suspicious for neurocysticercosis. Because of the high
degree of obstructive hydrocephalus, lumbar puncture is
contraindicated.
Findings were discussed by telephone Dr. [**Last Name (STitle) 33760**] with Dr. [**Last Name (STitle) **] -
9.00 am -
[**2157-2-25**].
MR spine (C-,T-, and L-spine) [**2157-2-28**]: IMPRESSION: 1. No focal
signal abnormality noted in the spinal cord. 2. No evidence of
significant spinal canal or neural foraminal stenosis. 3. No
abnormal enhancement.
4. Mild degenerative changes in the lumbar spine, with new left
paracentral disc herniation at L4-L5 level contacting traversing
left [**Name (NI) 13032**] nerve root.
Shunt series [**2157-2-28**]: Views from the skull to the upper abdomen
shows placement of a ventriculoperitoneal shunt that extends to
the upper abdomen with the tube curled somewhat on itself so
that the tip then goes to the mid portion of the abdomen on the
right
CT abdomen2/5/12: No abnormality seen along the course of the
ventriculoperitoneal shunt. The tip of it is seen in the
inferior right perihepatic region
NCHCT [**2157-3-7**]: 1. Unchanged position of the VP catheter. 2.
Significant interval decrease in size of the ventricles. 3.
Stable parenchymal calcifications suggest prior infection such
as old, healed neurocysticercosis.
Brief Hospital Course:
Mr. [**Known lastname 3234**] is a 39yoRHM who presented with a week long history
of headaches that were consistent with increased intracranial
pressure. Imaging revealed a large cyst in the 4th ventricle
causing obstructive hydrocephalus. He ultimately was diagnosed
with neurocystircercosis and treated symptomatically with a VP
shunt until surgical resection of the cyst could be performed.
1. Neurologic: Patient presented with signs of increased
intracranial pressure and clinically deteriorated on first day
of admission. He was transferred to the ICU where he was
monitored until the following day, when a VP shunt was placed.
He clinically improved and returned to the floor. He remained
clinically stable but did have continued mild nausea and
vomiting likely due to the location of the cyst. The shunt was
checked post-operative day 3 with a shunt series and was intact.
However, his abdominal pain persisted so given the shunt
(placement in right perihepatic region), both neurosurgery and
general surgery were re-consulted. Neither service felt surgical
intervention was required at this point. He continued to have
fluctuating mild pain but it overall improved prior to
discharge.
2. Infectious disease: The radiographic evidence was consistent
with neurocystircercosis. ID was consulted and per
recommendations, in addition to cystircercosis serology being
checked, so was a PPD, RPR, and HIV. The latter were all
negative and the serology confirmed neurocystircercosis. Also
checked was a total spine MRI and ophthamologic exam for other
cystircercosis. This was all negative as well. Clinically he
remained stable.
Due to the location of the cyst, multiple neurosurgeons as well
as the infectious disease team were consulted to discuss the
best treatment option. There is a consensus opinion from 3
senior nationally recognized ID attendings that surgical removal
is the safest option. We did explore the open of endoscopic
removal of the cyst, but Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] expert in this at
[**Hospital3 1810**], [**Location (un) 86**], who reviewed the images, was of the
opinion that this lesion is not amenable to this approach. The
options were presented to the patient and family who agreed to
go forward surgically.
3. GI: Pt continued to have nausea and vomiting throughout
hospitalization. It was severe prior to the VP shunt but did
continue on afterwards, likely due to the location of the cyst.
Zofran was used symptomatically and famotidine started due to
epigastric discomfort afterwards. However, due to continued
pain, a CT abdomen was performed and showed the shunt lying in
the right perihepatic region. As noted above, the surgical
services did not feel any intervention was required and since he
clinically improved, he was discharged home.
4. Cardiovascular: Hemodynamically stable throughout
hospitalization
5. Respiratory: Stable on room air throughout hospitalization.
Medications on Admission:
levothyroxine-50 mcg
pravastatin 20 mg
calcium carbonate-vitamin D3 500 mg (1,250 mg)-400 unit Tablet,
fish oil
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
6. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every six (6) hours as needed for nausea.
Disp:*10 Tablet, Rapid Dissolve(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Neurocystircercosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 3234**],
It was a pleasure taking care of you during your
hospitalization. You were admitted for headache and were found
to have a cystic lesion in your fourth ventricle of the brain.
This causes fluid buildup and the headaches you experienced.
This can be very dangerous so a ventriculoperitoneal shunt was
placed to drain some of the fluid into your stomach.
The [**Last Name **] problem was the cyst, which was due to an infection
called neurocystircercosis. This will ultimately need surgical
intervention which is being arranged. You will also need to be
followed in both neurology and infectious disease clinics,
appointments as scheduled.
.
Should you experience any of the below listed danger signs,
please seek immediate medical attention
.
Please keep your follow-up appointments as listed below
Dear Mr. [**Known lastname 3234**],
It was a pleasure taking care of you during your
hospitalization. You were admitted for headache and were found
to have a cyst in your fourth ventricle of the brain. This
causes fluid buildup and the headaches you experienced. This can
be very dangerous so a ventriculoperitoneal shunt was placed to
drain some of the fluid into your abdomen to prevent the buildup
of pressure in the head.
.
The [**Last Name **] problem was the cyst, which was due to an infection
called NEUROCYSTICERCOSIS. This will ultimately need surgical
intervention which is being arranged by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
and the [**Hospital1 18**] Neurosurgeons. You will also need to be followed
in neurology, neurosurgery, and infectious disease clinics,
appointments as scheduled.
.
We would like you to take the following medications:
1. Please take LEVETIRACETAM to prevent seizures.
2. You may take ZOFRAN as needed for nausea (one tablet as often
as every 8 hours).
3. You may take OXYCODONE-ACETAMINOPHEN as needed for pain (one
tablet as often as every 6 hours).
Please take your other medications as previously prescribed.
.
Should you experience any of the below listed danger signs,
please seek immediate medical attention
.
Please keep your follow-up appointments as listed below.
--------
Estimado Sr. [**Known lastname 3234**],
Ha sido un placer cuidar de [**First Name9 (NamePattern2) **] [**Last Name (un) 33761**] [**Doctor First Name **] hospitalizaci??????n.
[**Doctor First Name **] fue admitido para el dolor de [**Last Name (un) 33762**] y se encontr?????? [**Last Name (un) **]
tiene un quiste en el cuarto ventr??????culo [**Doctor First Name **] cerebro. Esto hace
[**Doctor First Name **] [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 33763**]??????n de l??????quido y los [**Doctor First Name **] de [**Last Name (un) 33762**] [**Last Name (un) **]
experiment??????. Esto puede ser muy peligroso por lo [**Last Name (un) **] una
derivaci??????n ventr??????culo-peritoneal fue colocado para drenar parte
[**Doctor First Name **] l??????quido en el abdomen para evitar [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 33763**]??????n de presi??????n
en [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 33762**].
.
El problema principal era el quiste, el cual se [**Female First Name (un) **]?????? a una
infecci??????n llamada neurocisticercosis. En ??????ltima instancia, ser??????
necesario una intervenci??????n quir??????rgica [**Female First Name (un) **] est?????? siendo organizado
por [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] y [**Location 33764**] [**Hospital1 18**].
[**Hospital1 **] tambi??????n tendr?????? [**Hospital1 **] seguir en neurolog??????a, neurocirug??????a, y
las cl??????nicas de enfermedades infecciosas, [**Location 33765**]
[**Location 33766**].
.
Nos gustar??????a [**Location **] [**Location **] tome [**Location 33767**] [**Location 33768**]:
1. Por favor tomar levetiracetam para prevenir las
convulsiones.
2. [**Location **] puede tomar ZOFRAN seg??????n sea necesario para las
n??????useas (un comprimido con [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 33769**] [**First Name9 (NamePattern2) **] [**Last Name (un) 33424**] 8 horas).
3. [**Last Name (un) **] puede tomar oxicodona-acetaminofen para el dolor seg??????n
sea necesario (un comprimido con [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 33769**] [**First Name9 (NamePattern2) **] [**Last Name (un) 33424**] 6
horas).
Por favor, tome sus medicinas como lo antes descrito.
.
Si [**Last Name (un) **] experimenta alguno de [**Location 33770**] de peligro [**Location **]
figuran a continuaci??????n, por favor, [**Last Name (un) 33771**] atenci??????n m??????dica
inmediata
.
Por favor, mantenga sus citas de seguimiento [**Last Name (un) **] se enumeran a
continuaci??????n.
Followup Instructions:
Follow-up in [**Hospital 878**] clinic with DR. [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 540**]:
[**2157-5-9**] at 2:30PM, [**Hospital Ward Name 33772**], [**Hospital Ward Name 23**] Building, [**Location (un) 858**], [**Location (un) 830**],
[**Location (un) 86**], [**Numeric Identifier 718**], PHONE: [**Telephone/Fax (1) 541**]
Follow-up with Infectious Disease Clinic: DR. [**Last Name (STitle) 1413**]: [**3-24**] at 1:30PM, [**Hospital1 69**], [**Hospital **]
Medical Office Building, Suite GB, [**Last Name (NamePattern1) 439**], [**Location (un) 86**],
[**Numeric Identifier **], PHONE [**Telephone/Fax (1) 457**]
Follow-up with Primary Care Physician: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**3-15**]
at 8:00PM, Location: [**Hospital6 28009**]
Address: [**Street Address(2) 33773**], [**Location (un) **],[**Numeric Identifier 33774**]
Phone: [**Telephone/Fax (1) 17826**]
Fax: [**Telephone/Fax (1) 33775**]
Follow-up with Neurosurgery is being arranged in conjunction
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. You will be contact[**Name (NI) **] by
telephone.
----
El seguimiento en [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]??????nica de Neurolog??????a con el DR. [**First Name8 (NamePattern2) 539**]
[**Last Name (NamePattern1) **]: [**2157-5-9**] a las 2:30 pm, [**Hospital Ward Name 33776**], Edificio [**Hospital Ward Name 23**], [**Location (un) 858**], [**Location (un) **], [**Location (un) 86**], [**Numeric Identifier 718**], tel??????fono: [**Telephone/Fax (1) 541**]
El seguimiento con Cl??????nica de Enfermedades Infecciosas: DR.
[**Last Name (STitle) **]: 23 de febrero a las 1:30 pm, [**Hospital1 827**], [**Hospital **] Medical Office Building, Suite E, [**Last Name (NamePattern1) 12939**], [**Location (un) 86**], [**Telephone/Fax (1) 33777**] TEL??????FONO
El seguimiento con el m??????dico de atenci??????n primaria: DR. [**Last Name (STitle) 14049**],
14 de febrero a las 8:00 pm, [**Last Name (un) 33778**]: JOS?????? [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1968**] Community
Health Center
Direcci??????n: [**Street Address(2) **]., [**Location (un) 577**], [**Numeric Identifier 33774**]
Tel: [**Telephone/Fax (1) 17826**]
Fax: [**Telephone/Fax (1) 33775**]
El seguimiento con Neurocirug??????a se est?????? organizando en
colaboraci??????n con [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**Last Name (NamePattern1) **] ser??????
contactado por tel??????fono.
|
[
"338.29",
"272.4",
"123.1",
"268.9",
"348.0",
"331.4",
"724.2",
"377.01",
"311",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"02.34"
] |
icd9pcs
|
[
[
[]
]
] |
12229, 12235
|
8396, 11382
|
276, 313
|
12299, 12299
|
6141, 8373
|
17288, 19896
|
3195, 3372
|
11545, 12206
|
12256, 12278
|
11408, 11522
|
12450, 17265
|
4350, 5681
|
3387, 3927
|
5697, 6122
|
228, 238
|
341, 2722
|
12314, 12426
|
2744, 2962
|
2978, 3179
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
641
| 110,557
|
5179
|
Discharge summary
|
report
|
Admission Date: [**2190-8-24**] Discharge Date: [**2190-9-8**]
Date of Birth: [**2112-10-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
[**2190-8-25**] Upper and Lower GI Endoscopy
[**2190-8-31**] Mitral Valve Replacement(29mm Mosaic Porcine valve) and
Three Vessel Coronary Artery Bypass Grafting(left internal
mammary to left anterior descending, vein grafts to obtuse
marginal and posterior descending artery)
History of Present Illness:
77 yo male with history of CAD and IMI. Elective cath done in
preparation for planned MVR. Cath revealed LM 50%, LAD 80%, CX
50%, RCA 100%, mild AI, EF 50%, moderate MR.Echo also showed 4+
MR and 2+ AI. Referred to Dr. [**Last Name (STitle) 1290**] for MVR/CABG/possible
AVR.
Past Medical History:
CAD/IMI
NIDDM
elev. chol.
HTN
CHF
DJD
very HOH
pacer for bradycardia [**2185**] ([**Company 1543**] Sigma 300 DR)
Social History:
retired, lives with wife
no ETOH
quit smoking 5 years ago, 55pack-yrs
no recr. drugs
Family History:
non-contrib.
Physical Exam:
HR 72 RR 16 right 124/60 left 120/58
5'8" 158#
WDWN in NAD
skin unremarkable
PERRL, EOMI, NC/AT, OP benign
neck full ROM, no JVD or bruits
CTAB
RRR 3/6 murmur
soft, NT, ND, + BS
warm, well-perfused, no edema, no varicosities
alert and oriented X 3, MAE, non-focal
2+ fem/DP/PT/radials
Pertinent Results:
[**2190-9-7**] 07:25AM BLOOD WBC-8.4 RBC-3.68* Hgb-8.9* Hct-28.1*
MCV-77* MCH-24.2* MCHC-31.7 RDW-21.9* Plt Ct-315#
[**2190-9-7**] 07:25AM BLOOD Plt Ct-315#
[**2190-9-7**] 07:25AM BLOOD PT-25.9* PTT-35.4* INR(PT)-2.6*
[**2190-9-7**] 07:25AM BLOOD Glucose-85 UreaN-24* Creat-1.4* Na-140
K-4.4 Cl-99 HCO3-32 AnGap-13
Brief Hospital Course:
Admitted for surgery on [**8-24**] and taken to the OR. Hematocrit
drawn prior to incision was 20.5. This represented a significant
drop from his last PAT Hct which was 27.5. Surgery cancelled in
the OR for anemia work-up to rule out a source of active
bleeding.Patient taken to CSRU in stable condition and extubated
there later in the day. Seen by general surgery team and GI
consult. Abd/pelvic CT scanning also done with no source of
bleeding or hematomas found. EGD and colonoscopy done on [**8-25**]
with were negative. Capsule endoscopy on [**2190-8-27**] showed
angioextasia in the distal small bowel. Angiography showed no
active bleeding. Hematology consult recommended iron
supplementation. General surgery deferred push enteroscopy via
laparotomy. He as taken to the operating room on [**2190-8-31**] where
he underwent a CABG x 3 and MVR (Porcine). Please see op note
for details. He was extubated on POD #1. He was seen by
electrophysiology who reprogrammed his PPM to a backup rate of
80 from 70, and turned off the sleep mode to help wean from his
epinephrine. The pacer was returned to its original settings on
[**2190-9-3**]. He was anticoagulated for underlying atrial
fibrilation.
Medications on Admission:
amiodarone 200 mg daily
lopressor 25 mg [**Hospital1 **]
omeprazole 20 mg daily
ASA 325 mg daily
glyburide 2.5 mg daily
combivent
lasix 40 mg [**Hospital1 **]
vytorin 10/40 mg daily
KCl
amoxicillin prn dental
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 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. 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*
5. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Vytorin 10/40 10-40 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
8. Potassium Chloride 20 mEq Packet Sig: One (1) PO twice a
day.
Disp:*60 * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
anemia
CAD
IMI
NIDDM
CHF
DJD
very HOH
pacemaker (bradycardia)[**Company 1543**] Sigma 300 DR
Discharge Condition:
good
Discharge Instructions:
follow up appts. as below
Followup Instructions:
see Dr. [**Last Name (STitle) 1057**] in [**1-11**] weeks
schedule follow up appt. with Dr. [**Last Name (STitle) 1290**] in 3 weeks ( after
hematology work-up is complete). Please call him this coming
Thursday [**9-2**] for update.
Completed by:[**2190-9-9**]
|
[
"455.3",
"250.00",
"428.0",
"403.91",
"447.1",
"V64.1",
"427.31",
"997.1",
"455.0",
"788.5",
"280.0",
"997.5",
"424.0",
"440.0",
"537.83",
"272.4",
"V53.31",
"414.01",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.47",
"45.23",
"45.13",
"35.23",
"99.04",
"88.72",
"89.45",
"99.07",
"36.15",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
4278, 4349
|
1846, 3049
|
325, 604
|
4486, 4493
|
1507, 1823
|
4567, 4830
|
1166, 1180
|
3308, 4255
|
4370, 4465
|
3075, 3285
|
4517, 4544
|
1195, 1488
|
282, 287
|
632, 909
|
931, 1046
|
1062, 1150
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,726
| 162,296
|
6382
|
Discharge summary
|
report
|
Admission Date: [**2181-12-4**] Discharge Date: [**2181-12-12**]
Date of Birth: [**2110-2-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
[**2181-12-5**]: Hemiarthroplasty, right hip.
History of Present Illness:
71 year old male s/p fall on [**2181-12-4**] resulting in a right hip
fracture requiring surgical management.
Past Medical History:
NIDDM2, HTN, hi chol, h/o TIA (R hemiparesis), prostate CA
s/p rads, carotid stenoses (70-79% L, 60-69% R), 1ppd smoker
Social History:
Lives with son, daughter-in-law, and three grandchildren. Able
to ambulate with prosthesis and cane at baseline. Former smoker,
quit 2 years ago, previously smoked 1 PPD x40 years. Occasional
beer, about once per week. No illicit drug use.
Family History:
No family history of diabetes mellitus, hypertension,
hyperlipidemia, or cancer. Per reports mother deceased secondary
to MI.
Physical Exam:
BP: 132/80 HR: 78 RR: 18 97%2L Temp: 97.5
General Evaluation Exam
Sensorium: Awake (x) Awake impaired () Unconscious ()
Airway: Intubated () Not intubated (x)
Breathing: Stable (x) Unstable ()
Circulation: Stable (x) Unstable ()
Musculoskeletal Exam
Neck Normal (x) Abnormal () Comments: no tenderness over
posterior scalp where pt recalls hitting it during the fall
Spine Normal (x) Abnormal () Comments:
Clavicle
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Shoulder
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Arm
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Elbow
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Forearm
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Wrist
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Hand
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Pelvis
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Hip
R Normal () Abnormal (x) Comments: minimal tenderness
with palpation over the greater trochanter. Severe tenderness
with internal/external rotation of the hip. No obvious brusing
or
skin discoloration
L Normal (x) Abnormal () Comments:
Thigh
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Knee
R Normal (x) Abnormal () Comments: pt able to
flex/extend knee without difficulty, minimal pain experienced in
the R hip. Small amount of serosang oozing from an open sore
(5mm
diameter) at the distal tip of RLE stump
L Normal (x) Abnormal () Comments:
Leg
L Normal (x) Abnormal () Comments:
Ankle
L Normal (x) Abnormal () Comments:
Foot
L Normal (x) Abnormal () Comments:
Vascular:
Radial R Palpable (x) Non-palpable () Doppler ()
L Palpable (x) Non-palpable () Doppler ()
Palpable graft pulse in LLE prox and distal
Neuro:
Quad R (x) L (x)
Ant Tib L (x)
[**Last Name (un) 938**] L (x)
Peroneal L (x)
GS L (x)
Pertinent Results:
Admission Labs:
[**2181-12-4**] 11:35AM BLOOD WBC-8.6# RBC-4.01* Hgb-12.8* Hct-36.0*#
MCV-90 MCH-32.0 MCHC-35.5* RDW-13.6 Plt Ct-214
[**2181-12-4**] 11:35AM BLOOD Neuts-77.1* Lymphs-16.4* Monos-5.5
Eos-0.6 Baso-0.4
[**2181-12-4**] 11:35AM BLOOD PT-29.7* PTT-30.0 INR(PT)-2.9*
[**2181-12-4**] 11:35AM BLOOD Glucose-189* UreaN-16 Creat-0.8 Na-140
K-4.0 Cl-104 HCO3-28 AnGap-12
UA:
[**2181-12-4**] 11:47AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.029
[**2181-12-4**] 11:47AM URINE Blood-TR Nitrite-NEG Protein-75
Glucose-250 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2181-12-4**] 11:47AM URINE RBC-0-2 WBC-[**3-16**] Bacteri-0 Yeast-NONE
Epi-0-2
[**2181-12-4**] 11:47AM URINE Mucous-MANY
Micro:
[**12-4**] Urine culture: negative
[**12-7**] Blood cultures: pending
Imaging:
Brief Hospital Course:
71yo male with h/o PVD, HTN, DMII, HL, distant prostate cancer
s/p radiation who initially presented from OSH on [**2181-12-4**] with
right displaced femoral neck fracture, s/p right hip
hemiarthroplasty on [**2181-12-5**] and was subsequently transferred to
MICU on POD #2 in setting of somnolence, tachycardia, and
desaturations most likely [**2-13**] to narcotic pain medication
administration and aspiration pneumonia.
.
#. Pneumonia: CXR [**12-7**] showed RLL opacity concerning for
pneumonia, and CTA chest [**12-7**] confirmed widespread patchy
opacities throughout the right upper lobe and both lower lobes
c/w bronchopneumonia. Most likely HAP vs. aspiration PNA in
setting of somnolence after receiving increased doses of
narcotic pain medication. Started on broad spectrum antibiotics
with vanc/cefepime and flagyl added on [**12-10**]. Blood cultures
were negative. Pt will resume antibiotics for a total 8 day
course, to be continued through: Friday, [**12-14**].
.
#. R displaced femoral neck fracture s/p R hip hemiarthroplasty:
Patient sustained right displaced femoral neck fracture, and
underwent R hip hemiarthroplasty on [**2181-12-5**]. Pain controlled on
low dose narcotics given his sensitivity to narcotics. He was
given acetaminophen 1gm q 6hrs, oxycodone 2.5mg q 6h and
morphine 0.5mg IV as needed. Pt will follow up with ortho
outpatient.
.
#. Tachycardia/A. Fib: During hospital stay, pt had intermittent
sinus tachycardia as well as intermittent afib with RVR to as
high as 170s-190s. On BB and Dilt which controlled his rate. Was
discharged on metoprolol succ 150 daily, Diltiazem 120mg long
acting, daily. Pt was in NSR with HR in 80 at time of discharge.
He was anticoagulated with coumadin. Coumadin was initially held
for surgery and was restarted on [**2181-12-12**]. He is also being
anticoagulated with prophylactic dose of Lovenox 40mg daily. Pt
should continue both lovenox 40mg daily and coumadin 2.5mg daily
for goal INR 1.8-2.5. After pt completes his 30 day course of
lovenox, his new INR goal should be [**2-14**] (standard INR goal for A
Fib). Pt should follow up with ortho to decide when to stop the
lovenox (it will likely be 30 days).
.
#. Anemia: HCT noted to drop from 28.2 to 21.5 on [**2181-12-7**]
likely in setting of GI lossess while on heparin drip. Baseline
HCT was 36 prior to admission presentation. S/p transfusion 2
units pRBCs on [**12-8**], with improvement and subsequent
stabilization of HCT. Heparin drip was d/c-ed since neg CTPA for
PE. Patient's downward trend in HCT also in setting of recent
hip surgery. Prior to discharge, he had stool guiac test which
was NEGATIVE.
*Will need GI workup outpatient for HCT drop. Needs colonoscopy
and possibly endoscopy. Per pt, he has not had any colonscopies.
Told pt to follow up with his PCP to organize this.
.
#. Delirium: Waxing and [**Doctor Last Name 688**] mental status while in ICU.
Delirium likely multifactorial, in setting of infection, pain,
narcotic pain medication administration, and hospitalization.
[**Month (only) 116**] also have been related to constipation. Pt was given
aggressive bowel regimen. Had no further episodes of delerium
after leaving the ICU. RPR negative, UA showed no signs of
infection, TSH and B12 wnl.
.
#. HTN: Continued metoprolol and diltiazem.
.
#. Diabetes mellitus type 2: Continued insulin s/s. Diabetic
diet.
.
#. Hyperlipidemia: Continued simvastatin 80mg daily.
.
#. h/o TIA: Continued ASA, statin.
.
#FEN: heart healthy/diabetic diet, replete electrolytes prn
.
#PROPHYLAXIS:
DVT ppx with enoxaparin 40mg SC daily (per ortho protocol) as
well as coumadin 2.5mg daily. Goal INR 1.8-2.5.
Medications on Admission:
Citalopram 20mg QD
Gabapentin 100mg TID
[**Month (only) 24650**] XR 2.5mg [**Hospital1 **]
Metoprolol 25mg [**Hospital1 **]
Simvastatin 80mg QD
Warfarin 2.5mg QD
ASA 81mg
Discharge Medications:
1. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous QHS (once a day (at bedtime)) for 4 weeks.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Followed insuline sliding scale
while in hospital. Takes [**Hospital1 **] 12.5 [**Hospital1 **] at home.
5. acetaminophen 325 mg Tablet Sig: Three (3) Tablet PO Q6H
(every 6 hours).
6. Diltia XT 120 mg Capsule,Degradable Cnt Release Sig: One (1)
Capsule,Degradable Cnt Release PO once a day.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours):
[**Month (only) 116**] wean as pt's pain improves.
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
12. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 3 days: Continue through [**2181-12-14**] and then
STOP.
13. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day: take
total of 150mg daily.
16. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day: take
total of 150mg daily.
17. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
18. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM: Goal INR 1.8-2.5 until lovenox is completed (30 days after
surgery). Then INR goal is [**2-14**].
19. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily): Continue for 30 days after surgery.
20. CefePIME 2 g IV Q12H
21. Vancomycin 1000 mg IV Q 12H
22. Morphine Sulfate 0.5 mg IV Q2H:PRN prior to moving
please hold for sedation or RR <12
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4542**] Rehabilitation and Nursing of [**Location (un) 38**]
Discharge Diagnosis:
1. Right hip fracture
2. Aspiration pneumonia
3. Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital for a femur (hip bone)
fracture. You had a procedure done to fix the bone. Below are
the reccomendations from the orthopedic doctors:
Wound Care:
-Keep Incision dry.
-Do not soak the incision in a bath or pool.
Activity:
-Continue to be non weight bearing on your right leg and full
weight bearing on your left leg.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
- You were found to be VERY sensitive to narcotic medications.
Please take as small a dose as you can tolerate. Narcotic pain
medication may cause drowsiness. Do not drink alcohol while
taking narcotic medications. Do not operate any motor vehicle
or machinery while taking narcotic pain medications. Taking
more than recommended may cause serious breathing problems.
If you have questions, concerns or experience any of the below
danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go
to your local emergency room.
During this hospitalization, you were noted to have a drop on
your hematocrit (anemia) that was thought initially to be due to
a gut source. It is important to follow this up with your
primary care doctor and a gastroenterologist. You say that you
have never had a colonoscopy, it is very important to get one
within the next few months.
During this admission, you were also found to have a pneumonia,
thought likely due to aspiration when you were on narcotics. You
were treated with antibiotics. Please continue to take
antibiotics for a total 8 day course.
After talking to the vascular surgeons, the decision was made to
restart your coumadin to protect your body from clots. Your goal
INR is 1.8-2.5 while you are on the 30 day course of Lovenox.
After you complete the lovenox, resume the coumadin for a goal
INR [**2-14**].
You heart rate was found to be fast occasionally. We increased
your medications to protect your heart and prevent it from going
to fast.
The following changes were made to your medications:
STOP Gabapentin 100mg TID. You may resume this in rehab or with
your primary care doctor.
[**First Name (Titles) **] [**Last Name (Titles) **] 12.5 twice a day. You may resume then in rehab or
with your primary care doctor. While in the hospital or rehab
you may get insulin sliding scale. It is very important to
resume this after you leave rehab. The rehab facility may wish
to start this while you are there.
CHANGE: Metoprolol 25mg twice a day--> Metoprolol succinate
150mg daily.
START: Lovenox 40mg inject yourself once a day for an entire
month. Follow up with the orthopedic doctors to determine when
to stop this.
CONTINUE: couamdin 2.5mg daily. Your new INR goal is 1.8-2.5
while you are also taking Lovenox. When you stop the lovenox,
you may resume your regular coumadin for the goal INR [**2-14**].
START: Diltiazem 120mg daily (long acting)
START: Vancomycin 1,000mg [**Hospital1 **], Cefepine 2g [**Hospital1 **], Flagyl 500mg
TID, last day is on [**2181-12-14**].
START: Pantoprazole 40mg daily
START: Thiamine 100 units daily
START:Oxycodone 2.5mg every 6 hrs
START: Morphine sulfate 0.5mg IV as needed every 2 hrs for pain
Followup Instructions:
You have an orthopedic appointment scheduled below. You may need
to make another follow up after the below date.
Department: ORTHOPEDICS
When: THURSDAY [**2181-12-27**] at 8:40 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2181-12-27**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
We Reccomend you follow up with a Gastoenterologist to work up
blood loss from the gut. You will likely need a colonoscopy or
endoscopy. Please discuss this with your primary care doctor to
arrange this.
Department: VASCULAR SURGERY
When: THURSDAY [**2182-3-28**] at 1 PM
With: VASCULAR LAB [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: VASCULAR SURGERY
When: THURSDAY [**2182-3-28**] at 1:45 PM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"V12.54",
"272.4",
"965.8",
"E849.7",
"427.31",
"V58.67",
"507.0",
"401.9",
"E885.9",
"578.9",
"433.10",
"518.81",
"820.8",
"799.02",
"780.09",
"443.9",
"V49.75",
"V15.82",
"285.1",
"E850.8",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.52"
] |
icd9pcs
|
[
[
[]
]
] |
10350, 10449
|
4179, 7832
|
320, 368
|
10549, 10549
|
3349, 3349
|
14043, 15484
|
926, 1054
|
8054, 10327
|
10470, 10528
|
7858, 8031
|
10732, 10901
|
1069, 3330
|
276, 282
|
10913, 14020
|
396, 507
|
3366, 4156
|
10564, 10708
|
529, 651
|
667, 910
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,584
| 116,324
|
16525
|
Discharge summary
|
report
|
Admission Date: [**2165-11-18**] Discharge Date: [**2165-12-12**]
Service: Trauma Surgery
HISTORY OF PRESENT ILLNESS: This 86-year-old female was
struck by an SUV with significant damage to the SUV's front
end on [**2165-11-18**]. The patient had a loss of consciousness
after this collision and was taken to an outside hospital
where her systolic blood pressure was in the 60s. She was
intubated and transfused. She was subsequently transferred
to [**Hospital1 69**] where she was
hemodynamically unstable in the trauma bay. She received 6
units of packed red blood cells and 5 liters of crystalloid.
Status post this treatment her blood pressure improved to
about the 120s systolic. The patient was taken to the CT
scan for scanning of her head, neck, chest and belly but this
scan was aborted once her systolic blood pressures again fell
to the 70s. She was then taken to the intensive care unit
where bedside echocardiogram was performed and was negative
for tamponade. A DPL was also performed which was negative.
A chest x-ray showed widened mediastinum and this was
followed up by the patient being taken to the angiography
suite where no bleeding from the aortic arch or pelvic
vessels was demonstrated. As the patient was hemodynamically
stable she was taken back to the intensive care unit where a
repeat echocardiogram was performed. This study was
consistent with significant pericardial fluid.
Other physical findings in this patient included a right
scalp laceration which was closed with staples. Her belly
was soft but her left thigh was tense on examination with an
obvious open left tibia-fibula fracture.
Admission laboratory studies were significant for an initial
hematocrit of 41.0 which fell to 25.8 over the course of a
four-hour period. Admission electrolytes were largely
unremarkable and her initial blood gas was 7.51, 24, 599, 20
and -1. After her hypotensive episodes the gases changed to
7.10, 92, 359, 30 and -3.
Pelvic x-ray showed no obvious fracture or dislocation and
left tibia-fibula film showed an open displaced and
comminuted fracture of the tibia and fibula. The orthopedic
service was consulted while the patient was in the intensive
care unit and their recommendation was that the patient be
taken to the operating room on the following day for external
fixator placement and open fracture washout of the open
fracture.
HOSPITAL COURSE: In the intensive care unit the plan
consisted of aggressive fluid resuscitation including packed
red blood cells, fresh frozen plasma and platelets. The
respiratory plan was for assisted ventilation. Serial
hematocrits were checked q. 1 hour. Her neurological status
was maintained under sedation. Bladder pressures were
controlled and Protonix was initiated.
On hospital day two the patient was maintaining her blood
pressures at 87/45 with a heart rate of 119. Her morning
hematocrit was 21.8 which had decreased from 30.2 and 25.8
the previous night. On examination the patient was intubated
and sedated, unresponsive in a hard cervical collar.
The patient was taken to the operating room early on hospital
day two for exploratory laparotomy and pericardial window.
This procedure was performed with no complications and a
blood loss of approximately 100 cc. There was no obvious
source of bleeding identified with either of these
procedures.
On hospital day two the hematology service was also consulted
and their recommendations for fluid resuscitation for this
patient included fresh frozen plasma to keep the PT and PTT
within normal limits, vitamin K 2 mg intravenous, transfusion
of platelets to maintain the platelet count close to 100,000,
repletion of calcium, repeat of fibrinogen levels and a
search for the patient's source of bleeding. These
recommendations were followed by the intensive care unit
team.
On hospital day three/postoperative day two status post an
open tibia-fibula washout, exploratory laparotomy and
pericardial window the patient was in stable condition and
her hematocrit had increased to 30.4. Her blood pressure was
118/65 with a heart rate of 85. The patient was awake but
sedated with notable bilateral periorbital edema. She had
notable left expiratory wheezes and her abdomen was distended
and edematous. She was moving all four extremities
spontaneously.
The patient was started on levofloxacin for her open
fractures until the patient's condition was stabilized
sufficiently for closure of her open fractures.
On [**2165-11-21**], the orthopedic service took the patient
to the operating room where an incision and drainage of her
open left tibia-fibula fracture and intramedullary rod
fixation was performed. Postoperative orders included
nonweight-bearing status on the left lower extremity and
Levaquin intravenous to be continued in light of the
patient's previously open fracture.
Plastic surgery was also consulted and the patient was seen
and examined with the plastic surgery attending.
Recommendation was for bedside debridement. Also notable was
a vacuum-assisted closure dressing which was in place on the
left lower extremity.
On postoperative day three the patient was in stable
condition with an hematocrit of 32. Plastic surgery,
orthopedics and interventional radiology services continued
to follow and were pleased with the recovery from their
respective procedures. The plan from the standpoint of the
intensive care unit team was for continued close monitoring
of the patient's cardiovascular status, and continuation of
the antibiotics for the patient's previously open fracture.
On [**2165-11-24**] the patient was alert and following
commands. Her cervical collar was still in place and her
cardiovascular status was regular with a chest examination
that was clear to auscultation bilaterally.
The patient's condition continued to improve in the intensive
care unit over the subsequent days. On postoperative days
six and four the vacuum-assisted closure dressing was still
in place but was scheduled to be changed and the plastic
surgery service suggested a soleus flap once the patient's
condition stabilized. The vacuum-assisted closure dressing
was indeed changed on this day by the orthopedic service and
per their description the underlying skin was red and warm
with a necrotic edge. There was a large seroma in the
lateral aspect of the thigh and palpation of the wound easily
expressed a small amount of brownish fluid. In light of the
appearance of the wound Ancef was added to the antibiotic
regimen for broader antibiotic coverage.
Over the subsequent three intensive care unit days the
patient's condition continued to improve including her mental
status where she was awake and responsive and following
commands.
On [**2165-11-29**] the patient was taken to the operating
room by plastic surgery where a soleus flap to her left leg
defect was performed by Dr. [**Last Name (STitle) 13797**] with the assistance of
Dr. [**First Name (STitle) **]. The patient was noted to have a significant amount
of oozing despite normal coagulations and a platelet count of
96,000. Postoperatively the patient recovered well and was
weaned to pressor support and CPAP. The left leg was
bandaged with a moderate amount of serosanguinous oozing.
The patient was returned to the surgical intensive care unit
for management consistent and appropriate with the patient's
postoperative condition.
On [**2165-11-29**] bilateral pleural effusions were noted in
this patient and bilateral chest tubes were placed which were
immediately productive of 200-300 cc of serosanguinous fluid.
These tubes continued to have high output until approximately
[**2165-12-3**] when the left chest tube was discontinued as
its output had diminished considerably. The right chest tube
was continued and the patient was extubated and was
saturating well on four liters of oxygen by nasal cannula.
On [**2165-12-4**] the patient's Foley catheter was
discontinued and the patient was evaluated by physical
therapy who commented that the patient's knee range of motion
was still limited and questioned institution of a continuous
passive motion therapy.
On [**2165-12-5**] the patient was transferred to the floor
where she received a video swallow evaluation that initially
showed aspiration. However repeat video swallow examination
showed no overt signs of aspiration and the patient was
placed on a diet consisting of honey-thickened liquids with
supervised p.o. intake. As the patient's right chest tube
output had declined the patient's right chest tube was
discontinued on hospital day 17, which was [**2165-12-5**].
Plastic surgery continued to follow the patient and on
[**2165-12-5**] the patient was taken to the operating room
with the plastic surgery service for a STSG. This procedure
was performed by Dr. [**Last Name (STitle) 13797**] and was more specifically a
STSG to the left soleus flap and left lower extremity lateral
wound. The procedure also included a wound debridement,
evacuation of hematoma of bilateral thighs with wound
debridement. The estimated blood loss from this procedure
was minimal and the patient was transferred in stable
condition to the recovery room.
One day after this procedure the plastic surgery service
noted that the vacuum-assisted closure on the soleus flaps
was outputting minimal amounts of fluid and the setting was
changed to 75 mmHg. Wet-to-dry dressings were continued at
the sites of the hematoma evacuation.
On [**2165-12-6**] the patient was in stable condition and
the plan from the standpoint of the trauma service was to
continue pulmonary toilet, to assist the patient out of bed
to chair with the assistance of the physical therapy service,
continuing the tube feeds, and discontinuing her antibiotics
which consisted of vancomycin after her sputum culture had
been positive for methicillin-resistant Staphylococcus
aureus.
Over the subsequent days the patient was evaluated by
physical therapy who commented that the patient's range of
motion on her left side was improving but that transfer to an
appropriate rehabilitation center for further assistance
before resuming her activities of daily living would be
necessary.
Over the subsequent days the patient's condition continued to
be stable and as the flap care per the plastic surgery
service was followed the patient was assessed to be suitable
for discharge on [**2165-12-12**].
On [**2165-12-12**] the patient was discharged to an
appropriate rehabilitation center in stable condition.
STATUS AT DISCHARGE: Approved.
CONDITION ON DISCHARGE: Good.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 13717**]
MEDQUIST36
D: [**2165-12-12**] 10:33
T: [**2165-12-12**] 10:42
JOB#: [**Job Number 46934**]
|
[
"823.32",
"902.53",
"285.1",
"E814.7",
"286.6",
"873.42",
"511.9",
"423.9",
"808.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.79",
"86.22",
"34.04",
"88.48",
"79.36",
"54.11",
"96.72",
"83.82",
"86.69",
"79.66",
"38.91",
"37.12",
"88.42",
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
2409, 10515
|
10530, 10541
|
128, 2391
|
10566, 10831
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,786
| 163,511
|
9321
|
Discharge summary
|
report
|
Admission Date: [**2110-8-26**] Discharge Date: [**2110-9-1**]
Date of Birth: [**2060-5-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3619**]
Chief Complaint:
Hypotension, shortness of breath
Major Surgical or Invasive Procedure:
Video swallow study.
History of Present Illness:
50-year-old woman with adenoid cystic carcinoma s/p left
pneumonectomy with metastasis to liver, kidney. Carboplatin
[**8-19**]. presented for follow up today at Heme-onc when patient
complained of chest pain [**5-4**]. 3 PM pale, diaphoretic BP
60/palp. P 145-150. 02 sat waxing [**Doctor Last Name 688**] 80-90% RA. 4 L NC
placed. Referred to the ED from outpatient chemotherapy session
due to shortness of breath, chest pain, low O2 sats, tachycardia
and hypotension.
.
In the ED her vital signs were: T 100.9, HR 140s, BP 99/58, RR
20, O2 sat 98% on 2L NC. EKG showed sinus tachycardia with ?
<1mm ST segment elevation, otherwise no ST-T segment
abnormalities. She was given approx 2L NS, Cefepime 2gm IV, and
Tylenol. She [**Doctor Last Name 1834**] CTA which showed no evidence of PE, but
did show new bilateral right upper and lower lobe opacities.
.
She was initially diagnosed with adenoid cystic carcinoma in [**Month (only) 116**]
[**2102**] after presenting for an eight-month history of cough. Chest
CAT scan showed left lower lobe collapse and mediastinal
enlargement encroaching on the left mainstem bronchus. She was
evaluated by Dr. [**Last Name (STitle) **] who performed an exploration with
bronchoscopy in early [**2103-3-26**]. This showed that the mainstem
bronchus was involved and obstructed by mass. Left pneumonectomy
was performed and path consistent with adenoid cystic carcinoma.
She received postoperative radiation. Discussion of palliative
care, decision to attempt chemotherpay. Chemo as stated below
with worsening mets as apparent by CT scan, last carboplatin
[**8-19**].
.
ROS:
(+) fever, chills, nausea, 75 pound weight loss over several yrs
since diagnosis. Decreased PO intake x 1 wk since chemotherapy.
No diarrhea, chest pain at this time. Improved shortness of
breath.
Past Medical History:
Oncological History:
Initially diagnosed with adenoid cystic carcinoma in 5/00 after
presenting with eight-month history of cough. Chest CT showed
left lower lobe collapse and mediastinal enlargement encroaching
on the left mainstem bronchus. Bronchoscopy at that time showed
that the mainstem bronchus was involved and obstructed by mass.
Left pneumonectomy was performed and pathology demonstrated a 6
x 5.5-cm adenoid cystic carcinoma. It had invaded the visceral
pleura and had perineural invasion. The 3 lobar nodes were
involved. The bronchial margin was positive. In 06/00, she
[**Month/Year (2) 1834**] a carinal resection. Pathology demonstrated a
microscopic focus of residual adenoid cystic carcinoma in a
bronchial wall in the submucosal area.
She received postoperative radiation. A CT scan in [**2105-2-23**]
showed no evidence of recurrence and a bronchoscopy at that time
was unremarkable. In [**2106-2-23**], she presented with some weight
loss, fatigue, and pain. CAT scan showed increased soft tissue
thickening in the left pneumonectomy site especially near the
diaphragm. On [**2106-8-5**] follow up CT scan showed increased soft
tissue throughout in the pneumonectomy cavity, especially in the
apex and medially adjacent to the descending aorta. A liver
hemangioma was identified.
Ms. [**Known lastname 14502**] [**Last Name (Titles) 1834**] a biopsy of the pleural thickening
([**2106-10-13**]). Pathology showed adenocarcinoma in fibrous tissue.
The pathology was compared to her primary resection from [**3-/2103**]
and felt to be consistent with her primary tumor.
She then [**Month/Year (2) 1834**] chemotherapy with Taxotere. Repeat CT after
therapy showed recurrent adenoid cystic carcinoma of the
trachea, now involving the lungs, pleura, and liver. She was
then started on regimen of doxorubicin and cisplatin for goal of
4 cycles. 2 cycles of carboplatin/taxol for stabilization of
liver lesions. In [**1-28**], she developed left arm pain and
weakness with tenderness along the medial aspect of the
extremity. Spinal MRI was negative, but brachial plexus MRI
showed tumor in the left paraspinal region from T2-T5.
Most recently, from [**2109-2-23**] until [**2109-4-25**] she received four
cycles of dose-reduced cisplatin and Navelbine with stable
disease radiographically, but resolution of arm pain and
improvement in arm strength. CT torso from [**2109-9-19**] showed
progression in the liver and kidney, and she was started on
gemcitabine on [**2109-10-8**]. Her schedule has been changed to
three week cycles with gemcitabine given on days 1 and 8.
-low-dose Taxotere in [**11-28**]
-four cycles of cisplatin and Adriamycin from [**10-28**] to [**12-30**]
with initial radiographic improvement, but a CT scan in [**9-29**]
revealed progression in the lungs and liver.
-Two cycles of carboplatin and Taxol were given ([**9-29**]) with
stabilization of her liver lesions but continued progression in
the left lung
- four cycles of dose-reduced cisplatin and Navelbine
([**Date range (1) 31896**])
- Gemcitabine ([**2109-10-8**]); limited by progressive myelosuppresion
- Carboplatin in [**7-/2110**]
.
PAST MEDICAL HISTORY:
Adenoid cystic carcinoma as above.
Paralyzed left true vocal cord with hoarseness.
GERD
s/p left pneumonectomy
Social History:
She does not smoke cigarettes or drink alcohol.
She moved from [**Country 3594**] to [**State 350**] in [**2091**]. She has a
daughter who lives in [**Name (NI) 17065**]. She also has a brother and
sister who live in the Greater [**Name (NI) 86**] area. She denies tobacco
or alcohol use and is currently not working. In the past, she
has worked in a bakery.
Family History:
Her mother is alive and healthy at age 68. Her
father died at age 80 from a stroke and heart attack. She has 5
sisters and 2 brothers, and some of them have hypertension,
hypercholesterolemia, and diabetes. She has 6 daughters and a
son; they are all healthy.
Physical Exam:
VS: T 99.2 BP 94/67 HR 111 RR 17 O2 100%
Gen: Cachectic, chronically ill-appearing woman
HEENT: MMD. non elevated JVP. OP clear.
Neck: supple. no neck stiffness
Heart: tachycardic, regular rate and rhythm
Lungs: Absent left side, clear apically right. Sparse crackles
left base
Abd: soft, non tender, non distended, + BS
Extrem: No edema, cyanosis of clubbing
Neuro: alert oriented x 3. Strenght [**2-27**] throughout. Warm well
perfused. No echymoses or other lesions noted.
Pertinent Results:
136 105 12 73 AGap=11
3.2 23 0.5
CK: 30 MB: Pnd Trop-T: Pnd
Source: Line-portacath
80
7.8 10.1 D 215
28.6 D
Comments: Hgb: Verified
Source: [**Name (NI) 31897**]
PT: 28.8 PTT: 48.8 INR: 3.0
.
Lactate: 2.4
.
Na 136, K 4.5, Cl 92, HCO3 25, BUN 17, Creat 0.9, Mg 1.5, Phos
5.8
WBC 9.9, Hgb 14.8, HCT 43.5, Plt 339, Gran-CT 8900
.
PT: 19.3, INR 1.8
CK 34, MB 3, Trop-T<0.01
.
Blood cx pending
.
Studies:
CXR ([**8-26**]):Changes from prior left-sided pneumonectomy with
calcification along the remaining cystic cavity within the left
hemithorax is unchanged when compared to [**2110-4-1**]. A right
subclavian CVL tip within the mid SVC is unchanged. There is
scarring at the right lung apex with post-surgical changes
within the mid right lung. There is no definite pleural effusion
or focal pulmonary opacity. Shift of the mediastinum to the left
is stable.
IMPRESSION: Stable post-surgical changes involving the left
hemithorax. No acute cardiopulmonary process identified within
the right lung.
.
CTA CHEST ([**8-26**]): No filling defects in the pulmonary arteries
to suggest pulmonary embolism. The patient is status post left
pneumonectomy. There is no significant change in appearance of
fluid filling the left hemithorax with peripheral
calcifications. There is no pericardial effusion.
There has been interval development of multiple patchy alveolar
opacities throughout most of the right upper and lower lobe,
most consistent with appearance of pneumonia. Again seen is a
right lower lobe pleural-based mass, measuring 2.1 cm,
essentially stable in size compared to the previous examination.
The appearance of the right apical, paramediastinal and right
middle lobe linear densities suggestive of scar/radiation change
is stable.
Limited evaluation of upper abdominal organs demonstrates
incompletely imaged hepatic lesions.
BONE WINDOWS: There is no significant change in appearance of
multiple sclerotic lesions in thoracic spine as well as a
deformity of the left hemithorax secondary to pneumonectomy.
IMPRESSION:
1. No evidence of pulmonary embolus.
2. Interval development of right upper and lower lobe patchy
alveolar opacities, most consistent with pneumonia.
3. Essentially unchanged size and appearance of right lower lobe
pleural-based pulmonary nodule.
.
MRI Head [**2110-8-29**]:
MPRESSION:
1. No evidence of acute infarction.
2. No enhancing lesions within the brain parenchyma to suggest
metastases.
3. Improved appearance of the vein of Trolard, and evolution of
the
previously described right frontal hemorrhage. The status of
the superior
sagittal sinus is not delineated on this non-MRV exam, in the
area of
attenuation seen on [**2109-12-9**]. The posterior portion of
the superior
sagittal sinus demonstrates a normal flow void.
.
Video Swallow Study [**2110-8-29**]:
FINDINGS: The oral phase demonstrated mildly impaired bolus
formation and
bolus control. There was mild-to-moderate premature spillover
into the
piriform sinuses with thin liquids via spoon and cup in mixed
consistencies.
The pharyngeal phase was within the normal limits. Minimal
residue in the
vallecula and piriform sinuses was seen.
Mild aspiration of occurred with cup sips of thin liquids before
swallow with
her head held in the neutral position. Mild penetration was
also seen with
thin liquids during swallow. A 13 mm barium pill was
administered with holdup
at the distal esophagus.
Mild-to-moderate oropharyngeal dysphagia with moderately
impaired bolus
control for thin liquids with mild-to-moderate premature
spillover into the
piriform sinuses with all thin liquids with the head in neutral
position. The
barium pill was held up at the level of the distal esophagus.
Brief Hospital Course:
Patient is a 50 year old female with metastatic adenoid cystic
lung cancer who presented with shortness of breath, tachycardia
and hypotension found to have new right upper and lower lung
opacities suspicious for pneumonia.
.
#) Shortness of breath: Findings on imaging studies
demonstrating abnormalities in right upper and lower lobes are
most suspicious for community acquired pneumonia. On history and
exam, there was no evidence of fluid overload. Initially there
was no history aspiration, as she had nausea with no vomiting
after chemotherapy, however speech and swallow studies
demonstrated aspiration, so she was also treated for an
aspiration pneumonia. Patient was not currently not neutropenic,
though CT scan with possible spreading of metastasis. She had no
recent hospitalizations to suggest other causes of pneumonia.
- Patient's shortness of breath resolved during her stay, and
nasal cannula oxygen was weaned.
- She was initially treated with Cefepime and Vancomycin, then
switched over to levofloxacin and flagyl, and eventually
switched to oral antibiotics at time of discharge.
- Nebulized bronchodilators were also used to help clear
secretions.
.
#) Hypotension: Initially there was concern for sepsis, however,
the patient's blood pressure stabilized in response to fluid
boluses.
- It was felt that the patient's baseline blood pressure was on
the lower side, with systolic in the mid 80s to low 100's, and
she was mentating well without any evidence of end organ damage.
- Patient was encouraged to drink plenty of fluids.
.
#) History pulmonary embolism and cerebral vein thrombosis:
Patient has been on Coumadin for antiocoagulation, which was
recently held due to supratherapeutic INR. Her INR remained
elevated during much of her stay, and her Coumadin was initially
restarted, however held due to high levels, likely due to
concurrent antibiotic use.
- At her follow up appointment just after discharge, her INR was
to be re-checked, and Coumadin re-started as necessary. Prior to
admission, she had been taking alternating 2 and 3 mg doses.
.
#) Adenoid cystic carcinoma: See detailed history above. Patient
recently completed course of carboplatin on [**2110-8-19**]. She has
received chemotherapy, surgical resection and radiation, however
continues to have spread of disease. Currently full code
- Supportive care was continued, and follow-up with oncology
clinic was arranged for just after discharge.
.
#) Chest pain: Her chest pain was chronic and pleuritic in
nature. The patient described it as dull, and has been present
intermittently since development of her malignancy and sugeries.
Her EKG demonstrated ST segment changes, however her cardiac
enzymes were followed and remained within normal limits.
- She continued on her home dose of Fentanyl for pain control,
along with oral morphine and neurontin.
.
#) Tachycardia: Patient has had history of baseline tachycardia,
with heart range in 120's. Her increased heart rate was likely
in part due to infection, further complicated by component of
hypovolemia, and reflexive given hypotension. She had no
evidence of pulmonary embolism.
- Patient's tachycardia improved with fluid resuscitation and
treatment of her infection, and was in the 90's-110's range at
time of discharge.
.
#) GERD: She continued on a proton pump inhibitor.
.
#) Dysphagia/Poor PO intake: Patient related that she has had
continued difficulty eating and swallowing, and has been eating
primarily softs and fluids. Her main difficulty remains a poor
appetite which she felt was the primary reason she has not been
eating very much.
- Restarted megace for assistance with appetite, discontinued
dexamethasone as no longer had nausea.
- Speech and swallow evaluated the patient and assisted with
evaluating her dysphagia. She had previously been worked up with
EGD, which demomstrated extrinsic stricture. Final video swallow
results demonstrated signs of aspiration-- recommendations made
to crush pills and have pt tuck chin while eating to avoid
aspiration.
- MRI did not demonstrate any central process responsible for
dysphagia.
- Gastroenterology consulted to evaluate and assist with
coordinating outpatient EGD with possible esophageal stent
placement for her dysphagia and aspiration. Follow up with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for evaluation and possible placement of a stent to
help was in process of being set up at time of discharge, and
the gastroenterology service was to contact the patient.
.
#) Prophylaxis: Patient received proton pump inhibitor,
initially subcutaneous heparin (which was held due to elevated
coagulation studies, which resolved with d/c of heparin), and a
bowel regimen.
.
#) Code Status: Full, patient confirmed her wishes for full code
status during stay via interpreter.
.
Medications on Admission:
Meds as per pt:
Pt unaware of doses
Zofran q8 hrs
Prilosec
Oxycodone q 6 hrs
Neurontin TID
Megace [**Hospital1 **]
fentanyl patch
Decadron QD as per steroid taper
.
Meds ([**3-31**]) note:
COMPAZINE 10 mg po q8h prn nausea
COUMADIN po daily as directed (held since [**8-22**] for elevated INR)
EMEND [**Medical Record Number 31898**] mg (taken on days 1,2,3 of chemotherapy)
FENTANYL 225 mcg/hour q72 hours
Megace Oral 400 mg/10 mL--10 ml po daily
NEURONTIN 300mg po tid
OXYCODONE 5 mg - 1 to 2 tabs q6hr prn
PRILOSEC 20mg po daily
ZOFRAN 8 mg po q8h prn
DECADRON 4 mg po daily
Discharge Medications:
1. Fentanyl 100 mcg/hr Patch 72 hr [**Medical Record Number **]: Two (2) Transdermal
Q72H (every 72 hours).
Disp:*10 patches* Refills:*2*
2. Megestrol 40 mg/mL Suspension [**Medical Record Number **]: One (1) PO DAILY (Daily).
Disp:*1 bottle* Refills:*2*
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
4. Gabapentin 250 mg/5 mL Solution [**Last Name (STitle) **]: One (1) PO TID (3 times
a day).
Disp:*1 bottle* Refills:*2*
5. Morphine 10 mg/5 mL Solution [**Last Name (STitle) **]: One (1) PO q4-6 hours PRN
as needed for pain.
Disp:*1 bottle* Refills:*0*
6. Augmentin 250-62.5 mg/5 mL Suspension for Reconstitution [**Last Name (STitle) **]:
Ten (10) ml PO every eight (8) hours for 4 days.
Disp:*1 bottle* Refills:*0*
7. Fentanyl 25 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1) Transdermal
every seventy-two (72) hours.
Disp:*10 patches* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Caregroup VNA
Discharge Diagnosis:
Primary Diagnosis:
- Pneumonia
Secondary Diagnoses:
- Cystic Adenoid Carcinoma
- GERD
- Vocal cord paralysis
- History of pulmonary emboli
- Cerebral vein thrombosis
Discharge Condition:
Stable, ambulating at baseline without assistance.
Discharge Instructions:
You were admitted due to shortness of breath, low blood
pressure, and fever. It was thought that these were all due to a
pneumonia that was seen on the CT scan. You were given
antibiotics and intravenous fluids to treat the infection and
replete your fluids to improve your blood pressure. Your blood
pressure remained stable, and your fevers resolved. While you
were hospitalized, the speech and swallow pathologists also
further evaluated your difficulty with eating, along with the
gastroenterologists. You will need follow up care in the
gastroenterology clinic to evaluate if a stent in your esophagus
would be of benefit.
.
Please contact your oncologist or primary care physician, [**Name10 (NameIs) **] go
to the emergency room, if you experience fever, chills, new or
worsening chest pain, difficulty breathing, abdominal pain,
nausea, vomiting, or other concerning symptoms.
.
You should not take your Comadin until further instructed, due
to a high level noted while hospitalized. You may be instructed
to take an injected medication called Lovenox at your follow
appointment with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **].
Followup Instructions:
Please follow up at the appointments made for you as noted
below:
-Oncology:
You have an appointment with Drs. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] and [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] on [**9-3**] at 12:30 pm. The number for the clinic
is [**Telephone/Fax (1) 22**]. You also have an appointment with [**Name6 (MD) **]
[**Name8 (MD) **], RN on [**9-3**] at 1:30 pm.
.
-Gastroenterology:
You will need to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for evaluation
and possible placement of a stent to help improve your ability
to eat and swallow. He has been contact[**Name (NI) **] about your case, and
Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] [**Name5 (PTitle) **] assist with getting this further
evaluated.
.
You will need to have your INR (Coumadin level) checked on
Wednesday [**2110-9-3**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 3621**]
|
[
"530.81",
"197.2",
"507.0",
"197.7",
"478.31",
"434.00",
"147.1",
"197.0",
"V12.51",
"530.3",
"285.9",
"198.5",
"458.9",
"V58.61",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16901, 16945
|
10401, 15225
|
347, 370
|
17155, 17208
|
6683, 10378
|
18406, 19451
|
5909, 6171
|
15855, 16878
|
16966, 16966
|
15251, 15832
|
17232, 18383
|
6186, 6664
|
17018, 17134
|
275, 309
|
399, 2212
|
16985, 16997
|
5402, 5514
|
5530, 5893
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
871
| 141,369
|
12513+56371
|
Discharge summary
|
report+addendum
|
Admission Date: [**2125-4-7**] Discharge Date: [**2125-5-4**]
Service: [**Hospital1 **]
HISTORY OF PRESENT ILLNESS: This is an 81-year-old with no
significant past medical history who is transferred from [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] Hospital for anemia, melena, acute renal failure and
rule in myocardial infarction. This is an 81-year-old with
no medical history except for tophaceous gout who was in her
usual state of excellent health until three days prior to
admission when after lunch, she laid down because she did not
feel well. She sleeps in a different room from her husband,
with whom she lives. When he asked her later that evening
how she was, she said she was fine. The next day, she
continued to remain in bed. He offered her some [**Location (un) 2452**]
juice, which she drank, but she was slowly becoming more
confused and lethargic. On the third day, she was barely
arousable and incoherent. He called EMS who found her to be
"incontinent of urine." She was taken to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Hospital where she was lethargic, oliguric and confused. She
had a rectal temperature of 87 degrees. Her pulse was 80
with a systolic blood pressure of 72-135. She was found to
be guaiac positive with a fingerstick of 38. Her white blood
cell count was 17.1, 87% neutrophils, 14% bands, 4%
lymphocytes and 2% monocytes. Her hematocrit was found to be
16.1. He platelet count was 100,000. Her Chem-7 revealed a
sodium of 148, potassium 4.8, chloride 118, bicarbonate 15,
BUN 83 and creatinine 2.5. Her CK was 499 with an MB of 60
and an index of 12. Her INR was 2.6. Blood cultures times
two were negative. A head CT was performed which showed
enlarged ventricles, but was otherwise negative. She was
resuscitated and given two units of packed red blood cells.
She was warmed to a rectal temperature of 94 and transferred
to [**Hospital6 256**] for further care.
On arrival, her temperature was 98 and she had a systolic
blood pressure in the low 100s. She received more blood
products and Vitamin K and was admitted to the Medical
Intensive Care Unit.
PAST MEDICAL HISTORY: Tophaceous gout.
MEDICATIONS: Advil 1 tablet q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No tobacco or alcohol use. Never visited a
doctor. Lives with her husband in [**Name (NI) 13011**]. Does the
banking, and shopping and cooking. Is very active at home,
taking care of her husband of the past 60 years.
FAMILY HISTORY: A sibling with diabetes.
PHYSICAL EXAMINATION: This is an ill-appearing elderly woman
who had a temperature of 98 rectally, a blood pressure of
106/50. Pulse of 87. Respiratory rate of 28 and an oxygen
saturation of 100% on 100% nonrebreather. She was
normocephalic, atraumatic with a 2 mm right pupil and a 1 mm
sluggish left pupil. She had anicteric sclera. Her mucous
membranes were dry. She had upper dentures and dried blood
on her upper palate above her dentures. Her neck had no
masses. Her chest was clear except with good air movement
except for decreased breath sounds at the right base. Her
heart was regular in rate and rhythm with no murmurs. Her
abdomen was moderately distended without rebound or guarding
and good bowel sounds. Her back had no overt lesions. She
had a fluctuant mass along her right thorax extending from
her axilla to her iliac crest without erythema. She had
large gouty tophi and joint disease of bilateral hands and
feet. She had 2+ anasarca. She had 2+ bilateral radial and
dorsalis pedis pulses. She had ischemic discoloration of her
right second finger, left second to fourth digits in all ten
toes bilaterally. She had numerous ulcerations on her feet.
Her gout involved the small joints of her hands, as well as
both her elbows and both her knees. On neurological exam,
she was awake and responded to voice, but did not answer
questions. Her extraocular movements were intact and she was
moving all her extremities, as well as withdrawing to pain.
LABORATORY DATA ON ARRIVAL: White blood cell count of 15.9,
hematocrit of 24.9, a platelet count of 117,000, INR of 2.6,
an arterial blood gas of 7.41, 28 and 114. A negative
toxicology screen and a Chem-7 consistent with that of the
outside hospital. Albumin is 3.1, AST of 749 with ALT of
437. Alkaline phosphatase of 269 and a total bilirubin of
1.9. Her TSH was 6 with a free T4 of 0.7. Her cortisol was
55. Amylase and lipase revealed a 123 and 405. Her CK was
485. It peaked at 1064 and then returned to [**Location 213**]. Her
troponin peaked at 1.4.
Electrocardiogram revealed normal sinus rhythm at 90 beats
per minute with low voltage in the limb leads. She had
normal axis, normal intervals and no acute ST changes.
Chest x-ray showed low lung volumes and bilateral pleural
effusions, right greater than the left, with associated
collapse of her right lower lobe and right middle lobe.
Abdominal CT revealed a large right and a moderate left
pleural effusion, as well as ascites. She also had a right
subcutaneous fluid collection. She had a uterine fibroid.
Her bowels appeared normal as did her liver and gallbladder.
She had atrophic kidneys with scattered cysts. She had
normal pancreas, spleen and adrenals.
HOSPITAL COURSE: On admission to the Medical Intensive Care
Unit, she was resuscitated with two units of FFP, 1 mg of
intravenous Vitamin K, intravenous fluids and she was started
on antibiotics, mainly vancomycin, Ceftriaxone and Flagyl.
She did not require pressors at any point during her stay.
The main initial differential included TTP, although, her
coags were abnormal and she had a negative lupus
anticoagulant and anticardiolipin antibodies, so that
diagnosis was excluded. The main concerns then were either
sepsis leading to DIC or massive gastrointestinal bleed
leading to DIC. She spent six days in the Intensive Care
Unit where she was persistently obtunded and guaiac positive.
However, she was hemodynamically stable and was easily weaned
off all supplemental oxygen and remained with a good blood
pressure. Multiple blood cultures were negative. She had a
single urine culture on presentation that had 10-100,000
pansensitive E. Coli, but all subsequent urine cultures were
negative. Her necrotic toes were cultures and grew out
polymicrobial gram positive cocci and gram negative rods.
She was given the diagnosis of sepsis of unknown etiology
with complications of DIC and multisystem organ failure,
namely acute renal failure, shock liver, acute myocardial
infarction, altered mental status and digital necrosis. She
also had gross anasarca.
Given her altered mental status, MR of her head was performed
which revealed chronic microvascular infarct, but was
negative for anoxic brain injury or major infarct. An lumbar
puncture was negative with normal protein and glucose and
negative cultures. An electroencephalogram was consistent
with toxic metabolic encephalopathy. Her B12, folate and RPR
were all normal. Her arterial blood gases remained within
normal limits. Her white blood cell count fell to
approximately 13. Her INR improved with Vitamin K and FFP.
She initially had a lactate of 3.9 that dropped to 1.9. Her
hematocrit remained stable at about 26-28. Her platelets
remained low in the 80,000s. Her creatinine peaked at 3.9
and then slowly dropped to approximately 1.4. Her
bicarbonate improved from 17 to 25. Her transaminases
returned to [**Location 213**]. Her alkaline phosphatase stabilized in
the 300-400 range.
Numerous consultations were obtained including a Cardiology
that stated that her myocardial infarction was likely in the
setting of severe anemia and sepsis. An echocardiogram
revealed severe apical hypokinesis with decreased systolic
function and a small effusion with fiber and deposits on the
cardiac surface. Cardiology recommended no anticoagulation
given her anemia and guaiac positive stools. They
recommended keeping her hematocrit about 30 and the use of a
beta-blocker if she became hypertensive or tachycardic,
neither of which happened during her stay.
Hematology was also consulted regarding her coagulopathy.
They felt it was consistent with DIC and was not TTP. They
recommended Vitamin K supplementation which improved her INR.
She did, however, have a persistently elevated PTT despite
having a negative lupus anticoagulant and anticardiolipin
antibody.
The Renal Service was consulted and diagnosed her with ATN
with muddy brown casts. He creatinine slowly improved from a
peak of 3.9 to 1.4. Her anasarca improved with diuresis.
She did not require hemodialysis. A Rheumatology Consult
stated that she had chronic gout with no apparent acute flare
of any joints. She was unable to receive colchicine or
NSAIDs due to her acute renal failure and would not have
benefited from allopurinol at that time. Her right elbow was
causing her some discomfort and was tapped twice during her
stay. Both times, it was negative for infectious arthritis,
but did reveal crystals suggestive of gout.
The Vascular Surgery Service was consulted and continues to
follow her throughout her stay with regard to the gangrene of
her toes. Her lower extremities were elevated and received
wound care. Amputations were recommended when she was
medically stable. Her toes were never a cause of her sepsis
and never look infected. They were debrided as necessary.
They became very well demarcated and healed nicely.
The Gastrointestinal Service was consulted. They felt that
she most likely had pancreatitis and were uncertain what the
initial cause of her sepsis or her massive gastrointestinal
bleed was. They recommended transfusions, following her
guaiac and no NG suction. They stated that neither
esophagogastroduodenoscopy nor colonoscopy could be done
until six weeks after her myocardial infarction unless she
demonstrated active bleeding. However, her hematocrit
remained stable after her initial transfusion. After six
days in the unit, she was transferred to the floor. There was
a concern that her mental status were due to the morphine and
Ativan she was receiving because of her extreme pain during
dressing changes. During her stay in the unit, she was
nearly constantly crying or screaming.
On the floor, she remained hypothermic with an alkaline
phosphatase of about 500. Her white blood cell count
increased to about 26. Her stool culture was negative for C.
difficile times three. She was changed from Ceftriaxone to
ceftazidime and remained on broad spectrum coverage. She
continued to have excellent saturations and blood pressures.
Her only focal sign remained abdominal pain. An ultrasound
was unhelpful. A second CT was obtained which showed a large
gallbladder that was not inflamed with a large gallstone.
There was no pericholecystic fluid or biliary dilatation or
obstruction. During this time, she had been started on tube
feeds. However, she had an episode of nausea and vomiting
with aspiration and so she was made NPO and TPN was started
via a PICC.
Due to the concern for cholecystitis, a HIDA scan was
performed which showed no uptake. This was consistent with
acute cholecystitis and there was a potential that this could
have been the triggers setting off her sepsis. A gallbladder
drain was placed by Interventional Radiology as General
Surgery consulted and stated that she was far too ill to
undergo surgery. Her viral culture was negative.
In the continued search for a source of her sepsis, her
pleural effusion was tapped. It was transudate and the
cultures were negative. Her ascites was also tapped. Her
serum to ascites albumin gradient was 1.1. She had 1700
white blood cells with 60% polys and a negative Gram stain
and cultures. At that point, she had received adequate
coverage for bacterial peritonitis with Ceftriaxone and then
ceftazidime.
After the gallbladder drain was placed. Her white blood cell
and alkaline phosphatase started to decrease, but after a few
days, her total bilirubin, white blood cell count and
alkaline phosphatase once again started to rise for unclear
reasons. A GGT was checked to insure that the alkaline
phosphatase was of liver source and it was very elevated.
She also had a mild lipase leak at this point from 45 to 71.
There was a concern for gallstone pancreatitis or
cholangitis. She continued to have melena throughout this
time. A magnetic resonance cholangiopancreatography was
performed which showed pancreatitis and no biliary
dilatation, but raised the question of a mass in the head or
uncinate process of the pancreas and also a question of duct
disruption. As her alkaline phosphatase continued to rise,
from the 500s to the 1000s and her total bilirubin increased
to 2.2 and her lipase increased to 123, an Endoscopic
retrograde cholangiopancreatography Consult was obtained.
The endoscopic retrograde cholangiopancreatography fellow
recommended a cholangiogram as an initial first step. This
was done injecting dye through her gallbladder drain. This
revealed a distal common bile duct obstruction, question
stenosis versus stone with no duodenal filling and mild
dilatation of her hepatic and common bile ducts.
Also during this time, other sources of infection were being
sought and an MRI of her feet were done, which were negative
for infection. As above, her right elbow joint was also
tapped and was negative for septic arthritis.
After the cholangiogram revealed obstruction, an endoscopic
retrograde cholangiopancreatography was performed which
revealed no pus or masses but did reveal ampullary stenosis.
A sphincterotomy was performed. On the floor, after her
endoscopic retrograde cholangiopancreatography, she developed
post endoscopic retrograde cholangiopancreatography
pancreatitis and her lipase rose to 163. She had increasing
abdominal tenderness and became slightly more confused.
Prior to the endoscopic retrograde cholangiopancreatography,
her mental status had greatly improved, although, she still
was not speaking, she was alert. After the endoscopic
retrograde cholangiopancreatography, a third abdominal CT
with intravenous contrast was obtained to evaluate for
potential endoscopic retrograde cholangiopancreatography
induced perforation of the intestine or for pancreatic mass
given the question raised on the magnetic resonance
cholangiopancreatography done earlier.
Abdominal CT number three revealed pancreatitis with no
hemorrhage or significant necrosis and no pancreatic mass.
She had no signs of perforation secondary to her endoscopic
retrograde cholangiopancreatography and no bowel ischemia.
After the endoscopic retrograde cholangiopancreatography, her
total bilirubin dropped to normal, however, her alkaline
phosphatase continued to increase from the 1100s to the
1700s. As she slowly recovered from her endoscopic
retrograde cholangiopancreatography pancreatitis, not only
did her alkaline phosphatase continue to rise, but she
developed a direct hyperbilirubinemia again. At this point,
she began growing [**Female First Name (un) **] from her blood and her urine. She
received 24 days of broad spectrum antibiotics at this point.
Her antibiotics were stopped and her TPN was stopped as
well. Her PICC line was removed. She was started on
fluconazole. Right around this time, she developed
dysarthria and a facial droop that was unclear if it was new.
A repeat MRI with gadolinium was the same as her previous.
The repeat was done on [**5-2**] and it showed no changes from
the MRI on [**4-10**]. A repeat electroencephalogram was
normal. Over a few days, her dysphonia improved. She
remained on her fluconazole. Surveillance blood cultures
were negative. A repeat cholangiogram showed normal biliary
tree and flow. This cholangiogram was performed as her
alkaline phosphatase had continued to rise from the 1700s to
the [**2123**]. A repeat bile culture grew yeast. Her white
blood cell count remained stable between 16 and 20,000
throughout this time. She was restarted on tube feeds as her
post endoscopic retrograde cholangiopancreatography
pancreatitis was improving. An Ophthalmology Consult was
obtained to evaluate for fungal eye disease secondary to her
candidemia. She had no evidence of fungal eye disease.
After she developed candidemia and with her increasing
alkaline phosphatase, her creatinine bumped from 1.4 to 1.6.
Despite her positive cultures, she continued to improve in
terms of mental status, abdominal pain, and renal function.
However, since her bile culture had grown out [**Female First Name (un) **], her
gallbladder drain was removed. After it was pulled, she had
leakage of her ascites out of the cutaneous fistula tract
that had led to her gallbladder. The ascitic fluid was
tinged brown with concern for bile spillage into the
peritoneal cavity. Over the afternoon after her gallbladder
drain was pulled, she demonstrated increasing abdominal
tenderness and guarding that was new. This was discussed
with the Gastrointestinal and Radiology Services who stated
that she should be started on broad spectrum antibiotics to
cover potential secondary bacterial peritonitis, although,
she was most likely suffering from a chemical peritonitis
secondary to bile spillage. Fluid was sent for Gram stain
culture and fungal culture. Radiology stated that in the
presence of ascites, the site of her gallbladder drain in the
gallbladder wall was less likely to close off immediately
after the catheter was pulled, but should close with time.
They recommended supportive care through this peritonitis.
Later that evening, she was noted to be bradycardic on
telemetry. A code was called. She underwent PEA arrest and
was transferred to the Medical Intensive Care Unit after she
was resuscitated.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3851**]
Dictated By:[**Name8 (MD) 1552**]
MEDQUIST36
D: [**2125-7-25**] 20:23
T: [**2125-7-25**] 20:23
JOB#: [**Job Number **]
Name: [**Known lastname 7001**], [**Known firstname 4169**] Unit No: [**Numeric Identifier 7002**]
Admission Date: [**2125-4-7**] Discharge Date: [**2125-5-11**]
Date of Birth: [**2043-11-6**] Sex: F
Service: MICU
Addendum to the discharge summary performed on [**2125-5-4**], but
which will also service as her final discharge summary for
her hospitalization here.
HISTORY OF PRESENT ILLNESS: After her arrest and transferred
to the Medical Intensive Care Unit, the patient was followed
for a number of conditions.
1. With regards to Infectious Disease, the patient continued
to be covered for her high-grade candidemia. In addition,
she was covered with broad-spectrum antibiotics to cover
other possible infectious contributions to her illness.
2. She continued to remain dependent on ventilator and could
not be successfully weaned without developing marked
respiratory distress.
3. GI. She continued to be followed by the GI team, who
remained concerned that her elevated LFTs represented hepatic
candidiasis or a potential biliary obstruction.
Unfortunately, the patient was not stable enough to undergo
MRI examination of her abdomen, and this remained an
unanswered question.
4. Neurology. After her arrest, the patient never regained
meaningful interactions with her caretakers or her family.
At various times she appeared very uncomfortable, and a
decision was ultimately made to focus treatment on her
comfort.
After extensive discussions with the family about her ongoing
issues and her grim prognosis, the decision was made to defer
further aggressive measures and focus care on her comfort.
In accordance with these wishes, the patient was extubated on
[**4-10**], and weaned from all antibiotics and blood pressure
supporting medicines. Shortly thereafter, the patient
expired.
TIME OF DEATH: 1:30 am on [**2125-4-10**].
CAUSE OF DEATH:
1. Cardiac arrest.
2. Sepsis.
No autopsy was performed per the family's request.
DISCHARGE STATUS: Deceased.
DISCHARGE DIAGNOSES:
1. Candidemia.
2. Sepsis.
3. Anemia.
4. Tachycardia.
5. Electrolyte abnormalities.
6. Hepatitis.
7. Acute cholecystitis.
8. Pancreatitis.
9. Status post pulseless electrical activity arrest.
10. Tophaceous gout.
11. Hypothyroidism.
DISCHARGE MEDICATIONS: None.
FOLLOW-UP PLAN: None.
[**First Name4 (NamePattern1) 460**] [**Last Name (NamePattern1) 461**], MD
Dictated By:[**Last Name (NamePattern1) 7003**]
MEDQUIST36
D: [**2126-6-11**] 10:28
T: [**2126-6-14**] 11:49
JOB#: [**Job Number 7004**]
|
[
"274.82",
"112.5",
"574.00",
"570",
"518.81",
"577.0",
"038.9",
"286.6",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.04",
"51.84",
"99.15",
"96.72",
"51.85",
"38.93",
"88.72",
"51.04"
] |
icd9pcs
|
[
[
[]
]
] |
2546, 2572
|
20106, 20339
|
20363, 20648
|
5318, 18473
|
2595, 5300
|
18502, 20085
|
2199, 2290
|
2307, 2529
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,871
| 149,726
|
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Discharge summary
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report+report
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Admission Date: [**2125-5-2**] Discharge Date: [**2125-5-8**]
Date of Birth: [**2064-5-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Atorvastatin
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
s/p Aortic root emlargement/Aortic valve replaceement(#21
tissue)Mitral valve replacement(#25 porcine)coronary artery
bypass graft x1(saphenous vein graft-posterior descending
artery).[**5-2**]
History of Present Illness:
60 year old woman with history of aortic stenosis followed by
serial echocardiograms. Patient now with worsening dyspnea on
exertion. Refered for surgical evaluation
Past Medical History:
hypertensiom
hypercholesterolemia
severe aortic stenosis
mild mitral stenosis
osteopenia
arthritis
asthma
breast papilloma
depression
PSH:
oopherectomy
breast cyst excision
c-section
bilateral carpal tunnel release
l trigger finger release
Social History:
receptionist
Tobbaco: 30 pack year history/quit 30 years ago
ETOH: denies
lives with husband
Family History:
father died of sudden death @37 years old
Physical Exam:
T HR 69 bP 117/60 RR 18 O2sat
Ht 5'0" Wt 227lbs
Gen NAD
Neuro A&Ox3, grossly intact
HEENT PERRL, [**Last Name (un) **] supple-full ROM, MMM
Chest CTA bilat
Cor RRR 3/4 systolic murmur
Abdm soft, non tender, non distended, nlormal bowel sounds
Ext warm well perfused, no varicosities
Pertinent Results:
[**2125-5-1**] 12:46PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-2
[**2125-5-1**] 12:46PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
[**2125-5-1**] 12:46PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2125-5-2**] 09:42AM HGB-12.4 calcHCT-37
[**2125-5-2**] 09:42AM GLUCOSE-108* LACTATE-1.3 NA+-139 K+-3.2*
CL--95*
[**2125-5-2**] 05:31PM UREA N-12 CREAT-0.6 CHLORIDE-112* TOTAL
CO2-20*
[**2125-5-8**] 06:05AM BLOOD WBC-19.8* RBC-3.28* Hgb-10.2* Hct-30.0*
MCV-91 MCH-31.1 MCHC-34.0 RDW-17.2* Plt Ct-250
[**2125-5-8**] 06:05AM BLOOD Plt Ct-250
[**2125-5-5**] 01:56AM BLOOD PT-13.3 PTT-27.2 INR(PT)-1.1
[**2125-5-8**] 06:05AM BLOOD Glucose-89 Creat-0.7 Na-138 K-4.3 Cl-100
HCO3-25 AnGap-17
======================================
[**Known lastname **],[**Known firstname **] [**Medical Record Number 102872**] F 60 [**2064-5-25**]
Radiology Report CHEST (PA & LAT) Study Date of [**2125-5-8**] 8:33 AM
Final Report
CHEST RADIOGRAPH
INDICATION: Evaluation for pleural effusions or atelectasis.
Status post
CABG.
COMPARISON: [**2125-5-5**].
FINDINGS: As compared to the previous radiograph, the size of
the cardiac
silhouette is unchanged. There is a newly appeared plate-like
atelectasis at the level of the left lung hilus. There is
unchanged retrocardiac
atelectasis. Blunting of the left costophrenic sinus suggests a
minimal
left-sided pleural effusion. In the right lung, there is minimal
atelectasis at the bases of the right upper lobe. Newly occurred
focal parenchymal opacities suggesting pneumonia are not seen.
No evidence of overhydration, no pneumothorax.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Approved: TUE [**2125-5-8**] 11:30 AM
====================================
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 102873**] (Complete)
Done [**2125-5-2**] at 11:34:24 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2064-5-25**]
Age (years): 60 F Hgt (in): 60
BP (mm Hg): 124/64 Wgt (lb): 224
HR (bpm): 64 BSA (m2): 1.96 m2
Indication: aortic stenosis, cad, mitral regurg. Intraop
management
ICD-9 Codes: 786.05, 440.0, 424.1, 394.0, 394.1, 424.0
Test Information
Date/Time: [**2125-5-2**] at 11:34 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW2-: Machine: 2
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.6 cm
Left Ventricle - Fractional Shortening: *0.16 >= 0.29
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Annulus: 1.8 cm <= 3.0 cm
Aorta - Sinus Level: 2.6 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.5 cm <= 3.0 cm
Aorta - Ascending: 2.9 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *2.7 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *28 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 15 mm Hg
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Mitral Valve - Peak Velocity: 1.2 m/sec
Mitral Valve - Mean Gradient: 4 mm Hg
Mitral Valve - Pressure Half Time: 104 ms
Mitral Valve - MVA (P [**12-15**] T): 2.1 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Moderate symmetric LVH. Low normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Critical AS (area
<0.8cm2). No AR.
MITRAL VALVE: Severely thickened/deformed mitral valve leaflets.
Severe mitral annular calcification. Severe thickening of mitral
valve chordae. Calcified tips of papillary muscles. Moderate
valvular MS (MVA 1.0-1.5cm2) Severe (4+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Results were
Conclusions
PREBYPASS
No spontaneous echo contrast is seen in the left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There is moderate symmetric left ventricular
hypertrophy. Overall left ventricular systolic function is low
normal (LVEF 50-55%). Right ventricular chamber size and free
wall motion are normal. There are simple atheroma in the
descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). No aortic regurgitation is seen. The
mitral valve leaflets are severely thickened/deformed. There is
severe mitral annular calcification. There is severe thickening
of the mitral valve chordae. There is moderate valvular mitral
stenosis (area 1.0-1.5cm2). Severe (4+) mitral regurgitation is
seen. Dr. [**Last Name (STitle) **] was notified in person of the results
during the surgery on [**2125-5-2**] at 1014.
POSTBYPASS
Patient is on phenylephrine infusion. A tissue valve is seen in
the aortic position, no perivalvular leaks are seen, max
gradient 26, mean gradient 12. A tissue valve is seen in the
mitral position, no perivalvular leaks are seen, max gradient 8,
mean gradient 2. Aortic contours are smooth after decannulation.
LV EF is somewhat reduced after bypass, the infrolateral,
lateral and anterolateral walls are hypokinetic in addition to
being intravascular volume dehydrated.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2125-5-8**] 09:57
=====================================
Brief Hospital Course:
Ms [**Known lastname **] was admitted to [**Hospital1 18**] as a same day admit on [**5-2**]. She
was brought to the operating room for a scheduled AVR/MVR/CABG
at that time. Please see OR report for full details. In summary
she had an aortic root enlargement, aortic valve replacement
with #21 [**Doctor Last Name **] pericardial valve, mitral valve replacement
with #25 [**Company 1543**] porcine valve, coronary bypass graft x1 with
reverse saphanous vein graft to posterior descending artery. Her
bypass time was 251 minutes with a xcoss clamp of 227 minutes.
The patient tolerated the operation well and was transferred
post operatively to the cardiac surgery ICU on Epinephrine and
Propofol infusions. The patient remained intubated overnight
given her inotropic support. ON POD1 she was weaned from the
inotropes, on POD2 she was weaned from thre ventilator and
extubated. Her chest tubes were removed and she was transferred
from the ICU to the stepdown floor on POD3.
Once on the floor she had an uneventful post operative course.
She was noted to have periods of intermittant atrial
fibrillation for which was treated with Beta blockers and
Amiodarone following which she converted to sinus rhythm. On POD
6 it was decided she was ready for discharge to rehabilitation
at [**Hospital 745**] Healthcare.
Medications on Admission:
KCL 20 QD
Amlopidine 10 QD
Prozac 40 QD
Advair 1 puff [**Hospital1 **]
HCTZ 25 QD
Crestor 5 QD
ASA 81 QD
Coenzyme Q 10 QD
Vitamin D 400 QD
MVI 1 QD
Fish Oil 1000 [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
5. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1 wk then 400mg QD x1 wk then 200mg QD.
7. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous QAC&HS.
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
15. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
16. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO BID (2 times a day).
17. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 7 days.
18. Furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection
[**Hospital1 **] (2 times a day) for 1 weeks: then convert to PO dosing.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] health care center
Discharge Diagnosis:
s/p Aortic root emlargement/Aortic valve replaceement(#21
tissue)Mitral valve replacement(#25 porcine)coronary artery
bypass graft x1(saphenous vein graft-posterior Diagonal artery).
PMH: Hypertension, hyperlipide,ia, Osteopenia, Depression,
Arthritis, s/p bilateral carpal tunnel release, s/p
Oopherectomy, s/p C-section, s/p breast cyst excision, breast
papilloma, Asthma, s/p trigger finger release
Discharge Condition:
good
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medication as prescribed.
Call for any fever, redness or drainage from wounds.
No creams lotions or ointments to wounds.
No lifting >10 pounds, no driving untill cleared by surgeon
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] in [**1-16**] weeks
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 696**] in [**1-16**] weeks
Dr [**Last Name (STitle) 7772**] in 4 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2125-5-8**] Admission Date: [**2125-5-14**] Discharge Date: [**2125-5-17**]
Date of Birth: [**2064-5-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Atorvastatin
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Bilateral Lower Extremity edema
Major Surgical or Invasive Procedure:
none
History of Present Illness:
60 yo female discharged [**5-8**] to rehab after AVR/root
enlargement/MVR/CABG x1 on [**5-2**]. Presented to emergency room
from rehab after LE edema noted.
Past Medical History:
hypertension
hypercholesterolemia
severe aortic stenosis
mild mitral stenosis
osteopenia
arthritis
asthma
breast papilloma
depression
atrial fibrillation
PSH:
s/p AVR (tissue)/Aortic root enlargement/MVR/cabg x1
oopherectomy
breast cyst excision
c-section
bilateral carpal tunnel release
l trigger finger release
Social History:
receptionist
Tobbaco: 30 pack year history/quit 30 years ago
ETOH: denies
lives with husband
Family History:
father died of sudden death @37 years old
Physical Exam:
Pulse: 71 Resp:18 O2 sat: 95%-RA
B/P Right: 108/70 Left:
Height: Weight:
General:
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Sternum: stable, incision CDI
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [] Edema: 2+ Varicosities:
None [x] Rt side EVH site with echymosis and small
instrumentation site with serous drainage
Neuro: Grossly intact[x]
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2125-5-15**] 05:40AM BLOOD WBC-16.9* RBC-3.24* Hgb-9.7* Hct-30.0*
MCV-93 MCH-30.1 MCHC-32.4 RDW-16.7* Plt Ct-398
[**2125-5-14**] 03:10PM BLOOD Neuts-81.4* Lymphs-10.8* Monos-5.3
Eos-2.2 Baso-0.3
[**2125-5-15**] 05:40AM BLOOD Plt Ct-398
[**2125-5-14**] 03:10PM BLOOD PT-14.1* PTT-26.3 INR(PT)-1.2*
*******************
[**2125-5-16**] 09:33AM BLOOD WBC-15.5* RBC-3.51* Hgb-10.5* Hct-33.1*
MCV-94 MCH-29.8 MCHC-31.7 RDW-16.4* Plt Ct-439
[**2125-5-16**] 09:33AM BLOOD Plt Ct-439
[**2125-5-16**] 05:55AM BLOOD UreaN-21* Creat-1.0 Na-139 K-3.9 Cl-99
HCO3-26 AnGap-18
LE duplex
IMPRESSION:
No evidence of deep venous thrombosis in the lower extremities
bilaterally.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39944**]
DR. [**First Name (STitle) 28783**] [**Name (STitle) 28784**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**]
Approved: TUE [**2125-5-15**] 1:05 AM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier **]TTE (Complete)
Done [**2125-5-15**] at 3:44:10 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2064-5-25**]
Age (years): 60 F Hgt (in): 60
BP (mm Hg): 90/68 Wgt (lb): 260
HR (bpm): 75 BSA (m2): 2.09 m2
Indication: Aortic valve disease. H/O cardiac surgery. Mitral
valve disease. 21 mm C-E aortic valve and 25 mm [**Company 1543**] Mosaic
mitral valve.
ICD-9 Codes: 402.90, V42.2, 424.1, 424.0
Test Information
Date/Time: [**2125-5-15**] at 15:44 Interpret MD: [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **], RDCS
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2009W011-0:20 Machine: Vivid [**6-20**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.3 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.9 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.9 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.6 cm
Left Ventricle - Fractional Shortening: *0.27 >= 0.29
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Sinus Level: 2.6 cm <= 3.6 cm
Aorta - Ascending: 2.2 cm <= 3.4 cm
Aorta - Arch: 2.6 cm <= 3.0 cm
Aortic Valve - Peak Gradient: *27 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 14 mm Hg
Mitral Valve - Mean Gradient: 7 mm Hg
Mitral Valve - Pressure Half Time: 117 ms
Mitral Valve - E Wave: 2.1 m/sec
Mitral Valve - A Wave: 1.2 m/sec
Mitral Valve - E/A ratio: 1.75
Mitral Valve - E Wave deceleration time: *304 ms 140-250 ms
TR Gradient (+ RA = PASP): *42 mm Hg <= 25 mm Hg
Findings
At one year the mean reported gradient for 25 mm [**Company 1543**]
Mosaic valve was 6.7 +/- 1.7.
LEFT ATRIUM: Marked LA enlargement.
LEFT VENTRICLE: Mild symmetric LVH. Mildly depressed LVEF. No
resting LVOT gradient.
RIGHT VENTRICLE: Dilated RV cavity. Normal RV systolic function.
[Intrinsic RV systolic function likely more depressed given the
severity of TR].
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR).
Normal AVR gradient.
MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR).
Normal MVR gradient.
TRICUSPID VALVE: Moderate to severe [3+] TR. Moderate PA
systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is markedly dilated. There is mild symmetric
left ventricular hypertrophy. Overall left ventricular systolic
function is mildly depressed (LVEF= 50-55 %). The right
ventricular cavity is dilated with normal free wall
contractility. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] A bioprosthetic aortic valve prosthesis is
present and appears well seated. The transaortic gradient is
normal for this prosthesis. A bioprosthetic mitral valve
prosthesis is present and appears well seated. The leaflets were
not well visualized. The transmitral gradient is normal for this
prosthesis. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
Electronically signed by [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2125-5-15**] 16:29
[**Known lastname **],[**Known firstname **] [**Medical Record Number 102872**] F 60 [**2064-5-25**]
Radiology Report CHEST (PA & LAT) Study Date of [**2125-5-14**] 4:42 PM
[**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Doctor First Name **] EU [**2125-5-14**] 4:42 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 102874**]
Reason: eval for dvt
[**Hospital 93**] MEDICAL CONDITION:
60 year old woman sp cabg who presents with increased bilateral
lower extremity swelling.
REASON FOR THIS EXAMINATION: eval for dvt
Final Report
HISTORY: 60-year-old patient, status post CABG, who presents
with increased bilateral lower extremity swelling, to assess for
a cardiopulmonary process.
TECHNIQUE: AP and lateral radiographs of the chest were
performed. Comparison is made with prior radiograph dated
[**2125-5-8**].
FINDINGS:
The patient is status post sternotomy. The heart remains
enlarged. A
valvular cardiac prosthesis is unchanged. Atelectasis and a
small right basal effusion are unchanged. The left basal
effusion has decreased. Linear atelectasis is present in the
left mid zone as well as right mid zone. There is no focal
pulmonary consolidation.
CONCLUSION:
Atelectasis in mid zones bilaterally and right lung base with a
persistent
right basal effusion. Interval improvement with decrease in the
left basal
effusion.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 28783**] [**Name (STitle) 28784**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**]
Approved: TUE [**2125-5-15**] 1:07 AM
Brief Hospital Course:
Ms [**Known lastname **] was readmitted for IV diuresis. Her emergency room
workup was negative for DVT by US and CXR showed cardiomegaly
small bilateral effusions and associated atelectasis. Her
troponin was elevated but her CPK was normal at that time, her
EKG was unremarkable.
She was agressively diuresed during her hospital stay. She
worked with physical therapy and was discharged home with
visiting nurses on HD# 4.
Medications on Admission:
Medications at discharge to rehab:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
5. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1 wk then 400mg QD x1 wk then 200mg QD.
7. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous QAC&HS.
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
15. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
16. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO BID (2 times a day).
17. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 7 days.
18. Furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection
[**Hospital1 **] (2 times a day) for 1 weeks: then convert to PO dosing.
Meds at rehab: Fish oil, MVI, ASA 81', KCL 10', Norvasc 10',
Loratidine 10', Fluoxetine 40', Advair 1 puff qs, Pravastatin
10', amiodarone 400', Oxycodone 5-15mg Q3/prn, Lasix 40'(po),
Zantac 150', Atrovent, Albuterol, Tramadol 50 Q6-8/prn,
Metoprolol 25/tid, Keflex 500 TID,
Allergies: Atorvastatin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 2 weeks.
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. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
5. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
Disp:*30 Tablet(s)* Refills:*0*
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 6 days: 400 mg daily until [**5-20**]; then 200 mg daily starting
[**5-21**].
10. Metolazone 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) for 2 weeks: take 1/2 hour before lasix
will assess need for futher dosing at follow up.
Disp:*7 Tablet(s)* Refills:*1*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 weeks: will eval if you need further dosing at follow up.
Disp:*14 Tablet(s)* Refills:*1*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks: continue this medication as long as you are on lasix.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*1*
13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
hypertension
hypercholesterolemia
severe aortic stenosis
mild mitral stenosis
osteopenia
arthritis
asthma
breast papilloma
depression
atrial fibrillation
PSH:
s/p AVR (tissue)/Aortic root enlargement/MVR/cabg x1
oopherectomy
breast cyst excision
c-section
bilateral carpal tunnel release
l trigger finger release
Discharge Condition:
stable
Discharge Instructions:
no lotions, creams or powders on any incision
shower daily and pat incision dry
call for fever greater than 100,redness, drainage, or weight
gain of 2 pounds in 2 days or 5 pounds in one week
no driving for one month
no lifting greater than 10 pounds for another 8 weeks
wear your surgical bra all day every day even when sleeping. You
may have it off for one hour per day.
Followup Instructions:
Call and schedule the following appointments:
Dr. [**Last Name (STitle) **] in [**12-15**] weeks
Dr. [**Last Name (STitle) 696**] on [**2125-6-14**] at 11:00am [**Telephone/Fax (1) 62**]
Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
ECHOCARDIOGRAM Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2125-6-8**] 10:00am
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2125-5-17**]
|
[
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"518.0",
"458.29",
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"493.90",
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"427.31",
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"E878.2",
"287.5",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.23",
"35.21",
"39.56",
"36.11",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
25678, 25733
|
21288, 21714
|
13009, 13015
|
26089, 26097
|
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|
13664, 13707
|
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|
20047, 20137
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25754, 26068
|
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|
26121, 26496
|
13722, 14445
|
12938, 12971
|
20169, 21265
|
13043, 13201
|
13223, 13537
|
13553, 13648
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,889
| 140,279
|
48947
|
Discharge summary
|
report
|
Admission Date: [**2114-1-23**] Discharge Date: [**2114-1-30**]
Date of Birth: [**2033-11-17**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Verapamil / Beta-Adrenergic Agents
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
Headache, dizziness
Major Surgical or Invasive Procedure:
Removal of Right hickman line
Placement of and removal of a left temporary [**First Name3 (LF) 2286**] line
Placement of a tunneled [**First Name3 (LF) 2286**] line
History of Present Illness:
80 yo F h/o DM, HTN, ESRD on HD, seizures, h/o SDH and IPH in
[**9-25**] who awoke from sleep with c/o headache this morning. Per
her sister she was acting differently the night before, and this
morning was confused prior to presentation to the ED. She was
scheduled for a line placement today due to recently clotted
[**Month/Year (2) 2286**] line. The patient and her sister deny any falls,
syncope, photophobia, seizure, nausea or vomiting. No loss or
change reported from pt in bowel or bladder habits.
.
In the ED: T 98.0 BP 186/80 HR 62 RR 126 100%@3L. Patient
denied dizziness, reported only hunger and headache. Found to
have hyperkalemia to 6.8 (already scheduled for [**Month/Year (2) 2286**] today)
with peaked T waves on EKG. She was given Labetalol 10mg x1, Ca
Gluconate, D50 with regular insulin, Kayexalate and Dilantin 1g
IV load. K improved to 5.7. Head CT demonstrated subdural
bleeds, full report below. Her mental status declined from full
sentences to 1 word answers. Transferred to MICU with Neurosurg
consulted.
.
On admission to the ICU, the patient is somnolent but responsive
to questioning. She denies any active pain or discomfort at
this time.
Past Medical History:
DM
CAD
PVD
HTN (labile)
h/o SDH and IPH in [**9-25**].
[**9-25**] s/p syncopal fall resulting in acute SDH and IPH (non
surgical)
Lower extremity edema/venous insufficiency
Arthritis
Lumbar disc disease
Chronic kidney disease on HD, previously via left UE fistula but
that was infected [**6-25**] at an area of repaired aneurysm so no via
tunnelled HD cath
Pulmonary hypertension
Toxic Multinodular Goiter
Anemia- low iron and EPO
s/p Breast biopsy
s/p Hysterectomy,
s/p excision of a left ear mass
s/p right toe amputation of digits one, two,
three, four, and five
Social History:
Lives with her sister. [**Name (NI) 1351**], denies tobacco/etoh or
illicit drug use
Family History:
Diabetes
Physical Exam:
T 97.3 HR 51 BP 141/54 RR 17 100%@2L Sp02 Weight 74kg
General: Somnolent, breathing comfortably on 2L
HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink
Neck: supple, trachea midline, no thyromegaly or masses, no LAD
Cardiac: RRR, s1s2 normal, no m/r/g, no JVD
Pulmonary: CTAB, [**Name (NI) **] cath in R anterior chest
Abdomen: +BS, soft, nontender, nondistended, no HSM
Extremities: warm, 1+ DP pulses, no edema
Neuro: A&Ox3, speech limited to few word answers, CNII-XII
intact, moves all extremities, Slow finger to nose, possible
poor cooperation
Pertinent Results:
[**2114-1-23**] 08:51PM GLUCOSE-188* UREA N-25* CREAT-4.3*#
SODIUM-142 POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-28 ANION GAP-18
[**2114-1-23**] 08:51PM CALCIUM-9.0 PHOSPHATE-3.9# MAGNESIUM-1.6
[**2114-1-23**] 01:55PM GLUCOSE-121* LACTATE-2.3* NA+-144 K+-5.7*
CL--102 TCO2-24
[**2114-1-23**] 01:45PM CALCIUM-9.1 PHOSPHATE-6.0* MAGNESIUM-2.2
[**2114-1-23**] 01:45PM PT-13.1 PTT-22.8 INR(PT)-1.1
[**2114-1-23**] 09:54AM PH-7.54* COMMENTS-GREEN TOP
[**2114-1-23**] 09:54AM GLUCOSE-111* LACTATE-1.1 NA+-143 K+-6.6*
CL--104 TCO2-22
[**2114-1-23**] 09:54AM freeCa-0.94*
[**2114-1-23**] 09:50AM GLUCOSE-113* UREA N-67* CREAT-8.7*#
SODIUM-142 POTASSIUM-6.8* CHLORIDE-102 TOTAL CO2-22 ANION
GAP-25*
[**2114-1-23**] 09:50AM estGFR-Using this
[**2114-1-23**] 09:50AM CALCIUM-8.8 PHOSPHATE-6.2* MAGNESIUM-2.2
[**2114-1-23**] 09:50AM WBC-7.1 RBC-3.39* HGB-10.2* HCT-31.5* MCV-93#
MCH-30.0 MCHC-32.3 RDW-17.3*
[**2114-1-23**] 09:50AM NEUTS-64.0 LYMPHS-23.9 MONOS-5.9 EOS-5.2*
BASOS-1.0
[**2114-1-23**] 09:50AM PLT COUNT-220
.
[**1-23**] 9 am CT head: New bifrontal extra-axial fluid collections,
compatible with acute on subacute
subdural hematomas. Alternatively, these could represent acute
hemorrhage
within established subdural hygromas. There may be a component
of acute
epidural hematomas, particularly anteriorly where the morphology
is more
biconvex.
.
[**1-23**] 8:24 pm CT head: hange in configuration of acute-on-chronic
bilateral subdural
hematomas; either stable or minimally-increased in size
(allowing for
differences in positioning).
.
[**1-24**] CT head: 1. Stable appearance of bilateral extra-axial fluid
collections which
represent either acute-on-chronic bilateral subdural hematomas
or relate to
anticoagulation at time of presentation.
2. Bilateral small parafalcine subdural hematomas, unchanged.
.
[**1-26**] CT head: 1. Stable acute on chronic bilateral subdural
hematomas.
2. Bilateral small parafalcine subdural hematomas, which are
unchanged.
.
[**1-23**] CXR: No evidence of acute pulmonary edema. Focal opacity
seen in the
left lower lobe, nonspecific but could represent aspiration or
pneumonia.
.
[**1-28**] CXR: IMPRESSION: Minimal patchy retrocardiac density is
stable -- ?
atelectasis/scarring or less likely a pneumonic infiltrate. The
lungs are
otherwise clear.
.
[**2114-1-24**] 1:39 pm BLOOD CULTURE Source: Line-Hickman.
**FINAL REPORT [**2114-1-27**]**
Blood Culture, Routine (Final [**2114-1-27**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 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
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- 2 I
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
PENICILLIN G---------- 0.25 R
Aerobic Bottle Gram Stain (Final [**2114-1-26**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2114-1-26**]):
GRAM POSITIVE COCCI IN CLUSTERS.
.
[**2114-1-24**] 1:39 pm BLOOD CULTURE Source: Line-Hickman.
**FINAL REPORT [**2114-1-27**]**
Blood Culture, Routine (Final [**2114-1-27**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 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
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- 1 I
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
PENICILLIN G---------- =>0.5 R
Anaerobic Bottle Gram Stain (Final [**2114-1-25**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2114-1-25**] 9:40AM.
Aerobic Bottle Gram Stain (Final [**2114-1-25**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Brief Hospital Course:
Assessment and Plan: An 80 year old with DM, ESRD and history of
subdural hematomas presents with HA found to have new
acute/subacute hematomas and hyperkalemia with altered mental
status. Also with Bacteremia. Hemodynamically stable, K normal,
MS cleared when transfered to the floor
.
# Altered mental status: Somulent after arrival to MICU
responding in one word answers only. Back at baseline prior to
transfer. Toxic metabolic may have been contributing
(hyperkalemia). However, more Likely subdural hematomas,
bacteremia, and delirium contributing. After transfer to the
floor mental status worsened but CT showed stable SDH.
Exacerbation was felt to be secondary to infection and delirium.
Ms [**Name13 (STitle) 102790**] required haldol for aggitation. Her mental
status improved with minimal haldol and antibiotic therapy so
that she was Alert and oriented x 3 for 4 days prior to
discharge. Neurosurgery felt that burr holes were no longer
needed since her mental status improved.
.
# acute on chronic Subdural hematoma: Presented to the ED with
a headache. Found to have acute changes in her bilateral chronic
hematomas. Etiology uncertain. No fall or syncopal history.
Could be uremia in combination with hypertension. They remained
stable on serial CT scans. She was loaded with Dilantin and
continued on 100mg PO TID. The patient was followed by
neurosurgery. Bilateral burr holes were originally planed but
postponed [**2-19**] positive blood cultures. Then when the infection
was controled her mental status improved. Neurosurgery felt that
burr holes were no longer needed since her mental status
improved. She will have a repeat CT head on [**2-8**] and be seen by
Dr [**First Name (STitle) **] of neurosurg on [**2-8**] who will monitor for stability in
the SDH and determine the course of therapy. If they remain
stalbe surgery can likely be avoided.
.
# Fever/Positive blood culture: The patient was febrile up to
101.3 in MICU and had coag neg staph in 4 bottle on [**1-24**].
Possible source of infection is recently clotted [**Month/Day (4) 2286**] line (
positive cultures off Hickman). CXR also shows possible
infiltrate but no finding on lung exam and sating well so felt
to be less likely. The Hickman was pulled and she got a
temporary HD placed by IR. Ms [**Known lastname 89279**] was started on
vancomycin per HD protocol (first dose 1/8 pm) for fear of MRSA.
Cultures grew only coag neg staph, however she was continued on
Vanco for easy of dosing with HD. Nafacilllin was considered but
this would entail a separate PICC line for q6h dosing, and was
therefore rejected. Will continue vancomycin for a 2 week course
of therapy to finish [**2114-2-8**]
.
# ESRD: Continue [**Month/Day/Year 2286**] as scheduled on T, Th, and Sat.
Continued Sevelamer & Cincalcet. Will continue HD at her normal
location in [**Location (un) **]. The Renal follow will contact the
facility with [**Location (un) 2286**] orders.
.
# Hyperkalemia: Upon arrival at the ED found to have
hyperkalemia to 6.8 with peaked T waves on EKG. She was given
Ca Gluconate, D50 with regular insulin, Kayexalate with
improvment to 5.7. The hyperkalemia resolved after [**Location (un) 2286**].
.
# Diabetes Mellitus: Controlled on Humalogy ISS. Held Starlix
while inhouse in case of procedure. Restarted Starlix on
discharge. Continue humalog ISS. Pt was on lantus (unknown dose)
at home. Consider switching to lantus based on insulin
requirement once stable on Starlix.
.
# Toxic multinodular goiter: Continued Methimazole 15mg home
dose
.
# Hyperlipidemia: Continued atorvastatin
.
# Access: Right Hickman removed because of multiple positive
blood cultures drawn from it. Pt had a temporary HD line placed
on the left. After multiple following cultures remained negative
a new tunneled line was placed for [**Location (un) 2286**] and the temporary
line was removed.
.
# Code: FULL (confirmed)
.
# Communication: [**First Name8 (NamePattern2) **] [**Name (NI) **] SISTER/hcp [**Telephone/Fax (1) 102786**]
CELL [**Numeric Identifier 102791**]
.
Medications on Admission:
ASA 81mg PO QDay
Atorvastatin 10mg PO Qday
Labetalol 200mg PO BID PRN
Colace 100mg PO BID PRN
Heparin 5000 units SC TID
Lantus
Methimazole 15mg PO Qday
Phenytoin 125mg PO Q8
Starlix 60mg TID AC
Sensipar 20mg PO Qday
Fosrenol 2g TID QAC
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Hold dose on mornings before HD.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
4. Methimazole 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
6. Starlix 60 mg Tablet Sig: One (1) Tablet PO three times a
day: dose AC.
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
8. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
with HD for 9 days: Dose with [**Numeric Identifier 2286**] to complete a 14 day
total course on [**2114-2-8**]. Check Vanco troughs on HD days.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
4000-[**Numeric Identifier 2249**] UNIT DWELL Injection PRN (as needed) as needed for
line flush: [**Numeric Identifier **] Catheter (Tunneled 2-Lumen): [**Numeric Identifier **] NURSE
ONLY: Withdraw 4 mL prior to flushing with 10 mL NS followed by
Heparin as above according to volume per lumen. .
13. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
14. Insulin Lispro 100 unit/mL Solution Sig: 1-10 units
Subcutaneous ASDIR (AS DIRECTED): as directed by sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
bilateral acute on chronic subdural hematomas
hyperkalemia
ESRD on HD
coag negative staph bacteremia
.
Secondary dx:
Diabetes
CAD
PVD
Hypertension
toxic multinodular goiter
Discharge Condition:
good
Discharge Instructions:
You were admitted to the hospital for a headache and high
potassium. You were found to have an acute progression of your
chronic subdural hematoma. Its progression was followed with
multiple CT scans. You were confused over your hospital stay,
likely from a combination of the sudural hematoma, infection,
and delirium. However, you have signifciantly improved over the
last 4 days and neurosurgery no longer feels that surgery is
needed at this time.
.
You high potassium was treated with [**Last Name (NamePattern1) 2286**]
.
You had an infection of your [**Last Name (NamePattern1) 2286**] line. Therefore your old
line was pulled and you had a temporary line placed. Later a
permanent new line was placed.
.
The following changes were made to your medication regimen:
Vancomycin was added for your infection
senna was added for consitpation
Fosrenol was replaced with Sevelamer.
.
Please follow up with your doctors as detailed below.
.
If you develop headaches, nausea or vomitting, change in your
vision, focal weakness, confusion, fevers, chills, chest pain,
shortness of breath, abdominal pain, or any other worrisome
symptom please call your doctor or go to the emergency room.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 4283**] [**Last Name (NamePattern1) 10803**] [**Telephone/Fax (1) 250**]. You are scheduled to see
[**Name6 (MD) 102792**] [**Name8 (MD) **] NP. on [**2114-2-23**] at 940 am.
.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2114-2-8**] 10:15
.
Neurosurg: Dr. [**First Name8 (NamePattern2) **] [**2-8**] at 11:00am [**Hospital Unit Name **]. ([**Telephone/Fax (1) 88**]
.
Previously scheduled appointments
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2114-2-9**] 1:40
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 8222**], MD Phone:[**Telephone/Fax (1) 2928**]
Date/Time:[**2114-3-12**] 9:00
Completed by:[**2114-1-30**]
|
[
"250.00",
"E849.8",
"416.8",
"041.19",
"996.74",
"999.31",
"241.1",
"432.1",
"E879.1",
"276.7",
"403.91",
"280.9",
"790.7",
"585.6",
"440.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95",
"97.49"
] |
icd9pcs
|
[
[
[]
]
] |
13762, 13858
|
7799, 8096
|
330, 497
|
14075, 14082
|
3018, 4069
|
15317, 16124
|
2416, 2426
|
12142, 13739
|
13879, 14054
|
11881, 12119
|
14106, 15294
|
2441, 2999
|
271, 292
|
525, 1707
|
4870, 7776
|
8111, 11855
|
1729, 2297
|
2313, 2400
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,928
| 124,720
|
3119
|
Discharge summary
|
report
|
Admission Date: [**2100-10-18**] Discharge Date: [**2100-10-21**]
Service: MED
Allergies:
Vioxx / Aspirin
Attending:[**First Name3 (LF) 4309**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89F [**Hospital 14785**] [**Hospital **] Rehab Resident h/o AF, Recent Stroke
(1.5 m/a), HTN, PUD, Recent UTI (Rec'd ABX), made CMO after
being admitted to [**Hospital Unit Name 153**] with resp distress. Pt had dementia/decr
MS [**First Name (Titles) **] [**Last Name (Titles) 5348**], but had rapid deterioration in MS over [**3-2**] wks
PTA. Had witnessed aspiration at NH and then fevers and incr
resp distress.
Past Medical History:
Atrial Fibrillation, Chronic abd pain, HTN, Osteoarthritis,
Glaucoma, CRI, Diverticulosis, Dastric/Duodenal ulcers, Atypical
Chest Pain, Stroke (1.5 m/a).
Social History:
Russian-born. Pt lived in [**Hospital 100**] Rehab. No h/o tobacco, ETOH.
Family member contact: [**Name (NI) **] [**Name (NI) 14786**] ([**Telephone/Fax (1) 14787**]). Now DNR/DNI.
Family History:
Non-contributory.
Physical Exam:
ADMISSION EXAM:
T100.6 BP74/58-134-88 HR101-148 RR23-34 OS95-100% on BIPAP100%.
GEN - MILD RESP DISTRESS.
HEENT - ANICTERIC, SLIGHTLY DRY MMM.
RESP - DIFFUSE B/L RHONCHI AND EXP WHEEZES.
CV - IRREG IRREG. UNABLE TO AUSC HS SECONDARY TO LOUD BS.
ABD - S/NT/ND.
EXT - BOOTS ON HEELS. PITTING EDEMA TO SHINS.
NEURO - INTERMITTENTLY RESPONDS TO QUESTIONS IN RUSSIAN. MOVES
ALL EXT.
TRANFER EXAM:
BP98/45 HR104 RR24 OS91%5L NC.
GEN - MILD RESP DISTRESS. LETHARGIC. OCC MOAN
HEENT - ANICTERIC, DRY MMM, BLOOD CLOTS ON TOUNGUE.
RESP - MOUTH BREATHING. GOOD AIR FLOW. DIFFUSE B/L RHONCHI AND
EXP WHEEZES.
CV - IRREG IRREG. FAINT HS. NO MGR DETECTED.
ABD - DIFFUSELY TENDER AND STIFF. GUARDING. NO DISTENSION.
EXT - BOOTS ON HEELS. PITTING EDEMA TO SHINS. RADIAL PULSES 1+.
NEURO - MOANS TO COMMANDS. MOVES ALL EXT.
Pertinent Results:
[**2100-10-20**] 04:44AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.4
[**2100-10-20**] 04:44AM BLOOD Glucose-146* UreaN-64* Creat-1.1 Na-142
K-4.7 Cl-114* HCO3-19* AnGap-14
[**2100-10-20**] 04:44AM BLOOD PT-14.4* PTT-26.9 INR(PT)-1.3
[**2100-10-20**] 04:44AM BLOOD Plt Ct-580*
[**2100-10-20**] 04:44AM BLOOD WBC-29.2* RBC-3.26* Hgb-10.2* Hct-31.6*
MCV-97 MCH-31.1 MCHC-32.1 RDW-13.0 Plt Ct-580*
Brief Hospital Course:
Mrs [**Known lastname 14788**] was admitted to [**Hospital Unit Name 153**] in resp distress. She had a
repeat witnessed aspiration event in [**Hospital Unit Name 153**]. Her initial CXR was
unremarkable despite having diffuse rhonchi on exam along with a
moderate oxygen requirement. She was started on BiPAP. along
with Steroids, Levofloxacin, and Nebs (Alb/Atr) for a
presumptive COPD flair given her lack of CXR findings (despite
no smoking hx). She then had slight improvement in her
respiratory status. However, the patient's respitory status
worsened and a follow-up CXR showed a RLL infiltrate. She also
had epidodes of atrial fibrilliation, initially managed with
Diltiazem, which often resulted in hypotension, which was
subsequently managed with IVF.
After discussions with the family, facilitated by the [**Hospital 153**]
medical team, the patient's BiPAP was changed to face mask O2
when the decision was made to make the patient CMO given her
poor prognosis. After the CMO decision was made, no further IVF,
antibiotics, or steroid therapies were pursued. She was given
supplemental O2 and pain management (Morphine and Ativan) to
focus on the patient's comfort. She was seen and followed by
Palliative Care and finally discharged to with a focus on
hospice care.
Medications on Admission:
[**Hospital Unit Name 153**]-->Floor Transfer Medications: Albuterol Neb Soln 1 NEB IH
Q3-4H:PRN, Ipratropium Bromide Neb 1 NEB IH Q3H, Morphine
Sulfate 2-4 mg IV Q4H:PRN, Olanzapine (Disintegrating Tablet) 5
mg PO Q24 PRN, Lorazepam 0.5 mg PO/IV Q4H:PRN, Acetaminophen
325-650 mg PO Q4-6H:PRN
Discharge Medications:
1. Roxanol 20 mg/mL Solution Sig: 5-20 mg PO every 4-6 hours as
needed for pain.
Disp:*1 bottle* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Dx: Aspiration Pneumonia.
Discharge Condition:
Poor
Discharge Instructions:
1) Your doctors [**First Name (Titles) **] [**Last Name (Titles) 2449**] [**Name5 (PTitle) **] manage you symptoms to make you
as comfortable as possible.
2) Please phone your primary doctor ([**Last Name (LF) **],[**First Name3 (LF) 5106**] [**Telephone/Fax (1) 5105**])
if you an questions or concerns.
Followup Instructions:
1) Please contact your primary doctor as needed ([**Last Name (LF) **],[**First Name3 (LF) 5106**]
[**Telephone/Fax (1) 5105**]).
|
[
"593.9",
"507.0",
"427.31",
"401.9",
"532.90",
"V12.59",
"491.21",
"715.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4235, 4305
|
2355, 3636
|
241, 247
|
4382, 4388
|
1947, 2332
|
4741, 4873
|
1085, 1104
|
3980, 4212
|
4326, 4361
|
3662, 3699
|
4412, 4718
|
1119, 1928
|
181, 203
|
3721, 3957
|
275, 692
|
714, 870
|
886, 1069
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,750
| 173,458
|
52029+59394
|
Discharge summary
|
report+addendum
|
Admission Date: [**2111-2-21**] Discharge Date: [**2111-2-27**]
Service: MEDICINE
Allergies:
Ultram / Sertraline
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
This is a [**Age over 90 **] year old female with a past medical history of
hypertension, dyslipidemia and panic disorder who was last seen
in her USOH at 2:30 pm. While having lunch with her daughter at
a restaurant, she started complaining of a headache at 2:30 pm,
and she then lost her consciousness. She was sitting upright and
did not hit hear head. Per report she had 1.5 glasses of wine at
this meal. Family reports that she occasionally passes out when
she drinks.
EMS arrived at the scene and at the time she was only responsive
to painful stimuli per report. She received etomidate 20 mg and
succinylcholine 125 mg and versed and was intubated with LMA to
protect her airway. She was then transferred to [**Hospital1 18**]. She did
not have any seizure-like activity during her EMS transfer
On arrival to the ED, she was intubated with ET for airway
protection but not hypoxic. Imaging showed an ET tube at 1 cm
above the [**Last Name (LF) **], [**First Name3 (LF) **] it was pulled back 1 cm. She received
propafol for sedation. LP was performed and was benign. CTA head
[**Last Name (un) **] calcifications and mild narrowing of the carotid
bifurcation. A neuro consult was obtained, which felt there was
no clear cut neurologic cause for this event. On transfer, VS
were 68, 179/94, cmv 440 x16, Fi02 50, 100RA.
In the ICU, patient is sedated and feels comfortable.
Review of systems:
Patient unable to answer questions
Past Medical History:
# hypertension
# panic disorder
# lactose intolerance
# hypercholesterolemia,
# migraine headaches
# history of adenomatous polyp
# low back pain
# LVH by EKG
Social History:
(From prior records) Retired teacher. Does volunteer work.
Several sibs in [**State **].
Family History:
(From prior records) Mother: died 86 Parkinsons; Father: died
63, pneumonia. Sister [**Name (NI) **]: HTN. 2 brothers died in 50s of
CAD; sister died at 76, had RA.
Physical Exam:
Vitals: T: 99.4 BP: 177/79 P: 70 R: 16 18 O2: 98% on AC 440x16
on Fi)2 50% with PEEP 5
General: Intubated, Sedated, minimally responsive but does
grimace to sternal rub
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils minimally
responsive bilaterally
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: + foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: 2+ patellar reflex bilaterally, withdraws to pain
bilaterally, negatie babinski bilaterlly
Pertinent Results:
Labs on admission:
[**2111-2-21**] 04:50PM FIBRINOGE-206
[**2111-2-21**] 04:50PM PLT COUNT-271
[**2111-2-21**] 04:50PM PT-12.4 PTT-21.6* INR(PT)-1.0
[**2111-2-21**] 04:50PM WBC-10.7 RBC-4.68 HGB-14.4 HCT-42.2 MCV-90
MCH-30.8 MCHC-34.1 RDW-15.1
[**2111-2-21**] 04:50PM ASA-NEG ETHANOL-144* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2111-2-21**] 04:50PM CK-MB-2 cTropnT-<0.01
[**2111-2-21**] 04:50PM LIPASE-35
[**2111-2-21**] 04:50PM CK(CPK)-35
[**2111-2-21**] 04:50PM UREA N-14 CREAT-0.8
[**2111-2-21**] 04:58PM HGB-14.6 calcHCT-44
[**2111-2-21**] 04:58PM GLUCOSE-130* LACTATE-2.3* NA+-145 K+-3.8
CL--104 TCO2-25
[**2111-2-21**] 05:43PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2111-2-21**] 05:43PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
Urine Culture, [**2111-2-23**]: > 100k GNR not further speciated
IMAGES/STUDIES:
CHEST X-RAY [**2111-2-21**]:
SUPINE AP VIEW OF THE CHEST: An endotracheal tube tip is
slightly low lying, terminating approximately 1 cm from the
[**Month/Day/Year **]. Nasogastric tube tip terminates within the stomach.
Cardiac silhouette is mildly enlarged with a left ventricular
predominance. The aorta is slightly tortuous with vascular
calcifications noted. There is patchy opacity in the
retrocardiac region, likely atelectasis. A small left pleural
effusion is likely. The right lung is grossly clear without
pleural effusion or focal consolidation. No sizable pneumothorax
is present. The pulmonary vascularity is not engorged. Thoracic
scoliosis convex to the right is noted. There are no displaced
rib fractures seen.
IMPRESSION:
1. Low-lying endotracheal tube, terminating approximately 1 cm
from the [**Month/Day/Year **], and recommend withdrawal.
2. Nasogastric tube tip within the stomach.
3. Retrocardiac atelectasis with probable small left pleural
effusion.
HEAD CT [**2111-2-21**]:
NON-CONTRAST HEAD CT: There is no evidence of acute intracranial
hemorrhage, edema, mass effect, hydrocephalus, or large vascular
territorial infarction. Global atrophy is mild for the
patient's age. Mild periventricular white matter hypodensities
likely relate to chronic small vessel ischemic disease.
Calcifications are noted along the cavernous carotid arteries
and vertebral arteries. Small soft tissue nodule or sebaceous
cyst is noted along the left temporoparietal scalp. No large
soft tissue hematoma nor skull fracture is seen. The patient has
had right lens surgery. Large amount of fluid and debris is
noted layering within the nasopharynx, likely due to
endotracheal tube which is in situ. There is mild mucosal
thickening in the ethmoid air cells, without layering fluid seen
in the visualized paranasal sinuses. The mastoid air cells are
well aerated.
IMPRESSIONS:
1. No skull fracture or acute intracranial hemorrhage seen. If
there remains concern for acute infarct, MRI would be
recommended for more sensitive evaluation.
2. Mild ethmoid sinus mucosal disease.
CTA HEAD AND NECK [**2111-2-21**]:
FINDINGS: There is no evidence of acute intracranial hemorrhage,
mass, mass effect or large vascular territorial infarction. The
ventricles and sulci are slightly prominent, likely age related
and involutional in nature. Mild periventricular white matter
hypodensities are detected, likely related with chronic small
vessel ischemic disease. Dense atherosclerotic calcifications
are visualized along the cavernous carotid arteries and
vertebral arteries. Endotracheal tube is in place, persistent
fluid and debris layering within the nasopharynx.
CTA OF THE HEAD. The major intracranial arteries demonstrate no
critical occlusion/stenosis, the anterior, middle and posterior
cerebral arteries are patent, no aneurysms larger than 2 mm in
size are detected.
CTA OF THE NECK. Atherosclerotic disease with tortuous vessels
and vascular calcificationsare demonstrated involving the right
and left carotid bifurcations with dense atherosclerotic
plaques. There is also evidence of soft plaques bilaterally, the
right carotid bifurcation demonstrates no evidence of critical
stenoses. On the left carotid bifurcation, there is evidence of
moderate carotid stenosis. The internal lumen of the right
common carotid artery measures approximately 9.2 mm and distally
approximately 3.8 mm. The left common carotid artery measures
approximately 7.7 mm and distally 3.6 mm. Punctate
atherosclerotic calcifications are noted at the left subclavian
artery and aortic arch, the origin of the vertebral arteries
appears patent. The bone structures demonstrate mild
degenerative changes at C6/C7 consistent with posterior
spondylosis. The soft tissues demonstrate an exophytic
heterogeneous rounded formation on the right thyroid lobe,
correlation with thyroid ultrasound in a non-emergent basis is
recommended if clinically warranted. Small bubble of gas is
identified at the right neck lateral to the carotid, probably in
the vein (2:88).
IMPRESSION:
1. There is no evidence of major intracranial occlusion or
critical stenosis. No aneurysms larger than 2 mm in size are
identified.
2. Atherosclerotic disease with tortuous vessels and
calcifications, causing mild right carotid stenosis and moderate
left carotid stenosis as described above.
3. 13-mm partially visualized exophytic formation involving the
right thyroid lobe, correlation with thyroid ultrasound in a
non-emergent basis is recommended if clinically warranted.
ECG [**2111-2-22**]: Sinus rhythm. Prolonged P-R interval. Left axis
deviation, likely due to left anterior fascicular block. Left
ventricular hypertrophy. Compared to the previous tracing of
[**2103-11-6**] the findings are similar.
CHEST X-RAY [**2111-2-22**]:
FINDINGS: Interval intubation and removal of nasogastric tube.
Stable mild cardiomegaly and tortuosity of the thoracic aorta.
Improved aeration in left retrocardiac region with some residual
atelectasis. Small right pleural effusion. IMPRESSION: Improving
left lower lobe atelectasis.
ADDENDUM: Symmetrical narrowing of the subglottic airway is
demonstrated and could be due to post-intubation edema
considering recent extubation.
ECHOCARDIOGRAM [**2111-2-23**]:
The left atrium is dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). There is no ventricular septal
defect. The ascending aorta is mildly dilated. The aortic valve
leaflets are mildly thickened (?#). There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion. IMPRESSION: Mild symmetric left ventricular
hypertrophy with preserved global and regional biventricular
systolic function. No significant valvular abnormality seen.
Compared with the report of the prior study (images unavailable
for review) of [**2104-9-1**], the findings are similar.
Brief Hospital Course:
[**Age over 90 **] year old female with a past medical history of hypertension,
dyslipidemia and panic disorder who presents with syncope and
intubated for airway protection
# Intubation. Patient was intubated prior to admission for
unresponsiveness and concern over her ability to protect her
airway. She was successfully extubated the day following
admission. Following extubation, she complained of throat pain
as well as copious respiratory secretions. She was evaluated by
the speech and swallow team, who felt that secretions were
building up as a result of the patient's unwillingness to
swallow secondary to the pain. Neck CT did not show abscess or
other abnormality that would explain patient's pain; this was
therefore felt most likely secondary to post-intubation
inflammation/irritation. CXR on [**2-22**] showed evidence of
subglottic airway narrowing that may represent edema related to
intubation and which could account for her pain. She was treated
symptomatically with chloroseptic throat spray. She was
re-evaluated by speech and swallow the following day and they
felt comfortable with advancing her diet as her pain at
significantly decreased.
# Syncope: Unclear precipitant - telemetry showed no evidence of
arrythmia, and cardiac enzymes were negative. Head CT was
negative. Echocardiogram did not show evidence of significant
structural heart disease likely to cause syncope. The patient's
symptoms were not consistent with seizure activity. EEG was
unremarkable. Hct and electrolytes were unremarkable, and there
was no leukocytosis or clear infectious process on imaging.
This episode could potentially be related to alcohol abuse and
further history obtained from the patient's niece was consistent
with this explaination.
# Psychosocial situation: Although she did not present as a
direct result of her social situation, this become of concern
during her hospitalization. She lives alone after the recent
passing of her two sisters. She appeared very sad with
interrupted sleep and inability to concentrate. She was seen by
geriatrics for formal evaluation as well as OT and PT.
Geriatrics agreed that patient appeared depressed with likely
mild cognitive impairment. She was started on Celexa 10mg
daily. They recommended neuropsych tesing as an out-patient
once patient has been taking celexa for at least one month.
They also concluded that she was an elder at risk and needed
additional services. The patient was very resistent to the idea
of living with anyone or having people come into the home to
support her. PT felt she was unsafe to return home and
recommended rehabilitation placement.
Patient and niece identify her niece as a HCP but no paperwork
was signed to this effect. On [**2111-2-26**] there was a family
meeting with the niece and a HCP was signed. At this meeting
she agreed to go to a [**Hospital 3058**] rehab facility as recommended
to regain her strength.
# Thyroid lesion. A 13-mm partially visualized exophytic
formation involving the right thyroid lobe was noted on CTA of
the neck. Correlation with thyroid ultrasound in a non-emergent
basis is recommended if clinically warranted.
# Etoh intoxication: Unclear if ethanol contributed to current
event. Serum tox otherwise negative. She was maintained on a
CIWA scale until three days after extubation. She did not have
symptoms of withdrawal.
# Hypertension: Patient was generally ~ normotensive during this
admission. As her home medical regimen was unconfirmed, she was
written for IV hydralizine PRN in the ICU and then started on
lisinopril and BB as in discharge medications.
# UTI: U/A consistent with UTI and UCx growing out > 100k GNR.
Treated with course of cipro.
# Anxiety: Patient states a history of anxiety and takes Ativan
0.5 mg daily at bedtime.
# Prophylaxis: Subcutaneous heparin
# Code: Full
Medications on Admission:
Unclear regimen
"Sleeping Pill"
ATENOLOL 75 mg daily
ATIVAN 0.5 mg qhs prn anxiety
LISINOPRIL 20 mg daily
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
2. Thiamine HCl 100 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. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
6. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 1 days: last dose on [**2111-2-28**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Primary:
Fall
Alcohol intoxication
.
Secondary:
hypertension
panic disorder
lactose intolerance
hypercholesterolemia
migraine headaches
history of adenomatous polyp
low back pain
LVH by EKG
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Lethargic but arousable
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to [**Hospital1 69**] for
evaluation of your fall. You were intubated and admitted to the
Medical Intensive Care Unit. You were able to breath well on
your own after the tube was removed. You were able to eat well.
You were seen by physical therapy, who thought you were safe to
live at home alone. You were seen by neurology who did not
think you had a stroke or seizure. You were seen by geriatrics,
who thought you would benefit from services at home.
You should limit your alcohol intake as it seems to be related
to your fall.
You should take the following medications:
Celexa 10 mg daily
Lisinopril 10 mg daily
Toprol XL 50 mg daily
Ativan 0.5 mg daily at bedtime
Multivitamin, thiamine, and folate supplements
You may take the following over-the-counter medications as
needed:
Colace 100 mg twice daily for constipation
Followup Instructions:
Please schedule an appointment with your primary care physician
within one week of discharge. You will need her to order an
ultrasound of your thyroid.
The following appointments were made for you:
Dr. [**First Name (STitle) **] [**Name (STitle) **] (Gerontology) on Thursday, [**3-5**], at
1pm in [**Last Name (NamePattern1) **], [**Location (un) 86**]. [**Hospital Unit Name **], [**Hospital Unit Name 5676**].
Please call [**Telephone/Fax (1) 719**] with further questions.
Please talk with Dr. [**Last Name (STitle) **] about making arrangements to have
follow up care with a psychiatrist as well.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 877**] (Neurology) on [**Last Name (LF) 766**], [**3-23**], at 11am at
[**Location (un) **], [**Location (un) 86**]. [**Hospital Ward Name 860**] building, [**Location (un) **].
Please call [**Telephone/Fax (1) 44**] with further questions.
Please have the rehab facility call the geriatrics fellow Dr.
[**Last Name (STitle) 107700**] [**Name (STitle) 107701**] by paging him: [**Telephone/Fax (1) 9986**] at pager [**Numeric Identifier 107702**].
Name: [**Known lastname **],[**Known firstname 665**] Unit No: [**Numeric Identifier 17589**]
Admission Date: [**2111-2-21**] Discharge Date: [**2111-2-27**]
Date of Birth: [**2017-4-11**] Sex: F
Service: MEDICINE
Allergies:
Ultram / Sertraline
Attending:[**First Name3 (LF) 3870**]
Addendum:
[**Hospital 17590**] rehab stay is less than 30 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 474**]- [**Location (un) 164**]
[**Name6 (MD) **] [**Name8 (MD) 3872**] MD [**MD Number(2) 3873**]
Completed by:[**2111-3-2**]
|
[
"511.9",
"300.01",
"272.4",
"518.0",
"478.6",
"041.4",
"724.2",
"276.4",
"780.2",
"346.90",
"311",
"599.0",
"401.9",
"E885.9",
"305.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
18003, 18198
|
10208, 14058
|
235, 248
|
15352, 15352
|
2951, 2956
|
16446, 17980
|
2020, 2186
|
14214, 15024
|
15139, 15331
|
14084, 14191
|
15534, 16423
|
2201, 2932
|
1679, 1715
|
188, 197
|
276, 1660
|
4931, 10185
|
2970, 4922
|
15367, 15510
|
1737, 1898
|
1914, 2004
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,152
| 108,589
|
33091
|
Discharge summary
|
report
|
Admission Date: [**2110-5-7**] Discharge Date: [**2110-6-17**]
Date of Birth: [**2049-10-26**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Nausea
Abdominal Pain
Major Surgical or Invasive Procedure:
Ultrasound-guided imaging for vascular access,
inferior vena cava catheter placement with inferior vena cava
imaging and G2 IVC filter.
.
1. Laparoscopic-assisted retroperitoneal pancreatic
necrosectomy.
2. Retroperitoneal abscess drainage and irrigation.
.
1. Exploratory laparotomy with protracted extensive lysis
of adhesions.
2. Small bowel resection with primary enteroenterostomy
anastomosis.
3. Gastrojejunostomy.
4. Open cholecystectomy.
5. Feeding jejunostomy tube placement.
History of Present Illness:
This is a 60 year old male s/p recent necrosectomy on [**2110-3-18**] for
gallstone pancreatitis now with abdominal pain, N/V. He was
discharged on [**2110-5-6**] toleratng a regular diet and doing well.
He currently has one drain in place. He is tentatively schedule
to go to the OR on [**2110-5-14**] for pancreatic debridement.
Past Medical History:
PMH: Necrotizing Pancreatitis
CAD, DMII, HTN, Hyperlipidemia, CRI ([**Date range (1) 76919**] dialysis),
suicide attempt (antifreeze)
PSH:
- s/p Pancreatic debridement [**2110-3-18**]
-colectomy for diverticulitis w/ ostomy s/p revision and
takedown
approx 8y ago.
-ventral hernia repair with mesh
-L knee repair
-L shoulder repair
-back surgery
Social History:
lives with wife at home. Retired town administrator, non-smoker,
rare EtOH
Family History:
non contributory
Physical Exam:
VS: 98.8, 115, 120/78, 16, 99 3L
NAD
CV: Reg tachy
Chest: CTA
Abd: + Abd tenderness, no rebound, no guarding. Drain with
thick, [**Doctor Last Name 352**] drainage
Ext: WNL, +2 pulses bilat.
Pertinent Results:
[**2110-5-7**] 01:55PM BLOOD WBC-5.5 RBC-3.47* Hgb-9.4* Hct-29.5*
MCV-85 MCH-27.0 MCHC-31.8 RDW-14.3 Plt Ct-337
[**2110-5-13**] 04:55AM BLOOD WBC-4.7 RBC-4.00*# Hgb-10.4*# Hct-33.2*#
MCV-83 MCH-26.0* MCHC-31.4 RDW-14.3 Plt Ct-383
[**2110-5-14**] 04:49AM BLOOD Glucose-157* UreaN-23* Creat-1.0 Na-136
K-4.7 Cl-103 HCO3-25 AnGap-13
[**2110-5-13**] 04:55AM BLOOD ALT-12 AST-18 LD(LDH)-158 AlkPhos-84
Amylase-51 TotBili-0.4
[**2110-5-13**] 04:55AM BLOOD Lipase-42
[**2110-5-14**] 04:49AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.0
.
CHEST (PRE-OP PA & LAT) [**2110-5-6**] 9:21 AM
IMPRESSION: Bibasilar atelectasis without other abnormalities.
.
CT CHEST W/CONTRAST [**2110-5-13**] 5:32 PM
IMPRESSION:
1. Small left main pulmonary embolus of unclear chronicity.
2. No significant change in appearance of peri-pancreatic air
and fluid collections.
3. No change in multiple hypoattenuating renal lesions.
4. Interval decrease in hypoattenuating liver lesions likely
indicative of subcapsular fluid collection.
5. No significant change in right middle lobe pulmonary nodule.
6. Cholelithiasis without evidence of cholecystitis.
.
ECHO [**2110-5-14**]
Conclusions
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
.
[**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) [**2110-5-15**] 9:59 AM
IMPRESSION: Left cephalic vein thrombosis in the mid distal
upper arm. No evidence of deep vein thrombosis.
.
CTA ABD W&W/O C & RECONS [**2110-5-16**] 12:40 PM
IMPRESSION:
1. Compared to prior exam from [**2110-5-13**], there is decreased
size of collection containing fluid and gas within the
pancreatic bed. Extensive peripancreatic stranding and fluid
extending down the root of the mesentary is grossly unchanged.
Small fluid collections are seen surrounding the residual
pancreatic tissue within the head and neck consistent with
pseudocysts, not significantly changed from prior exam.
2 Arterial vasculature including the celiac, hepatic, splenic,
left gastric, gastroduodenal arteries are intact. The portal
vein is patent. The splenic vein and SMV are not visualized and
likely obliterated, unchanged.
3. Cholelithiasis without evidence of cholecystitis.
4. Bilateral lower lobe atelectasis and small left pleural
effusion.
.
Cardiology Report ECG Study Date of [**2110-5-16**] 11:36:36 AM
Sinus tachycardia. Low voltage in the limb leads. Diffuse
non-specific
ST-T wave changes. Compared to the previous tracing ST-T wave
changes are
new.
Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
120 178 78 334/439 3 21 73
.
CT ABDOMEN W/CONTRAST [**2110-5-19**] 3:09 PM
IMPRESSION:
1. Increased size of left pleural effusion with associated
relaxation atelectasis. There is increased size of perisplenic
fluid collection.
2. No significant change in size and appearance to pancreatic
collection containing fluid and gas with an intraluminal drain.
No fistula is demonstrated, however, for better evaluation of a
fistulous connection, injection of contrast into the drains
would be of use. Of note, this should only be performed after
the current contrast within the bowel has passed.
3. Cholelithiasis.
.
CHEST (PA & LAT) [**2110-5-22**] 4:16 PM
FINDINGS: In comparison with earlier study of this date, there
is again evidence of increased opacification at the left base
consistent with pleural effusion and atelectasis. Much improved
lung volumes since the previous study. Right subclavian catheter
tip lies either at the cavoatrial junction or into the upper
aspect of the right atrium itself.
.
CT ABDOMEN W/CONTRAST [**2110-5-25**] 4:21 PM
IMPRESSION:
1. Slight increase in size of a pancreatic gas and
fluid-containing collection with two drains well positioned
within the collection. No evidence of oral contrast
extravasation to suggest a fistula.
2. Stranding extends from the pancreatic collection to the
descending colon, however, there is no definite evidence of a
fistula.
3. Complex pseudocyst about the pancreatic head is approximately
unchanged in size but contains new focus of gas, possibly
tracking from the adjacent collection.
4. Unchanged large left pleural effusion and left lower lobe
atelectasis.
5. Cholelithiasis.
6. Unchanged subxiphoid calcified mass.
.
ERCP BILIARY ONLY BY GI UNIT [**2110-5-30**] 1:25 PM
IMPRESSION: No contrast filling of the pancreatic or biliary
ducts.
.
CHEST (PORTABLE AP) [**2110-6-4**] 7:34 AM
IMPRESSION:
1. Stable severe left pleural effusion with mild left to right
shift of the cardiomediastinal structure and stable left lower
lobe atelectasis.
2. Right internal jugular line tip is in the right atrium and
needs to be positioned.
.
ABDOMEN (SUPINE & ERECT) [**2110-6-9**] 10:19 AM
IMPRESSION: No evidence of ileus or small bowel obstruction is
visualized. No pneumoperitoneum is noted.
.
CT ABDOMEN W/CONTRAST [**2110-6-13**] 1:27 PM
IMPRESSION:
1. Slight interval decrease in size of gas- and fluid-containing
collection in the pancreatic bed. Consideration may be given to
slightly retracting both drains which are coiled several times
within the collection. No new collections are seen.
2. Interval progression of ascites, which is now moderate in
amount.
3. Increased anasarca.
4. Chronic thrombus seen in left sided pulmonary arteries,
unchanged since [**2110-5-13**].
.
ABDOMEN (SUPINE & ERECT) [**2110-6-14**] 11:29 AM
NG tube tip is in the stomach. The side port is just distal to
the GE junction. Multiple surgical clips project in the left
hemi abdomen. There is no evidence of obstruction. Few small
bowel loops are prominent on the right side, measuring up to 25
mm. Patient has known ascites.
.
Brief Hospital Course:
This is a 60 yo male admitted with nausea and vomiting. He is
well known to the service. He is s/p pancreatic necrosectomy
[**2110-3-18**]. His admitting diagnosis was:
1. Status post fulminant emphysematous pancreatitis.
2. Pancreatic necrosis.
3. Retroperitoneal abscess.
He received a PICC and TPN and he received antinausea meds as
needed and he was pre-op'd for the OR.
A pre-op CT showed Small left main pulmonary embolus and
pancreatic pseudocyst w/ multiple air fluid level and PE (12mm
filling defect in prox LL pulm a).
He was started on Heparin and the vascular service was consulted
for IVC Filter. He had a filter placed on [**2110-5-15**].
the next day he went to the OR on [**2110-5-16**] for:
1. Laparoscopic-assisted retroperitoneal pancreatic
necrosectomy.
2. Retroperitoneal abscess drainage and irrigation.
He had placed under direct laparoscopic vision two 19-French
[**Doctor Last Name 406**] drains into the abscess cavity which were exteriorized out
through the sinus tract on the left flank
and then secured at the skin level and positioned into an ostomy
appliance bag to serve for postoperative passive drainage.
In the PACU he was septic, with Hypotension and tachycardia. He
had brief support with Levophed, but then fluid support only. He
was admitted to the TSICU for one night and recovered well.
Pain: He pain was well controlled with a PCA.
Abd/GI: He remained NPO with TPN and drain care. The drain fluid
was showed:
GRAM POSITIVE COCCI, GRAM NEGATIVE ROD(S), and GRAM POSITIVE
ROD(S). He was treated with Vancomycin, Cipro, and Flagyl.
The contents look feculent and so he continued to be NPO.
A CT showed no significant change in size and appearance to
pancreatic collection containing fluid and gas with an
intraluminal drain.
No fistula is demonstrated, however, for better evaluation of a
fistulous connection, injection of contrast into the drains
would be of use. Cholelithiasis.
He went for EGD on [**5-30**] for a pancreatic duct stent placement.
Contrast injection in duodenal bulb suggestive of fistulous
tract not consistent with PD. Contrast drained rapidly.
Unsuccessful cannulation of pancreatic duct (cannulation).
Stricture of the area of the papilla
.
Anticoag: He continued with Heparin and then switched to Lovenox
for his PE.
Post-op Pleural Effusion: On POD 6A CXR noted increased
opacification at the left base consistent with pleural effusion
and atelectasis. He received Lasix with over a Liter response.
[**2110-6-3**] he went back to the OR for
1. Exploratory laparotomy with protracted extensive lysis
of adhesions.
2. Small bowel resection with primary enteroenterostomy
anastomosis.
3. Gastrojejunostomy.
4. Open cholecystectomy.
5. Feeding jejunostomy tube placement.
Pain: He had a PCA for pain control.
GI/ABD: He was NPO, NGT with an IVF and TPN. We were able to
wean the TPN and ramp up tubefeedings. He was tolerating
tubefeeding. However, after NGT removal he had continued nausea
and bilious emesis. A NGT was placed and ~1-liter of bile was
draining. Clamp trials were done after several days and we were
able to remove the NGT.
A CT abdomen was performed on [**2110-6-13**] showed Slight interval
decrease in size of gas- and fluid-containing collection in the
pancreatic bed. Consideration may be given to slightly
retracting both drains which are coiled several times within the
collection. No new collections are seen. Interval progression of
ascites, which is now moderate in amount. Increased anasarca.
Chronic thrombus seen in left sided pulmonary arteries,
unchanged since [**2110-5-13**].
He had 2 drain in the left flank. One drain was removed prior to
discharge.
Overall, he continued to do well and tolerate tubefeedings and
sips for comfort. He continued to have daily emesis (large
volume and bilious). This emesis will likely take several weeks
to settle out. A NGT is not necessary and he will likely
continue to vomit occasionally. His Gastrojejunostomy is open
and patent and there is no mechanical reason that he can not
empty his stomach. Due to the complexity of the pancreatitis and
abscess, he needs more time for the emesis to resolve.
Medications on Admission:
pancrease 1-2caps''', lipitor 80', celexa 40mg, trazodone 100',
colace 100'', protonix 40', Lorcet 10/650mg PRN, MOM, [**Name (NI) 8472**] 60
units, [**Name (NI) **] SS, metformin ?dose
Discharge Medications:
1. Octreotide Acetate 100 mcg/mL Solution Sig: One (1)
Injection Q8H (every 8 hours).
2. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Acetaminophen 160 mg/5 mL Solution Sig: 1000 (1000) mg PO TID
(3 times a day).
4. Oxycodone 5 mg/5 mL Solution Sig: 5-10 mg PO Q4H (every 4
hours) as needed: J-tube.
5. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours).
6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed.
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for back pain: on for 12 hours, off for 12 hours .
8. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) Units
Subcutaneous once a day.
11. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day) as needed for diarrhea.
12. Metoclopramide 10 mg Tablet Sig: Two (2) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2857**] - [**Location (un) 9188**]
Discharge Diagnosis:
Pancreatic Fluid Collection
Pulmonary Embolism
Nausea
Vomiting
.
1. Fulminant emphysematous pancreatitis.
2. Postoperative sepsis.
3. Retroperitoneal abscess.
4. Status post laparoscopic retroperitoneal pancreatic
necronectomy.
5. Failure to thrive.
6. Gallstones.
7. Duodenal stenosis.
8. Duodenal fistula.
9. Small intestinal obstruction.
10.Status post numerous intra-abdominal operations from
this procedure and prior diverticulitis and complications.
Discharge Condition:
Good
Continues to vomit about daily. Vomiting will likely continue
for some time.
Tolerates tubefeedings and sips for comfort.
Discharge Instructions:
You were admitted for nausea, vomiting, abdominal pain secondary
to pancreatitis.
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 have persistent vomiting and cannot keep in fluids or
your medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* No heavy lifting (>[**11-26**] lbs) for 6 weeks.
* Continue with drain care and flushing of the left sided drain.
* Monitor your incision for sign of infection (redness or
increased drainage).
* Keep incision clean and dry.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2110-7-11**] 9:00
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2110-7-11**]
10:30
Completed by:[**2110-6-17**]
|
[
"998.59",
"537.3",
"576.2",
"574.10",
"577.0",
"038.9",
"567.38",
"537.4",
"995.91",
"415.19",
"560.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"52.22",
"99.15",
"45.93",
"38.7",
"51.22",
"44.39",
"45.62",
"51.10",
"54.59",
"46.39",
"54.0",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
13783, 13857
|
8061, 12225
|
335, 834
|
14365, 14494
|
1918, 8038
|
16221, 16495
|
1674, 1692
|
12462, 13760
|
13878, 14344
|
12252, 12439
|
14518, 16198
|
1707, 1899
|
274, 297
|
862, 1195
|
1217, 1565
|
1581, 1658
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,738
| 145,558
|
26953
|
Discharge summary
|
report
|
Admission Date: [**2147-5-22**] Discharge Date: [**2147-5-30**]
Date of Birth: [**2090-12-20**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Scoliosis fusion
History of Present Illness:
[**Known firstname **] is a 56-year old woman who has had a longstanding history
of scoliosis, which was not treated with bracing or srugery.
She currently has x-rays today which demonstrate a T3-T12 curve
measuring 76 degrees and 67 degree compensatory curve. from T12
to L5. She has complaints of chronic back and leg pain and has
progressive loss of height. She has pain with stading, bending,
abd walking.
Past Medical History:
Bladder infx
HTN
measles
cnacer
chicken pox
gallbladder surgery
Social History:
denies tobacco
Family History:
N/C
Physical Exam:
WDWN female
Signifiscnat right thoracic prominence. She has a hypokyphosis
of the thoracic spione and relatively [**Name2 (NI) 66266**] lumbar spin.
She has a significant deviation of her trunk to the right. She
has no evidence of hairy patches or dimpliing or other signs of
spinal dysraphism. Her strength is good in terms of hip flexion
a, abduction-adduction, knee extension and flexion, ankle
dorsiflexion and plantar flexion. [**Last Name (un) 938**] is [**4-19**] on the right. Her
deltoid biceps, triceps, wrist extension and flexion, finger
flexion and intrinsics are [**5-19**]. She has a normal vascular
examand negative straight leg rase. She has 1+ quadriceps and
Achilles reflexes. Sensation is intact to light touch. She has
a negative babinskin and no clonus. She walks with a normal
heel to toe gait.
Pertinent Results:
[**2147-5-26**] 06:50AM BLOOD WBC-13.5* RBC-3.05* Hgb-9.7* Hct-27.2*
MCV-89 MCH-31.7 MCHC-35.5* RDW-14.6 Plt Ct-286
[**2147-5-25**] 02:49AM BLOOD WBC-17.8* RBC-3.18* Hgb-10.0* Hct-28.2*
MCV-89 MCH-31.5 MCHC-35.5* RDW-15.1 Plt Ct-210
[**2147-5-24**] 03:00AM BLOOD WBC-12.1* RBC-3.89* Hgb-12.0 Hct-33.5*
MCV-86 MCH-30.9 MCHC-35.8* RDW-15.4 Plt Ct-209
[**2147-5-23**] 06:39PM BLOOD WBC-8.8 RBC-3.71* Hgb-11.5* Hct-32.1*
MCV-87 MCH-30.9 MCHC-35.7* RDW-15.2 Plt Ct-184
[**2147-5-25**] 02:49AM BLOOD Glucose-129* UreaN-7 Creat-0.3* Na-137
K-4.5 Cl-106 HCO3-27 AnGap-9
[**2147-5-24**] 03:00AM BLOOD Glucose-207* UreaN-9 Creat-0.5 Na-141
K-3.7 Cl-108 HCO3-25 AnGap-12
[**2147-5-25**] 03:02AM BLOOD Type-ART pO2-113* pCO2-42 pH-7.42
calHCO3-28 Base XS-3
[**2147-5-24**] 11:48AM BLOOD Type-ART pO2-140* pCO2-45 pH-7.41
calHCO3-30 Base XS-3
[**2147-5-24**] 03:09AM BLOOD Type-ART pO2-154* pCO2-40 pH-7.44
calHCO3-28 Base XS-3
[**2147-5-23**] 05:35PM BLOOD Glucose-129* Lactate-4.6* Na-138 K-3.6
Cl-107
[**2147-5-23**] 04:02PM BLOOD Glucose-135* Lactate-4.4* Na-138 K-3.2*
Cl-102
[**2147-5-23**] 03:15PM BLOOD Glucose-138* Lactate-4.7* Na-136 K-3.5
Cl-101
Brief Hospital Course:
Ms. [**Known lastname 66267**] was admitted to the hospital under the care of
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**]. She was informed and consented for a scoliosis
fusion and agreed to this procedure. it was performed over two
days. Please see Operative Report for procedure in detail.
After the second of her two surgeries she was transfered to the
SICU for close monitoring. They were able to utilize her
epidural catheter and her pain was well controlled. Her hemovac
was monitored for output. She was given antibiotics and she was
extubated the following day. She remained in the SICU for
weaning off the ventilator and subsequently transfereed to the
floor for further managment.
While on the floor she was able to work with physical therapy.
She made improvements in strength and balance. Her drains and
catheter were removed and she was fitted for a brace.
She was discharged to home after clearance by physical therapy.
She was discharged in good condition.
Medications on Admission:
metoprolol
HCTZ
Clobetasol
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 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*2*
3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every
3 to 4 Hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Community Nurse [**First Name (Titles) **] [**Last Name (Titles) **] Care,Inc
Discharge Diagnosis:
Scoliosis fusion
Discharge Condition:
Good
Discharge Instructions:
Please continue to take your discharge medication with an over
the counter laxative. Call the clinic if you notice any redness
or discharge from the incision site. Please call the clinic for
any additional concerns.
Physical Therapy:
Activity: Activity as tolerated
[**Month (only) 116**] be out of bed without TLSO with assistance
Treatments Frequency:
Please continue to change the dressing daily with dry sterile
gauze.
Followup Instructions:
Please keep your follow up appointments that have been scheduled
for you.
Completed by:[**2147-5-30**]
|
[
"788.41",
"V45.71",
"401.9",
"737.10",
"V10.3",
"737.34"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.06",
"81.63",
"99.00",
"99.07",
"77.79",
"84.52",
"81.64",
"99.04",
"80.51",
"81.08",
"03.90",
"81.05",
"84.51"
] |
icd9pcs
|
[
[
[]
]
] |
4481, 4589
|
2961, 3971
|
330, 349
|
4650, 4657
|
1793, 2938
|
5132, 5237
|
925, 930
|
4048, 4458
|
4610, 4629
|
3997, 4025
|
4681, 4899
|
945, 1774
|
4917, 5017
|
5039, 5109
|
281, 292
|
377, 790
|
812, 877
|
893, 909
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,021
| 110,804
|
51290
|
Discharge summary
|
report
|
Admission Date: [**2163-11-24**] Discharge Date: [**2163-11-26**]
Date of Birth: [**2104-11-26**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Percocet / Doxycycline / Penicillins / Latex / Banana
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Dark red blood per rectum
Major Surgical or Invasive Procedure:
[**First Name3 (LF) **]
Cauterization of GI bleed
Blood transfusions.
History of Present Illness:
This is a 58 year-old female with a history of chronic
pancreatitis who presents with dark red blood per rectum 2 days
s/p [**First Name3 (LF) **]. She had her first episode of pancreatitis in [**December 2162**]. At that time, endoscopic ultrasound revealed biliary
sludge. No stones were noted. She is not a drinker. She
underwent cholecystectomy in [**February 2163**]. In [**Month (only) 359**], she
developed similar pain to her first episode of pancreatitis but
even more severe. She was hospitalized at an OSH for this. Two
weeks later, she suffered a third episode, but chose to get
herself through it at home. Since then she continued to have
mild abdominal discomfort. She was evaluated by Dr. [**First Name4 (NamePattern1) 10168**]
[**Last Name (NamePattern1) 174**] (pancreas) approximately 4 weeks ago and he recommended
that she undergo [**Last Name (NamePattern1) **] for sphincterotomy. Pt had [**Last Name (NamePattern1) **] on [**11-22**]
which was only notable for mimimal diffuse dilation of the
common bile duct suggestive of ampullary stenosis.
Sphincterotomy was performed and she was admitted for overnight
observation. Pt reports that she developed severe nausea after
receiving dilaudid for pain and vomited 6-7 times that evening.
By the following day, she was tolerating clears and was
discharged to home. At home, she ate chicken for dinner and then
developed severe RUQ pain with radiation to her R chest. She
subsequently had a large, loose, dark-colored stool and reports
that the abdominal pain resolved. On the morning of admission
she had 2 more loose, dark bowel movements. After the third, she
reports that she realized the stool was grossly bloody and
called Dr. [**Last Name (STitle) **]. Dr. [**Last Name (STitle) **] recommended that she come to the
ED for evaluation.
In the ED, her BP was initially 82/60 at triage and she had a
witnessed syncopal episode. Her BP subsequently improved to
115/70 by the time she got back to her room without any
intervention. Otherwise vitals remained within normal limits.
Bedside ultrasound revealed no free fluid in the abdomen. CXR
was clear. Hct was noted to be 31.5 from 38.5 prior to the
procedure. Received 3L IVF. Two large bore IV's were placed. She
was admitted to the [**Hospital Unit Name 153**] for close monitoring.
On arrival to the [**Hospital Unit Name 153**], the patient complains of headache and
lightheadedness. Denies chest pain or SOB. No further episodes
of bleeding per rectum.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, constipation, chest pain, shortness of breath,
orthopnea, PND, lower extremity oedema, cough, urinary
frequency, urgency, dysuria, gait unsteadiness, focal weakness,
vision changes, headache, rash or skin changes.
Past Medical History:
Chronic pancreatitis
Pancreatic serous cyst
h/o MGUS
Fibromyalgia
Social History:
Formerly worked in a dermatologist's office, now takes care of
her grandchildren a few days per week. Denies tobacco or EtOH
use.
Family History:
No history of pancreatitis.
Physical Exam:
Vitals: T: 97.5 BP: 109/64 HR: 62 RR: 12 O2Sat: 98% RA
GEN: Pale middle-aged female, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, no cervical lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2163-11-24**] 04:45PM GLUCOSE-124* UREA N-20 CREAT-0.7 SODIUM-138
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
[**2163-11-24**] 04:45PM ALT(SGPT)-87* AST(SGOT)-66* ALK PHOS-98 TOT
BILI-0.3
[**2163-11-24**] 04:45PM LIPASE-85*
.
[**2163-11-24**] 04:45PM WBC-8.4 RBC-3.55* HGB-11.0* HCT-31.5* MCV-89
MCH-31.0 MCHC-34.9 RDW-12.6
[**2163-11-24**] 04:45PM NEUTS-55.8 LYMPHS-38.9 MONOS-3.9 EOS-0.9
BASOS-0.5
[**2163-11-24**] 04:45PM PLT COUNT-254
.
[**2163-11-24**] 11:00PM HCT-25.8*
.
[**2163-11-24**] 04:45PM PT-14.7* PTT-27.5 INR(PT)-1.3*
.
EKG: Sinus rhythm. Non-diagnostic inferior Q waves.
Non-diagnostic Q waves are also in leads V5-V6. Non-specific T
wave flattening in lead aVL with
T wave inversion in lead V1 and biphasic T wave in lead V2.
Compared to the previous tracing of [**2163-11-22**] the T wave changes
in leads V1 and V2 are new.
.
CXR:
Mild borderline cardiomegaly as above. No acute pulmonary
process.
.
[**Date Range **] 12/5
Blood clot at the apex of the prior sphincterotomy site.
Successful hemostasis with Bicap probe at apex of
sphincterotomy.
The common bile duct, common hepatic duct, right and left
hepatic ducts, biliary radicles and cystic duct were filled with
contrast and well visualized.
Successful placement of a 10Fr x 5cm double pigtail stent into
the right hepatic system to protect against biliary obstruction
s/p bicap.
Brief Hospital Course:
.
# Gastrointestinal bleed with acute blood loss anemia: She was
admitted with blood per rectum 2 days s/p sphincterotomy for
chronic pancreatitis, and underwent repeat [**Date Range **] with
cauterization of oozing sphincterotomy site and stent placement.
She required 2 units of blood. She continued to have maroon
stools throughout the day after her [**Date Range **], but subsequently had
no further bleeding. She was transferred out of the [**Hospital Unit Name 153**] on the
day prior to discharge. Her hematocrit remained overall stable
after transfusion, and was 31.5 at the time of discharge. She
will require repeat [**Hospital Unit Name **] in 4 weeks for stent removal. She will
also follow up with Dr. [**Last Name (STitle) 174**] as needed.
.
# Hypotension/Syncope: Transient event likely [**1-22**] acute blood
loss. With transfusion and fluids, this resolvedd. She did have
an EKG that showed a TW inversion in V1, and biphasic T wave in
V2, but had no cardiac symptoms.
.
# Transaminitis: AST and ALT were mildly elevated on admission
after her recent [**Month/Day (2) **], but trended down. These should be
rechecked by her PCP [**Last Name (NamePattern4) **] [**12-22**] weeks to verify resolution.
.
Medications on Admission:
Flonase
Multivitamin
Vitamin D
Glucosamine-chondroitin
Calcitrate
[**Doctor First Name **] prn
Restasis eye gtts
Discharge Medications:
1. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
2. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO ONCE (Once)
as needed for pain: Up to 4 g/day.
3. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
4. Glucosamine-Chondroitin Oral
5. Restasis 0.05 % Dropperette Sig: One (1) drop Ophthalmic
twice a day.
6. [**Doctor First Name **] 180 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Calcitrate-Vitamin D 315-200 mg-unit Tablet Sig: Two (2)
Tablet PO three times a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute blood loss anemia
Gastrointestinal bleed
Chronic pancreatitis
Fibromyalgia
Discharge Condition:
Stable, tolerating liquids, no further bleeding.
Discharge Instructions:
You were admitted after an [**Doctor First Name **] with bleeding. The bleeding
stopped after Dr. [**Last Name (STitle) **] was able to find the source and stop
it. You received 2 units of blood, and your blood count is
stable this morning.
.
Continue to take in liquids today, and then try a bland diet in
the next few days, low fat preferably.
.
Please return to the ED for continued bright red blood per
rectum or syncope. Please return for fevers, chest pain,
shortness of breath, night sweats, dizziness, vertigo, burning
on urination, unresolving cough, or any other concerning
symptom.
.
Please follow-up with your providors below. You have 3 (three)
appointments, each of which is critical to your post-hospital
course. You will need to return to have your stent removed in 4
weeks; Dr.[**Name (NI) 12202**] office will contact you to set this up.
.
We have not made any changes to your medications.
.
It has been a pleasure caring for you and we wish you the best
in the future.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2163-12-19**] 9:45
Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2164-1-6**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2164-1-6**] 11:30
.
Call Dr. [**Last Name (STitle) 53107**], PCP, [**Name10 (NameIs) **] an appointment in [**12-22**] weeks.
|
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icd9cm
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[
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icd9pcs
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[
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7533, 7539
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,243
| 142,670
|
1450
|
Discharge summary
|
report
|
Admission Date: [**2125-10-15**] Discharge Date: [**2125-10-17**]
Date of Birth: [**2045-8-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Elective LN biopsy
Major Surgical or Invasive Procedure:
EBUS tracheal lymph node biopsy
History of Present Illness:
80 yo M with h/o CAD s/p 3 vessel CABG, afib,
obstructive/restrictive lung dz presents to the medicine service
from the SICU after transbronchial biopsy for hilar mass
complicated by hypercarbic respiratory failure, SOB, and acute
hypertension. Patient originally presented for EBUS with
transbronchial biopsy of known hilar mass. The procedure was
performed without incident. However, the patient's
post-procedure course was complicated by hypercarbia and SOB,
which necessitated observation in the SICU. His pCO2 was 87 at
that time. He was oxygenated with BiPAP eventually weaning him
to to 1L NC. His pCO2 decreased to the mid 50s. He maintained
his oxygenation throughout. However, during this course, the
patient became hypertensive. Given his extensive history of
heart disease, the patient was ruled out for MI. The patient
also has known afib but had not been anticoagulated given the
recent procedure.
.
On transfer to the floor, the patient was in good spirits. He
did not complain of any residual pain, though he did have blood
tinged sputum. His BP was stable at 125/42.
Past Medical History:
CAD, s/p 3 vessel CABG in [**2122**]
Afib on coumadin
HTN
Type 2 DM
Hyperlipidemia
Obstructive/Restrictive lung dz FEV 1.0
LLL resection prior to [**2113**]
Prostate ca s/p radiation
s/p cholecystectomy
Social History:
Lives at home with family. Has remote hx of cigar smoking. No
current alcohol or tobacco.
Family History:
NC
Physical Exam:
VS: T 98, BP 125/42, HR 78, RR 24, 98% 1L
Gen: Alert, talkative, NAD
HEENT: EOMI, PERRL, anicteric sclera, MMM, dentition poor
Neck: supple, no LAD, no JVD, + bruits
Lung: CTAB, no wheezes, rales, or crackles
Heart: Irreg irreg, [**1-29**] sys murmur heard best at base
Abd: soft NT/ND, normoactive BS
Back: No CVA tenderness
GU: deferred
Ext: warm, well perfused, no pitting edema
Skin: warm, no rashes noted
Neuro: CN II-XII grossly intact
.
Pertinent Results:
13.5 D \ 14.1 / 209
--------
40.4
N:80.8 L:14.1 M:4.1 E:0.8 Bas:0.2
PT: 14.8 PTT: 30.4 INR: 1.3
.
140 99 19 / 199 AGap=13
-------------
4.0 32 0.7 \
MB: 4 Trop-*T*: <0.01
.
Bronchial biopsy: negative for malignant cells.
.
CXR:
FINDINGS: Compared with 11/20, allowing for interval development
of atelectasis at the left base medially, no obvious significant
interval change in the small left pleural effusion is
appreciated. The right lung is clear. The right CPA is not
included on this film.
Brief Hospital Course:
80 yo M with h/o CAD/CABG, afib, HTN, lung dz with perihilar
mass, s/p transbronchial biopsy complicated by hypercarbia and
HTN, who presented from the SICU for post-procedure management
and observation.
.
P:
Nodule s/p biopsy. A bronchoscopy was performed with sampling of
the mediastinal lymph nodes, and bronchial washings were
obtained as well. Patient's biopsy results were still pending at
time of discharge.
.
Anemia: Pt had acute hematocrit drop after the procedure, likely
secondary to acute blood loss anemia. He had an active type and
screen. His hematocrit stabilized two days after the procedure.
He was advised to restart his coumadin on discharge.
.
SOB/hypercarbia/s/p biopsy: Patient likely had hypercarbic
respiratory failure secondary to oversedation, initially but had
persistent hypoxia after discharge to the floor which was felt
to be secondary to baseline restrictive and obstructive lung
disease, with also component of anemia and recent bronchoscopy
with resultant atelectasis. This improved through the course of
the day, and on discharge, patient was oxygenating well on room
air on discharge, although had desaturation to 88-90% with
ambulation. Most recent ABG demonstrated CO2 in the mid 50's. He
had negative cardiac enzymes, and his EKG was unremarkable, as
was his repeat CXR. He was restarted on his home lasix dose on
discharge. He was ruled out for an MI in the SICU with negative
cardiac enzymes and no EKG changes. He was discharged to home
with home oxygen due to patient concern about hypoxia, despite
good oxygen saturations while in the hospital.
.
His atrial fibrillation was rate controlled and stable. His
coumadin dose was held during admission. For his CAD and
hypertension, his lisinopril dose was uptitrated.
.
He was discharged to home with followup.
Medications on Admission:
zocor 40mg qd, lasix 20mg [**Hospital1 **], asa 81mg qd, lisinopril 5mg qd,
salsalate 750mg [**Hospital1 **], glipizide 15mg [**Hospital1 **], coumadin 5mg daily (d/c
15 days ago), citalopram 10mg qd
Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for HTN: This dose is double your home dose. .
2. Salsalate 750 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Glipizide 10 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day) as needed for [**Hospital1 **].
4. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): This
is a new medication for your blood pressure. .
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Lung mass s/p biopsy
Post operative hypercarbic respiratory distress
Acute blood loss anemia
Hypertension
Discharge Condition:
Good
Discharge Instructions:
Please resume your home medications after discharge, including
your home coumadin. You have been started on a new medication
for your blood pressure called Atenolol, which you should take
daily. Your lisinopril dose was increased as well. These
medications can be titrated by your primary care doctor.
You may resume your normal activities. You may resume your
regular diet.
Please call or return to the ER if you experience:
- Fever (> 101.5)
- Increasing shortness of breath or trouble breathing
- Increasing pain
- Coughing up increased amounts of blood
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 3020**]. Please follow up with Dr. [**Last Name (STitle) **] for
your lung procedure.
[**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Doctor First Name **] [**Telephone/Fax (1) 693**]. Please follow up with Dr.
[**Last Name (STitle) **] in [**11-27**] weeks. You can restart your coumadin after
discharge from the hospital. You should have a repeat blood
count checked at that time to make sure that your blood count is
stable.
|
[
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icd9cm
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[
"40.11",
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icd9pcs
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5603, 5609
|
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|
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|
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1683, 1774
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,787
| 104,141
|
2526
|
Discharge summary
|
report
|
Admission Date: [**2123-12-16**] Discharge Date: [**2123-12-18**]
Date of Birth: [**2044-1-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
fever, hematuria
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
79 y/o M w/CAD, CHF, CVA, C diff, B urolithiasis causing ARF
requiring R ureteral stent and L perc nephrostomy tube, who
presented to the ED tonight with one day of fever,
nausea/vomiting. Per NH notes, he became increasingly lethargic
and had an O2 sat of 85% on 2L so was sent to the ED for further
eval. His only complaint is that he was having hematuria. He was
seen in the ED on [**12-13**] for hematuria, had a negative renal u/s
and was seen by urology who recommended d/c home with f/u.
.
In the ED, his vitals were T 102.8, BP: 106/56, P: 122, RR: 28,
98% on 4L (90%RA). His bp dropped as low as 80s/50s but was
mostly 90s-110s/60s-70s. He received 6L NS. He was noted to have
a UTI on his UA and was given levofloxacin, and also was given
flagyl as he has a hx of c.diff. Central line was attempted but
the wire was unable to be threaded.
Past Medical History:
CVA - [**2117**] with residual right-sided weakness
OSA - on 2L NC during day and night; refused home CPAP
CAD - s/p MI 3 yrs ago
CHF - diastolic dysfunction
Anemia - [**8-24**] EGD with gastritis, colonoscopy with
diverticulosis, with GI bleeding
C diff colitis [**8-25**], [**11-24**]
Depression
s/p right shoulder surgery
s/p knee replacement
h/o right ureteral stent placement and left nephrostomy tube
placement for obstructive nephrolithiasis - removed [**7-25**]
right subcapsular perinephric hematoma
Social History:
Married, currently at [**Hospital **] rehab. H/o tobacco, 30 pack-years,
quit about 20 years ago. Drinks 2 drinks/week. No IVDU
Family History:
Noncontributory
Physical Exam:
T: 95.8 BP: 111/67 P: 113 R: 29 O2 sat: 98% on 4L
Gen: sleeping, arouses to voice, answers ?'s appropriately but
quickly falls back to sleep
HEENT: NC, AT, MM dry
Neck: supple, neck veins flat
Lungs: CTA anteriorly, pt unable to sit forward for posterior
exam
CV: regular, tachycardic, no murmur
Abd: soft, nt/nd, +bs
Ext: warm/dry, no edema, 2+ dp bilaterally
Neuro: arouses to voice, R pupil reactive, L pupil surgical,
intermittently following commands
Pertinent Results:
[**2123-12-16**] 08:22PM GLUCOSE-125* POTASSIUM-4.1
[**2123-12-16**] 08:22PM CALCIUM-8.0* MAGNESIUM-2.3
[**2123-12-16**] 08:22PM HCT-24.5*
[**2123-12-16**] 05:39PM FIBRINOGE-391 D-DIMER-9675*
[**2123-12-16**] 04:41PM HCT-26.1*
[**2123-12-16**] 04:41PM FDP-80-160*
[**2123-12-16**] 03:53AM GLUCOSE-117* UREA N-27* CREAT-1.4* SODIUM-140
POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-22 ANION GAP-12
[**2123-12-16**] 03:53AM ALT(SGPT)-9 AST(SGOT)-20 ALK PHOS-49 TOT
BILI-0.6
[**2123-12-16**] 03:53AM CALCIUM-7.5* PHOSPHATE-3.4 MAGNESIUM-1.5*
[**2123-12-16**] 03:53AM WBC-13.7*# RBC-3.06* HGB-9.2* HCT-27.0*
MCV-88 MCH-30.1 MCHC-34.0 RDW-16.9*
[**2123-12-16**] 03:53AM NEUTS-79* BANDS-9* LYMPHS-3* MONOS-7 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2123-12-16**] 03:53AM HYPOCHROM-OCCASIONAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-OCCASIONAL
POLYCHROM-NORMAL
[**2123-12-16**] 03:53AM PLT COUNT-71*
[**2123-12-16**] 03:53AM PT-15.6* PTT-30.5 INR(PT)-1.4*
[**2123-12-16**] 12:15AM GLUCOSE-101 UREA N-27* CREAT-1.5* SODIUM-140
POTASSIUM-3.6 CHLORIDE-109* TOTAL CO2-19* ANION GAP-16
[**2123-12-16**] 12:15AM CALCIUM-7.7* PHOSPHATE-2.2* MAGNESIUM-1.3*
[**2123-12-15**] 09:43PM URINE COLOR-DkAmb APPEAR-Cloudy SP [**Last Name (un) 155**]-1.013
[**2123-12-15**] 09:43PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
[**2123-12-15**] 09:43PM URINE RBC->50 WBC-[**5-29**]* BACTERIA-OCC
YEAST-NONE EPI-0
[**2123-12-15**] 09:24PM LACTATE-2.0
[**2123-12-15**] 09:15PM GLUCOSE-131* UREA N-33* CREAT-1.7* SODIUM-136
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-23 ANION GAP-16
[**2123-12-15**] 09:15PM CK(CPK)-29*
[**2123-12-15**] 09:15PM CK-MB-NotDone cTropnT-0.05*
[**2123-12-15**] 09:15PM CALCIUM-9.1 PHOSPHATE-1.8*# MAGNESIUM-1.5*
[**2123-12-15**] 09:15PM WBC-7.3 RBC-3.69* HGB-10.9* HCT-31.8* MCV-86
MCH-29.5 MCHC-34.2 RDW-17.0*
[**2123-12-15**] 09:15PM NEUTS-84* BANDS-12* LYMPHS-3* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2123-12-15**] 09:15PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2123-12-15**] 09:15PM PLT SMR-VERY LOW PLT COUNT-79*
[**2123-12-15**] 09:15PM PT-13.3* PTT-25.0 INR(PT)-1.2*
.
Microbiology:
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2123-12-16**]):
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
.
Blood culture: [**12-15**]
KLEBSIELLA PNEUMONIAE
CEFTAZIDIME----------- S
CEFTRIAXONE----------- S
CIPROFLOXACIN--------- R
GENTAMICIN------------ S
LEVOFLOXACIN---------- R
MEROPENEM------------- S
TOBRAMYCIN------------ S
.
Urine culture: [**12-15**] >100,000
KLEBSIELLA PNEUMONIAE
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 32 R
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
Imaging:
[**12-16**]: CTU Abdomen/Pelvis
IMPRESSION:
1. Inappropriately placed Foley catheter, with the balloon
inflated in the bulbous portion of the urethra, causing
obstructive uropathy with a distended urinary bladder, prominent
ureters, and full collecting systems bilaterally.
2. Improvement in the right kidney subcapsular fluid collection
since the prior study. Nonspecific bilateral perinephric
stranding.
3. Punctate nonobstructing right kidney stones.
4. Multiple bilateral hypodensities in both kidneys are
incompletely
evaluated. Some of these are high density, and further workup
with ultrasound
or MR, if not already completed, should be considered.
5. Multiple small hypodensities in the liver are likely cysts
but are too small to characterize.
6. Diverticulosis without diverticulitis.
7. Pleural calcifications bilaterally consistent with prior
asbestos
exposure. Bibasilar atelectasis and small bilateral pleural
effusions.
.
[**12-17**]: Bladder US
IMPRESSION: Limited study that demonstrates Foley catheter
balloon in decompressed urinary bladder
Brief Hospital Course:
This is a 79 y/o M w/ CAD, CHF, CVA, hx C.diff, B urolithiasis
with ARF and R ureteral stent and left percutaneous nephrostomy
tube, who came to ED on [**12-16**] with fever, nausea, vomiting and
hematuria, likely with urosepsis, initially hypotensive on
arrival to the MICU, stabilized, developed volume overload and
oxygen requirment, then transferred to medical floor.
.
1. Urosepsis: Originally came in with fever to 103, hypotension
(80s/50s), resolved with the administration of 6L of NS in the
ED as well as IV antibiotics (Levo/Flagyl). Originally, he was
admitted to the MICU and treated for gram negative rod sepsis
with meropenem (start date: [**12-16**]) given history of EBSL in
urine. He did not require any pressors during his period of
hypotension. Lactate was not elevated and he did not have any
evidence of end-organ hypoperfusion. On the floor, he was
continued on meropenem, gram negative rods speciated to
Klebsiella pneumoniae. Sensitivities showed sensitivity to
ceftriaxone, so spectrum was narrowed, and he was discharged on
ceftriaxone 1g q24. This should be continued until [**2123-12-30**]. PICC line was placed for antibiotic administration.
.
2. Hematuria: Urology following patient while in house. ? If
hematuria was secondary to traumatic foley placement as
evidenced on CTU, but thrombocytopenia may have played a role.
Foley was placed on [**12-16**] (confirmed by ultrasound), and should
remain in place for a total of two weeks until he follows up
with Dr. [**Last Name (STitle) 4229**]. He should have his foley flushed every 8 hours.
Thrombocytopenia was resolving at discharge with
discontinuation of PPI (which was thought to be the cause).
.
3. Congestive Heart Failure: TTE [**5-25**] with preserved EF,
however, volume overloaded on exam after receiving 6L with
initial hypotension. He was given IV Lasix prn for diuresis and
responded well. He was weaned down to 1L of oxygen prior to
discharge.
.
4. Clostridium difficile: C.diff was checked given that he had
it in [**8-25**] as a possible cause of his sepsis, although he did
not have any symptoms of diarrhea. It came back positive and he
was started on flagyl on [**12-16**]. This should be continued for a
total of two weeks until [**2122-12-30**]. Patient not symptomatic with
diarrhea, leukocytosis is resolving.
.
5. Thrombocytopenia: ? cause as platelets were normal previously
as an outpatient. PPI was discontinued in MICU for question of
cause of thrombocytopenia. No heparin products administered
during stay. Platelets continued to trend up with
discontinuation of PPI. He should likely be kept off this
medication unless he is being monitored closels.
.
6. Chronic Renal Insufficiency: Creatinine at baseline. CKD
likely due to hydronephrosis from renal stones. Trended
creatinine, which remained stable.
.
7. CAD: No signs or symptoms of ischemia; troponin checked in ED
was mildly elevated at 0.05 but unclear significance of this.
Aspirin has been on hold at NH, ? if due to thrombocytopenia.
Initially held metoprolol given sepsis, but restarted due to
hypertension [**12-17**]. LDL < 100, not on statin.
.
8. Anemia: Hct above baseline, no indications for transfusion or
clinical signs of bleeding. He was continued on his outpt iron
regimen.
.
9. FEN: He was on a cardiac/heart healthy diet, lytes were
repleted prn
.
10. Code: Full
.
11. Communication: With patient
.
12. Dispo: Back to rehab center
Medications on Admission:
multivitamin
prilosec
spiriva
lopressor 25 [**Hospital1 **]
aspirin 81 (on hold)
tylenol
lidoderm patch
oxycodone
iron 325 mg tid
ultram 25 mg [**Hospital1 **]
colace
senna
dulcolax
compazine prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 11 days.
5. CeftriaXONE 1 gm IV Q24H
Day 1: [**12-16**]
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. 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.
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Famotidine 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
13. Compazine 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
14. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
C. diff colitis
Urosepsis with klebsiella pneumonia
CHF
.
Secondary diagnosis:
CAD
OSA
CVA with residual right-sided weakness
Depression
Pseudogout
Discharge Condition:
Good
Discharge Instructions:
You were admitted with urosepsis and C. diff colitis. You are
being treated with ceftriaxone and metronidazole, which should
be continued for a total of 2 weeks ([**2123-12-30**]).
.
Please call your doctor if you have fevers, chills, chest pain,
shortness of breath, abdominal pain, hematuria, diarrhea.
Followup Instructions:
You have the following appointment already scheduled with Dr.
[**Last Name (STitle) 4229**]. You should reschedule it for [**2123-12-30**] or close to it to
have your foley catheter removed. You can reach his office at:
Phone:[**Telephone/Fax (1) 10941**]
Your appointment is for: Date/Time:[**2123-12-21**] 11:30
.
Please make an appointment to see your primary care doctor, Dr.
[**Last Name (STitle) **] after discharged from rehab. You can reach his
office at: [**Telephone/Fax (1) 1579**]
|
[
"995.91",
"327.23",
"780.79",
"287.5",
"008.45",
"585.9",
"038.49",
"414.01",
"285.9",
"438.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11797, 11891
|
6715, 10154
|
332, 353
|
12103, 12110
|
2434, 6692
|
12464, 12963
|
1926, 1943
|
10401, 11774
|
11912, 11912
|
10180, 10378
|
12134, 12441
|
1958, 2415
|
276, 294
|
381, 1231
|
12010, 12082
|
11931, 11989
|
1253, 1764
|
1780, 1910
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,660
| 115,005
|
49358
|
Discharge summary
|
report
|
Admission Date: [**2127-1-23**] Discharge Date: [**2127-1-28**]
Date of Birth: [**2055-9-12**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Attending Info 87297**]
Chief Complaint:
Dizziness, weakness, fatigue, nausea, melanotic stool
Major Surgical or Invasive Procedure:
1. Endoscopy [**2127-1-24**]
2. Catheterization of the celiac trunk [**2127-1-24**]
History of Present Illness:
71 year old female with arthritis, osteoporosis, history of
duodenal ulcer and recently diagnosed gastric cancer initially
treated with chemotherapy c/b nausea/vomiting/lower GI bleed,
now presenting with melanotic stool and ten point hematocrit
drop. Per the patient, she had been in her usual state of health
(limited energy, but independent in ADLs at home) until this
morning, when she had three bowel movements with black stool.
Her stools were of varying consistency, from very hard to very
soft. She did not notice any BRBPR. She sought medical care and
her PCP obtained labs, which were notable for Hgb/Hct 6.7/20.0,
down from 11.3/32.3 when checked in [**Month (only) 359**]. She may have felt
some dizziness with ambulation for the last couple of days, but
denied falls, lightheadedness, dyspnea, chest pain, abdominal
pain, or hematuria. Per ED history, patient endorsed an episode
of bloody emesis, but she denied this after arriving to the
[**Hospital Unit Name 153**].
.
In the ED, initial VS were 97.08, 92, 91/54, 18, 100% RA. Exam
was notable for pale sclera and skin, and black stool on rectal
exam. ECG revealed normal sinus rhythm at 88 bpm, and no
ischemic changes. One unit of RBCs were transfused. A
pantoprazole bolus of 80 mg, then 8 mg/hr gtt was started. The
patient did not tolerate multiple attempts at NG tube placement
for lavage. RBC transfusion was started at [**2031**]. Foley catheter
was placed. GI was consulted, and recommended keeping patient
NPO for EGD in AM, and transfusing RBCs for goal Hct > 25.
.
Per recent radiation oncology notes, the patient has also had
significant short-term memory problems and a 40 lb weight loss
since starting chemo. The decision was made to defer raditation
treatment or further chemo, since the patient was feeling
generally well and her PET scan showed general decrease in size
of tumor burden.
Past Medical History:
Past Oncologic History:
Carcinoma of GE junction, likely gastric
- Presented in [**6-10**] with dysphagia, initial EGD showed ulcer
in cardia and gastritis but no mass and biopsies then negative
for malignancy. initally diagnosed in [**8-10**] after presenting with
dysphagia. CT showed showed 5 mm RLL nodule and ulcerated
gastric mass at GE junction. A CT scan of the chest, abdomen,
and pelvis was
performed on [**2126-9-13**], at [**Location (un) 2274**]. There was a 5 mm lung
nodule noted as well as an ulcerated gastric mass within the
fundus near the GE junction extending outside the lumen of the
stomach measuring 4.5 x 2.8, without adenopathy. EUS revealed
hypoechoic ill-defined mass and biopsy and cytology was
suspicious for signet cell tumor. Based these findings, she was
initiated on chemo.
- She received chemotherapy starting on [**2126-10-14**], one cycle of
EOF (epirubicin, oxaliplatin, and 5-FU). She was hospitalized
for dehydration. Second cycle was held and she subsequently
received a cycle of EOF on [**2126-11-12**]. A repeat PET scan
was performed, which revealed decreased bilateral hilar and
precarinal lymph node FDG uptake. Lung nodule was unchanged,
decrease in the size and uptake of the gastroesophageal mass.
Because the patient tolerated chemotherapy so poorly, she
elected
to discontinue chemotherapy at that time. She has not received
any chemotherapy since the end of [**Month (only) 359**]. She was seen by Dr.
[**Last Name (STitle) **] to discuss surgical options, but thought to be a poor
surgical candidate.
- Lost 40 pounds since diagnosis. She also has significant
short-term memory loss since initiating chemotherapy. She was
having some nausea related to mucus production; however, her
husband has placed her on a complimentary alternative medicine,
which is derived from the mushroom growing on the bark of the
white [**Doctor Last Name **], which is obtained from [**Country 532**]. He feels that this
has significantly decreased her mucus production and reduced her
vomiting. She was prescribed Megace, which she is not taking.
She is ambulating without difficulty and her husband says that
she is much more alert and does not sleep as much as she did
earlier in [**Month (only) **].
Other Past Medical History:
- Arthritis - per OMR, but patient denies
- Osteoporosis - diagnosed many years ago, was on Fosamax, but
discontinued this >1yr ago for unclear reasons
- Hypercholesterolemia - per OMR, but patient denies, never been
on a statin or other medication
- Anxiety
- Duodenal ulcer
- Gastritis
- Palpitations
Social History:
Married, originally from [**Location (un) 3156**]. She has 2 children, 47 yo and
36yo, who live in the US. Denies tobacco or ETOH use.
Family History:
Mother died of Leukemia many years ago. Her father died in [**Name (NI) 3106**]
and she is unaware of any medical problems. [**Name (NI) **] two children are
healthy.
Physical Exam:
On admission:
VS: Temp:97.7 BP:99/59 HR:83 RR:11 O2sat:100% 3L NC
GEN: pleasant elderly Russian woman, appears chronically ill and
weakened, comfortable, NAD
HEENT: + conjunctival pallor, PERRL, EOMI, anicteric, MMM, op
without lesions, no supraclavicular or cervical lymphadenopathy,
no jvd, no carotid bruits
RESP: CTA b/l with good air movement throughout
CV: RRR, S1 and S2 wnl, no m/r/g
ABD: Flat, NT/ND, +b/s, soft, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: Awake, alert, interactive, oriented to name, place, year,
month, but cannot name the date. Cn II-XII intact. 5/5 strength
in upper and lower extremities, proximally and distally. No
sensory deficits to light touch appreciated
RECTAL: Deferred
.
On discharge:
Pertinent Results:
ADmission Labs:
[**2127-1-23**] 03:52PM LACTATE-1.1
[**2127-1-23**] 03:52PM HGB-6.4* calcHCT-19
[**2127-1-23**] 03:35PM GLUCOSE-130* UREA N-20 CREAT-0.4 SODIUM-135
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-23 ANION GAP-11
[**2127-1-23**] 03:35PM estGFR-Using this
[**2127-1-23**] 03:35PM cTropnT-<0.01
[**2127-1-23**] 03:35PM CALCIUM-8.3* PHOSPHATE-3.0 MAGNESIUM-1.9
[**2127-1-23**] 03:35PM WBC-13.8*# RBC-2.04*# HGB-6.1*# HCT-18.5*#
MCV-91 MCH-30.0 MCHC-33.0 RDW-14.1
[**2127-1-23**] 03:35PM NEUTS-83.3* LYMPHS-13.9* MONOS-2.3 EOS-0.1
BASOS-0.5
[**2127-1-23**] 03:35PM PLT COUNT-406#
[**2127-1-23**] 03:35PM PT-13.9* PTT-36.8* INR(PT)-1.2*
.
Discharge Labs:
.
Studies:
Imaging:
CXR [**2127-1-23**]:
IMPRESSION: No acute intrathoracic process.
.
Mesenteric study [**2127-1-24**]: read pending
.
EGD [**2127-1-24**]:
A large ulcerated friable mass of malignant appearance was found
at the gastroesophageal junction. The mass caused a partial
obstruction, but the scope traversed the lesion. This was the
likely source of bleeding.
Normal duodenum, normal stomach
Brief Hospital Course:
71 y/o F with gastric adenocarcinoma and history of duodenal
ulcers, presenting with one day of black stools and dizziness,
found to have ten point hematocrit drop from most recent lab
work.
.
# Melena/anemia: Thought to be upper GIB secondary to gastric
malignancy versus possible ulcer. Patient was started on IV
Pantoprazole gtt and transfused PRBC X 1 unit in the ED, another
2 PRBC units were transfused in the ICU with appropriate Hct
rise from 18.5 on admission to 26 post transfusion. She
subsequently remained HD stable and had no significant
rebleeding per stable Hct on follow-up. She underwent bedside
EGD in the ICU which demonstrated a tumor in the GE junction
with no signs of active bleeding and was otherwise unremarkable.
Per the high risk of rebleeding from the tumor she was taken to
the IR suite for attempted embolization which was unsuccessful
d/t a common origin of the left gastric artery and inferior
diaphragmatic arteries off the celiac trunk thus the former
could not be embolized in isolation. As patient's hematocrit
remained stable Heparin were started for DVT prophylaxis. She
had a small guaiac positive stool on [**1-26**], but was asymptomatic
without a significant drop in hematocrit.
She was discharged on protonix 40mg [**Hospital1 **] and sucralfate 1gm po
qid. She was discharged with instructions and lab slip to repeat
a Hct within 7 days of discharge.
.
# Gastric CA: She did not tolerate her cycles of chemotherapy
well, and was hospitalized each time with nausea/vomiting and
bloody diarrhea, thought to be complications from chemo. Since
[**Month (only) 359**], she has been on holiday from either chemo or XRT.
Surgery notes indicate that she may have metastatic disease
which would preclude her from having curative surgical options.
Although percutaneous feeding tubes may be of some palliative
benefit, if within goals of care. She had a PET scan to assess
size of gastroesphogeal mass and whether there were metatastases
to determine further treatment - palliative radiation in setting
of gastric mass bleeding vs. surgery or other treatment. The
patient went for PET imaging the afternoon of discharge.
Patient will continue to follow-up with her primary oncologist,
Dr. [**First Name (STitle) 2405**].
.
# Leukocytosis: Likely secondary to stress in setting of GIB.
Remained afebrile without localizing symptoms. Was 12.2 on day
of discharge.
.
# Code status: DNI, ok to attempt resuscitation, confirmed with
the patient and her husband.
.
There were no labs pending on the day of discharge.
Medications on Admission:
Medications per the patient and her husband:
NONE, except for natural supplement ([**Doctor Last Name **] tree mushroom) for
nausea
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**5-7**]
hours as needed for pain: You may buy this over the counter.
Disp:*60 Tablet(s)* Refills:*0*
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
4. ondansetron HCl 8 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for nausea.
Disp:*84 Tablet(s)* Refills:*2*
5. Outpatient Lab Work
Please have Hematocrit checked in 7 days from day of discharge
([**2127-2-4**]) and have results faxed to your Primary Care Physician.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Gastric Cancer
2. Upper gastrointestinal bleed
3. Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was pleasure taking care of you during this hospitalization.
You were admitted because of blood loss from your
gastrointestinal tract which was thought to be caused by
bleeding from your gastric cancer. You were given blood to make
up for your blood loss. You underwent endoscopy which did not
demonstrate any active bleeding. You also underwent
catheterization with the aim of stopping blood flow to the
gastric tumor but this was unfortunately not achieved. Your
blood counts stabilized. You are being discharged and will need
to go straight to have a PET scan.
.
The following changes were made to your medications:
START Pantoprazole 40mg Tablet, take one tablet twice daily.
START Sucralfate 1mg by mouth four times daily
START Acetaminophen 325mg 1-2 tablets every 4-6hours as needed
for pain
START Ondansetron 8mg tablet by mouth every 8 hours as needed
for nausea
**It is important that you not take Ibuprofen, Aleve, or
Aspirin, as these can cause bleeding.
Followup Instructions:
***You will need a blood test to check your Hematocrit within 7
days of your discharge and hyave results faxed to Dr. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 6808**].
.
Name: [**First Name11 (Name Pattern1) 2890**] [**Last Name (NamePattern4) **], MD
Specialty: Internal Medicine
When: Wednesday [**2-5**] at 11:40am
Location: [**Hospital1 641**]
Address: [**University/College 2899**], [**Location (un) **],[**Numeric Identifier 2900**]
Phone: [**Telephone/Fax (1) 2115**]
.
Name: [**Name6 (MD) **] [**Name8 (MD) 87300**], MD
Specialty: Hematology Oncology
When: Thursday [**1-30**] at 10am
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3468**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 87298**]
|
[
"280.0",
"783.21",
"747.61",
"715.90",
"300.00",
"272.0",
"531.41",
"151.0",
"733.00",
"780.93"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
10696, 10702
|
7208, 9756
|
358, 444
|
10825, 10825
|
6105, 6105
|
12004, 12849
|
5124, 5293
|
9939, 10673
|
10723, 10804
|
9782, 9916
|
10976, 11981
|
6780, 7185
|
5308, 5308
|
6086, 6086
|
264, 320
|
472, 2345
|
6121, 6763
|
5322, 6070
|
10840, 10952
|
4650, 4955
|
4971, 5108
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,457
| 131,624
|
18613
|
Discharge summary
|
report
|
Admission Date: [**2126-2-25**] Discharge Date: [**2126-3-2**]
Date of Birth: [**2047-3-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Peripheral [**First Name3 (LF) 1106**] diasese, here for elective stent of Iliac
Arteries.
Major Surgical or Invasive Procedure:
Percutaneous transluminal angioplasty/stent of left external
iliac artery.
Percutaneous transluminal angioplasty/stent of left common iliac
artery.
Atherectomy of left external iliac artery.
Atherectomy of left superficial femoral artery.
Atherectomy of left profunda femoris artery.
Percutaneous transluminal angioplasty/stent of right common
iliac artery.
History of Present Illness:
78 year old female with CAD s/p NSTEMI, s/p LCx stent 6.03, and
RCA total occlusion, sefere PVD with bilateral carotid stenoses,
presents for elective stent of significant LE PVD. The patient
has an occluded L SFA, and stenoses of the L external iliac and
common femoral arteries. ABI 0.27 on the R, 0.26 on the L. The
patient has been having significant claudication with < 0.25 mi
ambulation.
Past Medical History:
CAD s/p stenting(3x18mm Cypher)of prox L circumflex [**7-5**] at
[**Hospital1 18**]
COPD/asthma on prednisone in past but never intubated
HTN
PVD-severe lft subclavian stenosis with diff UE BP's
Hyperlipidemia
Glaucoma OD
Osteoarthritis
Iron deficiency anemia
Social History:
Lives at home with husband. 20 pack-year smoking history, quit
in [**2110**]. She denies alcohol or drug use.
Family History:
Noncontributory.
Physical Exam:
VS: HR 75, 130/113, RR 18, 100% on 2L NC
Gen: Overweight caucasian female appearing well.
Lungs: CTA b/l
Cor: RR, normal rate, 2/6 systolic murmur at RUSB
Abd: NABS, soft, NT/ND
Vasculature: carotid bruits b/l, femoral bruits b/l, DP and PT
trace palpable b/l.
Pertinent Results:
[**2126-2-25**] Hct-36.3
[**2126-2-26**] Hct-31.0* Plt Ct-232
[**2126-2-27**] Hct-28.8*
[**2126-2-28**] WBC-13.0* Hgb-10.7* Hct-31.3* MCV-86 RDW-14.3 Plt
Ct-218
[**2126-2-28**] Hct-28.0*
[**2126-3-1**] WBC-11.6* Hgb-11.3* Hct-31.1* MCV-81* RDW-15.3 Plt
Ct-133*
[**2126-3-2**] WBC-13.0* Hgb-12.5 Hct-35.8* MCV-83 RDW-15.1 Plt Ct-176
[**2126-2-27**] PT-14.0* PTT-24.3 INR(PT)-1.2
[**2126-2-26**] UreaN-16 Creat-1.0 K-4.4
[**2126-3-2**] Glucose-103 UreaN-23* Creat-1.2* Na-143 K-4.3 Cl-107
HCO3-24
[**2126-3-1**] Glucose-99 UreaN-21* Creat-1.4* Na-135 K-4.4 Cl-105
HCO3-23
[**2126-2-25**] CK(CPK)-34
[**2126-2-26**] CK(CPK)-39
[**2126-2-26**] CK(CPK)-44
[**2126-2-28**] CK(CPK)-49
[**2126-2-28**] Calcium-8.7 Phos-4.3 Mg-1.8
[**2126-2-28**] URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]->1.035 Blood-LG
Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-6.5 Leuks-NEG RBC-[**7-12**]* WBC-0-2 Bacteri-NONE
Yeast-NONE Epi-0
AEROBIC BOTTLE (Final [**2126-3-6**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2126-3-6**]): NO GROWTH.
URINE CULTURE (Final [**2126-3-2**]): <10,000 organisms/ml.
EKG [**2-25**]: Sinus tachycardia and occasional ventricular ectopy.
Compared to the previous tracing of [**2125-7-24**] there are now more
prominent Q waves suggesting interim inferior myocardial
infarction. In addition, the ST segment depressions in leads I,
II, III and aVF are more prominent. Both atrial and ventricular
ectopy have appeared, the rate has increased and there is more
prominent downsloping ST segment depression in leads V5-V6. Rule
out myocardial infarction.
Catheterization [**2-25**]:
COMMENTS:
1. Retrograde access was obtained via the right CFA using a 6
French
sheath. Abdominal aortic angiography demonstrated moderate
distal
disease with a small infrarenal saccular aneurysm.
2. Nonselective angiography of the bilateral, single renal
arteries
demonstrated 40% proximal disease bilaterally.
3. The right CIA had a 50% lesion in the origin with a 6 mmHg
mean
gradient after administration of IA nitroglycerin. There was
diffuse
disease in the rightIIA with up to 50% stenoses.
4. The left CIA had proximal 60% disease with a 40 mmHg
peak-to-peak
gradient. The IIA had diffuse 40% disease. The distal EIA had an
eccentric 60% stenosis. The left SFA was ostially occluded and
reconstituted at the adductor canal. The left PFA had a 50%
lesion at
its origin. No angiographically apparent, flow-limiting disease
was
noted in the popliteal aftery. The AT had serial lesions with a
total
occlusion in the mid-shin. Slow filling was noted of the DP. The
peroneal had mild disease and terminated at the ankle. The PT
was the
principle vessel to the foot.
5. Successful treatment of the totally occluded left SFA using
adventitial dissection, an Outback catheter, angioplasty, and
stenting
with three overlapping self-expanding stents (from distal to
proximal
6.0 x 100 mm Absolute, 6.0 x 100 mm Dynalink, and 6.0 x 80 mm
Absolute)
all postdilated with a 6.0 mm balloon. Final angiography
demonstrated no
residual stenosis, a small proximal perforation, a distal
perforation
treated with prolonged balloon inflation and protamine, and
normal flow
(See PTCA Comments).
6. Successful treatment of ostial left PFA disease with a 5.0 x
18 mm
Highsail balloon. Final angigoraphy demonstrated a 30% residual
stenosis, no angiographically apparent dissection, and normal
flow (See
PTCA Comments).
FINAL DIAGNOSIS:
1. Mild abdominal aorta and renal artery disease.
2. Moderate disease in the right CIA and IIA.
3. Diffuse disease in left lower extremity with totally occluded
SFA.
4. Successful stenting of left SFA.
5. Balloon angioplasty of the left PFA.
6. Perforation of the distal SFA treated with balloon inflation
and
protamine.
Arterial Duplex [**2-27**]: IMPRESSION: No evidence of left leg
pseudoaneurysm or AV fistula.
Catheterization [**2-27**]:
COMMENTS:
1. Initial angiography was obtained by access of the right CFA
to the
contralateral left SFA using a 6 French sheath. The abdominal
aorta had
mild distal disease.
2. The right lower extremity was significant for a right CIA
with a
tubular 70% lesion.
3. The left lower extremity was significant for a left CIA with
a 90%
focal lesion. The EIA had an 80% lesion in the midsegment as
well as a
90% distal EIA lesion. The CFA had no significant disease. The
previous
stents in the SFA was without significant disease and normal
flow. The
distal perforation site was sealed. The origin of the SFA had a
70%
dissection. The origin of the PFA had a 70% tubular lesion.
4. Successful atherectomy using a SilverHawk LS device on the
left SFA,
PFA, and EIA. An 8.0 x 28 mm Dynalink self-expanding stent was
delivered
to the proximal EIA and postdilated with a 6.0 x 12 mm Viatrack
balloon
at 12 ATM. Final angiography demonstrated a 10% residual
stenosis in the
PFA, no residual stenosis, in the SFA, no residual stenosis in
the EIA,
no angiographically apparent dissection, and normal flow.
5. The left proximal CIA lesion was dilated with an 8.0 x 38 mm
Genesis
stent at 12 ATM. Final angiography demonstrated no residual
stenosis, no
angiographically apparent dissection, and normal flow.
6. The right CIA was stented with an 8.0 x 29 mm Genesis stent
at 12
ATM. A perforation was noted which was treated with multiple 5
minute
balloon inflations, administration of protamine, and finally
placement
of an 8.0 x 30 mm WallGraft covered stent postdilated with an
8.0 mm SDS
balloon. Final angiography demonstrated no residual stenosis, a
small
persistent perforation, and normal flow.
FINAL DIAGNOSIS:
1. Significant disease in the right CIA.
2. Significant disease in the left CIA, EIA, SFA, and PFA.
3. Successful atherectomy of the left SFA, PFA, and EIA.
4. Successful stenting of the left EIA.
5. Successful stenting of the left CIA.
6. Successful stenting of the right CIA.
7. Perforation of the right CIA treated with protamine, blood
pressure
control, prolonged balloon inflations, and a covered stent.
EKG [**2-27**]: Sinus rhythm with first degree A-V delay. Probable
left atrial abnormality. Prominent inferior Q waves - are
nonspecific. Modest nonspecific ST-T wave abnormalities. Since
previous tracing of [**2126-2-26**], first degree A-V delay present and
ST-T wave changes decreased.
CT ABD/PELVIS [**2-27**] 8 p.m.: IMPRESSION: Retroperitoneal
hemorrhage worse on the left, consistent with the history of
iliac artery perforation, although the exact origin of this
hemorrhage is not identified on this CT. Persistent nephrogram
raises concern for contrast induced nephropathy.
CT ABD/PELVIS [**2-28**] 3 a.m.: IMPRESSION: Interval increase in the
amount of retroperitoneal hemorrhage. Persistent contrast within
the renal collecting system which is concerning for contrast
induced nephropathy.
EKG [**2-28**]: Sinus rhythm. Probable prior inferior myocardial
infarction. Compared to the previous tracing of [**2126-2-27**] the ST
segment depressions and T wave inversions are slightly more
prominent in leads II, III and aVF and there is new downsloping
ST segment depression and T wave inversion in leads V5-V6. Rule
out myocardial infarction.
CXR [**3-1**]: Focal opacity in left retrocardiac region. It is
uncertain whether this represents a recurrent acute process
(pneumonia, aspiration) or a progressive abnormaltiy. Followup
dedicated PA and lateral radiographs of the chest are
recommended for initial further characterization. Followup films
would also be helpful to document resolution and to fully
exclude a neoplasm in this region.
Brief Hospital Course:
78 year old female with CAD and severe PVD, presents for
elective stent of significant biaortoiliac disease.
1) Peripheral [**Month/Year (2) 1106**] disease: On admission the patient was
taken to the catheterization laboratory for planned intervention
of the 100% stenosed L SFA and 50% stenosed L PFA. The L SFA
was stented post angioplasty, while the L PFA was balloon
dilated, without stent placement. Final angiography
demonstrated 30% residual PFA stenosis, no residual stenosis of
the L SFA, a small proximal perforation of the L SFA, a distal
perforation treated with prolonged balloon inflation and
protamine, and normal flow. The L CIA at this time had 60%
disease, the L internal iliac artery 40% disease, and the L
distal external iliac artery 60% disease.
She underwent another planned catheterization 2 days after
admission, for planned further intervention of her severe
bilateral [**Month/Year (2) 1106**] disease. This catheterization demonstrated L
SFA 70% stenosis, L PFA 70% stenosis, L external iliac artery
90% stenosis, L common iliac artery 90% stenosis, R common iliac
artery 70% stenosis. She had atherectomy of the L SFA, L PFA, L
EIA, with stenting of the EIA. Final angiography demonstrated a
10% residual stenosis of the L PFA, no residual stenosis in the
SFA, no residual stenosis in the EIA, no angiographically
apparent dissection, and normal flow. L CIA and R CIA were both
dilated and stented. Post-stenting of the R common iliac artery
there was extravasation of contrast which persisted despite
balloon pressure and protamine. The patient was placed on
nitroprusside drip for elevated blood pressure to 198/60 and
sent to the CCU.
2) Retroperitoneal hemorrhage: After her second catheterization
with perforation of the R CIA, she underwent CT of the
abdomen/pelvis to evaluate the extent of the bleed. This
demonstrated retroperitoneal hemorrhage worse on the left,
consistent with the history of iliac artery perforation,
although the exact origin of this hemorrhage was not identified
on this CT. Aproximately 8 hours after transfer to the CCU post
her second catheterization, the patient complained of abdominal
pain. She was noted to have hypoactive bowel sounds and a rigid
tender abdomen, and was therefore sent for a repeat stat CT of
the abdomen/pelvis which showed interval increase in the amount
of retroperitoneal hemorrhage, however the amount of increase
over the 8 hours since the previous CT scan was not considered
excessive, and the patient was hemodynamically stable
throughout, therefore it was decided to manage conservatively
with PRBC transfusion and clinical/laboratory observation. The
patient remained hemodynamically stable, and her hematocrit
remained stable status post 4 units of PRBCs over 24 hours. Her
abdominal exam was benign at the time of discharge.
3) CAD: The patient did have a number of episodes of chest pain
between the first and second catheterizations. These episodes
were accompanied by EKG changes consisting of ST depressions in
the lateral leads (V3-V6) of up to 3 mm. They consistently
resolved with SL nitroglycerin. She was continued on ASA,
plavix, and a statin (atorvastatin 10 mg daily).
4) Complete heart block: 1 day after her second catheterization
she was noted to have a 6 second period of complete heart block
during which time she had an atrial rate of approximately 75
beats per minute. She was also noted to have had several alarms
for bradycardia down to 39 post her first catheterization. Of
note, her PR interval was prolonged to 220 msec surrounding the
episode. The electrophysiology team saw the patient, and felt
that this CHB episode may have been consistent with a vagal
episode, given the prolonged PR interval around the time of her
block, as well as her known RP bleed. However, given the
significant duration of her pause, it was recommended that she
have a pacemaker placed should she have another one. After
extensive discussions with the patient, she persistently refused
pacemaker placement should the event recurr. She did indicate
understanding of the possible consequences of not having the
pacer placed. Fortunately, she did not have any further
episodes of CHB, though she did continue to have transiet
bradycardia to the 30s. She had no syncopal or pre-syncopal
episodes, nor was she ever symptomatic or unstable during her
episodes of bradycardia. AV nodal blockers were avoided, and
should continue to be avoided in the future given this history.
5) Contrast nephropathy: The patient's creatinine transiently
rose from 1.1 to 1.4 post her second catheterization. She was
also noted to have persistent nephrograms on CT scan (performed
for her RP bleed, as above), which raised concern for contrast
induced nephropathy. Her creatinine peaked at 1.4 and came down
to 1.2 on the day of discharge, however, and the patient was
producing adequate urine output. Her lisinopril and lasix were
held for the 2 days prior to discharge, but restarted on
discharge. The patient was to follow up with Dr. [**First Name (STitle) **] in [**2-3**]
weeks, at which time a chem 7 was to be drawn.
6) HTN: The patient was on a nipride drip for 24 hours post
catheterization, for blood pressure goal of 100-140.
Subsequently she was transitioned back to her home blood
pressure medications: Norvasc 10 mg daily, Lisinopril 10 mg
daily, and clonidine 0.3 mg TID.
7) COPD: Continued inhalers.
8) Fever: The patient had a fever on the day before discharge.
Blood and urine cultures were negative. A CXR revealed a
retrocardiac opacity which had been seen on previous CXRs.
Treatment was therefore not initiated, and the patient did not
have any further fevers. She should have a repeat CXR at some
point to assess for interval change in this opacity.
Medications on Admission:
Lasix 20 mg daily
Norvasc 10 mg daily
Lipitor 10 mg daily
Lisinopril 40 daily
ASA 325 daily
Clonidine 0.03 TID
Combivent
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain.
3. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Clonidine HCl 0.1 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
8. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation TID (3 times a day).
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
10. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*8*
Discharge Disposition:
Home
Discharge Diagnosis:
Retroperitoneal hemorrhage
Coronary artery disease
Peripheral [**Month/Day (2) 1106**] disease
Hypertension
Chronic obstructive pulmonary disease
Hypercholesterolemia
Discharge Condition:
Stable and improved. Having bowel movements, urinating, walking
without assistance.
Discharge Instructions:
You will need to schedule a follow up appointment with Dr.
[**First Name (STitle) **] for within the next 10-14 days. His number is listed
below.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if your weight increases
by more than 3 pounds.
Adhere to 2 gm sodium diet.
Seek medical help if you experience worsening abdominal pain or
lightheadedness.
Followup Instructions:
Please call Dr.[**Name (NI) 3101**] office at [**Telephone/Fax (1) 920**] to schedule an
appointment for 10-14 days from now.
You also have the following appointments already scheduled:
Provider: [**Name10 (NameIs) **] STUDY Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2126-5-7**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2126-5-7**] 4:30
F/U with Dr. [**Last Name (STitle) **] in [**2-3**] weeks
|
[
"440.21",
"786.59",
"401.9",
"493.20",
"E870.8",
"280.9",
"998.11",
"426.0",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"88.42",
"88.48",
"99.04",
"39.90"
] |
icd9pcs
|
[
[
[]
]
] |
16418, 16424
|
9529, 15331
|
385, 744
|
16635, 16721
|
1914, 5363
|
17131, 17713
|
1598, 1616
|
15502, 16395
|
16445, 16614
|
15357, 15479
|
7531, 9506
|
16745, 17108
|
1631, 1895
|
255, 347
|
772, 1171
|
1193, 1455
|
1471, 1582
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,776
| 185,397
|
9827
|
Discharge summary
|
report
|
Admission Date: [**2191-8-23**] Discharge Date: [**2191-9-2**]
Date of Birth: [**2134-8-5**] Sex: M
Service: MEDICINE
Allergies:
Enalapril
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
For foot surgery
Major Surgical or Invasive Procedure:
Foot surgery
History of Present Illness:
57 YO m s/p podiatry surgery transferred from the PACU with
hypotension, hyperglycemia, hyperkalemia.
He has a history of L foot I&D for abscess and wound cultures in
[**3-26**] with MRSA treated with vancomycin beads.
Intraop course without complications with 700cc blood loss. In
the PACU, HCT 24.6, low urinary output 30cc, K 5.5. sBP 90s.
A-line placed. Anesthesia contact[**Name (NI) **] [**Name (NI) 153**] for transfer based on
hypotension with low u/o, low HCT, hyperkalemia. Gave 4.7L
fluid. 2uPRB plus lasix
.
He denied CP, SOB, leg pain. No N/V. He denies SOB with
exersion, orthopnea, PND.
BP stablised and transferred to the floor.
Past Medical History:
Charcots foot: [**2191-8-23**]: s/p tibio-calcaneal athrodesis with
femoral head graft and intramedullary nail. external fixation
stabilization.
[**4-26**] MRSA wound culture
dm2 x20 years
HTN
Asthma
GERD
hypercholesterolemia
bronchitis
obesity
CAD s/p cardiac stent LAD [**2186**], denies CP,
hypothyroidism
s/p charcot recon [**10-24**].
h/o abscess of left foot s/p I&D [**2-23**]
s/p appendecomy
s/p tonsillectomy
Social History:
hx of tobacco abuse, 72 pack-yr hx, quit 5 yrs ago; hx of
alcohol abuse; no IVDA
Lives alone, manages his own medications
Quit smoking in [**2184**]
Reports occasional etoh use
Family History:
father- deceased from stroke-66 YO
mother-deceased, diabetic mellitus complications
Physical Exam:
In ICU:
VS: T98.1 83 102/48 sat 100%2lnc
GEN: awake and alert, NAD
CV: distant heart sounds, RRR, nl s1, s2, no m/r/g, JVP 7cm
Resp: CTAB
Abd: obese, nontender, nondistended, BS present.
ext: cool, no cyanosis or edema. cast on LLE. diminished pedal
pulses.
neuro: awake and alert. able to move lower extremities.
decreased sensation L and R LE.
Pertinent Results:
[**2191-8-23**] 07:32PM GLUCOSE-169* UREA N-42* CREAT-1.8* SODIUM-139
POTASSIUM-5.5* CHLORIDE-112* TOTAL CO2-18* ANION GAP-15
[**2191-8-23**] 07:32PM CALCIUM-7.9* PHOSPHATE-5.5*# MAGNESIUM-1.7
[**2191-8-23**] 07:32PM WBC-11.2* RBC-2.93*# HGB-8.3* HCT-24.6*
MCV-84 MCH-28.2 MCHC-33.6 RDW-16.9*
[**2191-8-23**] 07:32PM PLT COUNT-283
[**2191-8-23**] 03:05PM GLUCOSE-192*
.
BLOOD CX [**2191-8-31**]: pending
BLOOD CX [**2191-8-24**]: [**11-24**] coag neg staph
LEFT FOOT ANTIBIOTIC BEAD CX [**2191-9-2**]: NO GROWTH
.
EKG:
Sinus rhythm
First degree AV block
Lateral ST-T changes are nonspecific
Since previous tracing, no significant change
.
Foot path:
Left foot bone, debridement (A):
Bone with chronic inflammation, focal giant cell reaction,
intramedullary granulation tissue, and reactive changes.
No acute osteomyelitis is present.
.
FOOT AND LOWER LEG, FIVE VIEWS
FINDINGS: Comparison [**2191-8-8**]. An external fixator device has
been placed around the lower leg and foot. Evaluation of the
osseous structures is severely limited due to the overlying
hardware. Extensive post-operative changes of the hindfoot are
seen. A bone stimulation device is also noted. Lucent tracts in
the osseous structures reflect previous hardware. Evidence of
previous distal fibular resection is seen.
IMPRESSION: Interval placement of external fixator device.
Extensive post-operative changes of the lower leg and hindfoot.
Evaluation is obscured by the overlying device.
.
ANGIO for PICC placement: IMPRESSION: Successful placement of a
42 cm long single lumen line placed via the left brachial vein
with tip in the distal SVC. The line is ready for use.
Brief Hospital Course:
# Hypotension:
Resolved with IVF and 2 units PRBC. Suspect due to hypovolemia
+ anesthesia/fluid shifts but continued on antibiotics in house
for risk of component of presepsis. Lopressor initially held
but has been restarted and patient is tolerating this, in
addition to his regular blood pressure medications.
.
# Chronic osteomyelitis s/p left rear foot arthrodesis:
Patient tolerated the surgery well. His antibiotic bead was
removed during the surgery. He was continued on vancomycin,
levofloxacin, and flagyl per podiatry in house and will continue
outpatient on IV vancomycin only with follow-up with Dr. [**Last Name (STitle) **]
for continued management. Per podiatry, anticipate 4-6 weeks IV
antibiotics. Immobilizer in place. Dressing change to be done
by Dr. [**Last Name (STitle) **] in follow-up on [**9-6**].
.
# Chronic renal insufficiency: Patient remained at his baseline
Cr 1.3-1.5. Lytes stable. Euvolemic.
.
# Type 2 diabetes: Hgb A1C elevated (8.8% in [**6-26**]). Patient
continued on his home lantus 70 units qday, regular insulin 30
units qam and 30 u qpm, and pioglitazone 45mg po qday.
.
# History of alcohol abuse: Patient was monitored on CIWA but
required no benzo.
.
## PPX: hep sc, PPI, venodynes
.
# Access: PICC placed by angio prior to discharge for continued
IV antibiotics
PICC line.
.
# Code: full
.
# Communication: no family or friends that he would want to take
part in his medical decision making.
Medications on Admission:
Levothyroxine 300mcg po qday
Ascorbic Acid 500mg po BID
Lopressor 75mg po BID
ASA 81mg po qday
Lipitor 20mg po qday
Nortriptyline 75mg po qday
Oxycodone prn
Ca Carbonate 500mg po TID
Protonix 40mg po qday
Pioglitazone 45mg po qday
Epoetin 8000 QMOWEFR,
KCL 20 mEq po BID
Ferrous Gluconate 300mg po TID
Fexofenadine 60mg po qday
Finasteride 5mg po qday
Fluticasone-Salmeterol (250/50) IH [**Hospital1 **]
Tamsulosin 0.4mg po qday
Tiotropium Bromide 1 CAP IH qday
Hydralazine 40 Q6H
RISS
Lantus 40 units qday
Isosorbide Mononitrate (ER) 60mg qday
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Nortriptyline 25 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day) as needed.
9. Epoetin Alfa 3,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
10. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (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. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
16. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
17. Pioglitazone 15 mg Tablet Sig: Three (3) Tablet PO QAM (once
a day (in the morning)).
18. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
19. Polyethylene Glycol 3350 17 g (100%) Packet Sig: One (1)
Packet PO qd ().
20. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
21. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for abdominal discomfort.
22. Hydralazine 10 mg Tablet Sig: Four (4) Tablet PO Q6H (every
6 hours).
23. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO qd ().
24. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
25. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
26. 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.
27. Lantus 100 unit/mL Cartridge Sig: Seventy (70) units
Subcutaneous at bedtime.
28. Insulin Regular Human 100 unit/mL Cartridge Sig: Thirty (30)
units Injection qam and qdinner.
29. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: One (1)
injection Subcutaneous three times a day: per sliding scale.
30. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours): anticipate 4-6 weeks.
Disp:*60 gram* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
primary:
s/p left rear foot arthrodesis
Hypotension
Diabetes mellitus
secondary:
hypertension
asthma
GERD
hypercholesterolemia
CAD s/p stent '[**86**]
Charcot foot with history of MRSA infection
Discharge Condition:
good: afebrile, pain well controlled
Discharge Instructions:
Please monitor for temperature > 101, worsening pain or bleeding
in the left foot, low or high blood sugars, chest pain,
diarrhea, or other concerning symptoms.
You will require to comple the course of IV antibiotics as
indicated.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] from podiatry on [**9-6**] at
1:40 PM. Phone: [**Telephone/Fax (1) 543**]. Location: [**Hospital1 18**] [**Hospital Ward Name 517**] ([**Location (un) **]) [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 3.
Please call to schedule follow-up with your primary care doctor
within 1-2 weeks. Talk to your primary doctor about getting a
colonoscopy and upper endoscopy for work-up of your anemia.
|
[
"730.17",
"713.5",
"403.91",
"250.80",
"276.52",
"731.8",
"428.0",
"280.9",
"493.90",
"250.60",
"414.01",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"81.15",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8735, 8889
|
3773, 5225
|
285, 300
|
9129, 9168
|
2094, 3750
|
9448, 9918
|
1628, 1713
|
5820, 8712
|
8910, 9108
|
5251, 5797
|
9192, 9425
|
1728, 2075
|
229, 247
|
329, 976
|
998, 1417
|
1433, 1612
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,375
| 174,661
|
5238
|
Discharge summary
|
report
|
Admission Date: [**2173-8-27**] Discharge Date: [**2173-9-1**]
Date of Birth: [**2116-3-26**] Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
woman with a history of type 1 diabetes, hypertension, and
coronary artery disease with a recent positive stress
thallium, who was in her usual state of health until
approximately 1 p.m. on the day of admission when she was at
work in a medical center where she is a medical assistant.
She stood up and suddenly felt unsteady with a "heavy
feeling," nausea without vomiting, diaphoresis followed by
chills, and then experienced sharp left-sided chest,
shoulder, pain lasting a few seconds. This was followed by a
heavy feeling in both arms for about two to three hours until
she reached the Emergency Room and was given three sublingual
nitroglycerin which relieved this arm heaviness.
At work where she was surrounded by nurses and doctors, when
her vital signs were taken she had a pulse of 80 and systolic
blood pressure of 120, and an electrocardiogram done there
revealed 1-mm ST depressions in I, aVL and V3 through V6. She
had no dyspnea, cough, fever, dysuria, or any recent skin
infections. Laboratories in the Emergency Room were
consistent with diabetic ketoacidosis including
hyperglycemia, increased anion gap acidosis and dehydration.
She was started on intravenous fluids, insulin drip,
nitroglycerin drip, heparin drip, aspirin, and Lopressor.
Her initial creatine kinase was elevated at 227; the next one
was 182 with a MB of 6, troponin less than 0.3
Additionally, in the Emergency Department she also had two
bouts of emesis. She reports she has never experienced chest
pain or been admitted diabetic ketoacidosis before.
PAST MEDICAL HISTORY:
1. Type 1 diabetes since childhood.
2. Hypercholesterolemia.
3. Hypertension.
4. Hypothyroidism.
5. Peripheral vascular disease, status post right lower
extremity bypass.
6. Echocardiogram in [**2173-6-20**] showed an ejection
fraction of 50% with focal hypokinesis of her basal inferior
wall and basal inferior septum, mild-to-moderate mitral
regurgitation, focal hypokinesis consistent with coronary
artery disease.
7. Stress thallium in [**2173-4-20**] without a nuclear report
showed inferolateral defect, partially reversible, 65 maximum
heart rate, 18,000 rate pressure product, 5.5-minute [**Doctor First Name **]
protocol, ejection fraction of 54%.
MEDICATIONS ON ADMISSION: Medications at home included
Diovan 80 mg p.o. q.d., Zestoretic 20 mg p.o. b.i.d.,
aspirin 81 mg p.o. q.d., Synthroid 125 mcg p.o. q.d., Humalog
insulin, insulin pump which the patient has been on for
approximately six years, atenolol 25 mg p.o. q.d.,
Lasix 40 mg p.o. q.d., and Prempro.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Father died of a cerebrovascular accident at
the age of 60. Mother died of congestive heart failure at
the age of 78. Brother died of cerebrovascular accident at
the age of 38.
SOCIAL HISTORY: The patient is married with two children.
She is a medical assistant. She quit smoking 26 years ago
and drinks occasional alcohol. She does not use drugs.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs were
temperature of 97.9, pulse of 80, blood pressure 170/80,
respiratory rate of 18, oxygen saturation of 98% on room air.
In general, an obese pleasant woman in no apparent distress.
HEENT revealed normocephalic and atraumatic. Pupils were
equal, round, and reactive to light. Extraocular muscles
were intact. The oropharynx was clear. Mucous membranes
were dry. Neck had no lymphadenopathy. Jugular venous
pressure 10 cm, trachea was midline. Cardiovascular revealed
normal S1 and S2. No S3. A 1/6 systolic murmur at the left
lower sternal border. Pulmonary was clear to auscultation
bilaterally, and No wheezes, rhonchi or crackles. Abdomen
was obese, soft, nondistended, decreased bowel sounds, and
nontender. No hepatosplenomegaly. Extremities were warm, no
edema. Pulses were intact bilaterally. Chronic venous
stasis changes bilaterally. Central nervous system revealed
alert and oriented times three. A nonfocal motor and sensory
examination. Rectal per Emergency Room report was
guaiac-negative.
PERTINENT LABORATORY DATA ON ADMISSION: Arterial blood gas
was 7.19/26/112 on 1.5 liters nasal cannula oxygen.
Laboratories at 6 p.m. revealed white blood cell count 13.3,
hematocrit 35.8, platelets 318; differential with neutrophils
of 85%, bands 0, lymphocytes 12.6%, monocytes 2.2%,
eosinophils 2.2%, basophils 0.5%. PT 12.3, PTT 22.4, INR 1.
Sodium 126, potassium 8.5, chloride 95, bicarbonate 10,
BUN 84, creatinine 2, glucose 779, anion gap 30. Creatine
kinase 227, 182. MB of 6. Troponin less than 0.3.
Urinalysis revealed specific gravity 1.018, no blood, nitrite
negative, no protein, greater than 1000 glucose, 15 ketones,
negative bilirubin, 0.2 urobilin, pH of 5, 0 red blood cells,
0 white blood cells, no bacteria, no yeast, less than
1 epithelial cell. Midnight laboratories were sodium 133,
potassium 6.1, chloride 101, bicarbonate 12, BUN 84,
creatinine 2, glucose 610, anion 26. Calcium 8.4,
phosphorous 4.5, magnesium 2.
RADIOLOGY/IMAGING: Electrocardiogram at work revealed sinus
rhythm at 80 with borderline first-degree AV block, normal
axis, 0.5-mm to 1-mm ST depressions in I, aVL, V3 to V6,
decreased voltage in limb and precordial leads, poor R wave
progression. No comparison to previous electrocardiogram.
Electrocardiogram in the Emergency Room revealed normal sinus
rhythm, 0.5-mm ST depressions as above.
Electrocardiogram post sublingual nitroglycerin revealed
normal sinus rhythm, ST depressions resolved, poor R wave
progression.
Chest x-ray on admission revealed no acute pleural or
parenchymal disease.
IMPRESSION: A 54-year-old woman with multiple cardiac risk
factors including hypertension, hypercholesterolemia,
diabetes, family history, and postmenopausal state, who
presented with anginal symptoms consistent with unstable
angina. Recent positive stress test with a reversible
inferior defect and electrocardiogram changes consistent with
anterolateral ischemia as well as diabetic ketoacidosis.
HOSPITAL COURSE:
1. CARDIOVASCULAR: (a) Coronaries: The patient was ruled
out for myocardial infarction with creatine kinases and
troponin being negative. She was placed on aspirin, heparin
drip, and nitroglycerin drip to be titrated to pain. Her
captopril was held on the first night but was started on the
second day of admission. A cholesterol panel was checked.
Lopressor 25 mg p.o. t.i.d. was started for blood pressure
control, and she was scheduled for cardiac catheterization on
[**Last Name (LF) 766**], [**8-30**]. Repeat electrocardiograms were stable.
On the second day of admission she was started on
captopril 12.5 mg p.o. t.i.d. Cholesterol panel revealed a
total cholesterol of 180, LDL 98, HDL 55, triglycerides 136
which were all within normal limits. She was not started on
a lipid-lowering drug.
The patient's cardiac catheterization on [**8-30**] showed
a right dominant heart with a patent left main coronary
artery, diffuse disease of 50% to 60% in the left anterior
descending artery, minimal-to-moderate disease, diffuse
disease in the left circumflex, and total occlusion of her
right coronary artery proximally with right-to-right and
left-to-right collaterals. They were unsuccessful at passing
a wire passed the stenosis and the procedure was terminated.
It was unclear of the age of the right coronary artery
stenosis, especially given the presence of collaterals. It
was recommended that she undergo an exercise thallium in the
near future to evaluate for reversible defects and to then be
evaluated for coronary artery bypass graft if she was at
increased risk; however, it was also felt that her exercise
thallium could be held off until she experienced angina
again.
On [**9-1**] the patient did have hyperkalemia at
approximately 5.7. There were electrocardiogram changes
consistent with hyperkalemia including no peaked T waves.
She was sent home on the following medications for coronary
artery disease, including aspirin 325 mg p.o. q.d. and
metoprolol 50 mg p.o. t.i.d.
(b) Myocardium: The patient had no evidence of congestive
heart failure on examination or on chest x-ray. Her oxygen
saturations remained stable as did her urine output, vital
signs, and weight. The patient was treated initially with
aggressive hydration for her diabetic ketoacidosis. She was
also aggressively hydrated prior to her cardiac
catheterization on [**8-30**]. She was started on
captopril on hospital day two. The patient was sent home on
Lasix 40 mg p.o. q.d. and Zestril 5 mg p.o. q.d.
(c) C-conduction: The patient had prolonged P-R on her
admission electrocardiogram. Her electrolytes were followed
closely and she was maintained on telemetry. She was
interview he unit for one night, and on hospital day two was
stable enough to be transferred to the floor. After her
cardiac catheterization on [**8-30**] she was found to have
a high potassium at 5.7; on repeat it was 5.5, and the
following day it remained elevated at 5.6. On the day of
discharge she was given 15 mg of Kayexalate and instructed to
have her potassium rechecked 48 hours after discharge. She
had no electrocardiogram changes with hyperkalemia including
no peaked T waves.
2. PULMONARY: The patient's pulmonary status remained
stable with stable oxygen saturations throughout her
hospitalization stay. Her chest x-ray on admission showed no
acute cardiopulmonary process, and despite her aggressive
hydration her pulmonary status did remain stable. She was
sent home on Lasix 40 mg p.o. q.d. as she was on at home
prior to admission.
3. ENDOCRINE: The patient was admitted with metabolic
status consistent with diabetic ketoacidosis. It was unclear
whether this precipitated her cardiac ischemia or whether the
cardiac ischemia precipitated the diabetic ketoacidosis.
Other causes for diabetic ketoacidosis were ruled out
including infection of various systems of her body with a
negative chest x-ray and negative urinalysis. The patient
remained afebrile throughout her hospitalization stay. On
admission she had severe hyperglycemia with an increased
anion gap and osmolar gap as well as hyperkalemia. As her
hospital stay progressed, her metabolic status stabilized
quickly. Her anion gap, potassium, and bicarbonate, and
glucose were all followed very closely including every hour
glucose checks for the first 48 hours. She was hydrated
aggressively with intravenous fluids and was on an insulin
drip for the first few hours of her hospital stay.
An Endocrine consultation was requested regarding input of
control of her diabetes with her background of using an
insulin pump for the last several years. The patient was
asked to bring in her own pump from home but while she was
waiting for this to arrive she was covered with a
sliding-scale Humalog for meals and NPH 15 units b.i.d., and
her insulin drip was weaned off on hospital day two. The
patient was asked for her input on insulin dosing as she had
a lot of experience with this. Her NPH dosing was increased
to 20 units b.i.d. On the morning of her cardiac
catheterization her NPH was halved as she was n.p.o.
On [**8-31**] the patient was instructed to resume her
insulin in the morning, and her NPH insulin was discontinued.
However, there was delay with installing her pump and she
became hyperglycemic with a glucose of greater than 400 for
several hours in the afternoon, requiring several units of
regular insulin sliding-scale. That evening she became
hypoglycemic with her glucose reaching to the 40s; however,
she remained asymptomatic and after receiving food and drink
by mouth her glucose normalized and her pump was functioning
appropriately as she was discharged home. The patient was
discharged on her regular dosing of insulin using the pump
and Humalog sliding-scale at meals.
The patient was continued on Synthroid and TSH was checked on
admission. She was also continued on her home dose of
Prempro. Her TSH was low at 0.18, and the patient was
advised to see her endocrinologist in the near future as an
outpatient to perhaps decreasing her Synthroid dose. She was
discharged on the same Synthroid dose that she was admitted
on of 125 mcg p.o. q.d.
4. RENAL: On admission, the patient's creatinine was 2.
Her baseline was unknown. This was thought to be secondary
to prerenal azotemia secondary to her dehydration from her
diabetic ketoacidosis. Her creatinine was followed closely
throughout her hospital stay. On admission her sodium was
falsely decreased secondary to her hyperglycemia but was
within normal limits after correction. Her urine output was
followed and remained stable. Her renal function continued
to improve with aggressive hydration. Upon discharge she was
advised to have her BUN and creatinine rechecked in 48 hours.
5. FLUIDS/ELECTROLYTES/NUTRITION: The patient was hydrated
aggressively on admission to treat her diabetic ketoacidosis.
Her electrolytes were followed closely. The patient was
initially n.p.o. and then her diet was advanced slowly on
hospital day two to a cardiac American Diabetes Association
diet which she tolerated well. Her renal function,
potassium, anion gap, and bicarbonate all continued to
improve. She was n.p.o. overnight in preparation for her
cardiac catheterization on [**8-30**] with her NPH halved
the morning of her catheterization. Her magnesium was
repleted as needed, and afterwards she resumed her regular
diabetic and cardiac diet without problems. She was hydrated
overnight prior to this procedure. After her catheterization
her intravenous fluids were discontinued. On [**8-31**]
she was found to be hyperkalemic, and on [**9-1**] she was
given 15 mg of Kayexalate to treat this. She was advised to
have the potassium rechecked as an outpatient in 48 hours.
6. PROPHYLAXIS: Zantac.
7. LINES: Peripheral IV.
8. CODE STATUS: Full code.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge status was to home.
MEDICATIONS ON DISCHARGE:
1. Lasix 40 mg p.o. q.d.
2. Zestril 5 mg p.o. q.d.
3. Aspirin 325 mg p.o. q.d.
4. Synthroid 125 mcg p.o. q.d.
5. Insulin pump per patient.
6. Humalog sliding-scale per patient.
7. Metoprolol 50 mg p.o. t.i.d.
DISCHARGE INSTRUCTIONS: The patient was to follow up with
her primary care physician and her cardiologist within one to
two weeks after discharge. She should have her potassium,
BUN, and creatinine rechecked on [**Last Name (LF) 2974**], [**9-3**]. She
was also advised to see her endocrinologist in the near
future to discuss her Synthroid dose.
DISCHARGE DIAGNOSES:
1. Unstable angina.
2. Diabetic ketoacidosis.
3. History of type 1 diabetes.
4. Hypercholesterolemia.
5. Hypertension.
6. Hypothyroidism.
7. Peripheral vascular disease.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Last Name (NamePattern1) 7069**]
MEDQUIST36
D: [**2173-9-1**] 22:00
T: [**2173-9-5**] 14:38
JOB#: [**Job Number 21396**]
|
[
"244.9",
"276.5",
"272.4",
"414.01",
"V17.3",
"250.13",
"443.9",
"411.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
2795, 2975
|
14776, 15230
|
14186, 14403
|
2451, 2778
|
6197, 14058
|
14428, 14755
|
14073, 14160
|
160, 1736
|
4264, 6179
|
1758, 2424
|
2992, 3171
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,854
| 167,715
|
3940
|
Discharge summary
|
report
|
Admission Date: [**2143-6-4**] Discharge Date: [**2143-6-7**]
Date of Birth: [**2066-5-31**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
Osteoarthritis/DDH left hip
Major Surgical or Invasive Procedure:
Primary left total hip arthroplasty (press fit) [**2143-6-4**]
History of Present Illness:
Dr. [**Known lastname 17519**] returns today. She is just about two months out from
her [**2142-12-27**] primary right total hip replacement here at
[**Hospital1 18**]. She is doing extremely well. She has been given a
referral to outpatient physical therapy. She
says she has virtually no pain in the right hip at all. Her
focus is shifted to the contralateral left hip discomfort, which
radiographically shows a similar presentation of advanced
osteoarthritis. This pain propagates down the leg to the level
of the mid tibia. While the component of it may be radicular in
nature from the back, I think most of it is certainly coming
from the hip. Towards that end, we sterilely prepped out the
left knee today and injected with Celestone 1 mL plus Marcaine 2
mL in the hope that the predominance of left knee pain over left
lower extremity pain in general may be alleviated. We do not
have any x-rays on this knee, but if the cortisone shot helps,
then we
will perform radiography at the next visit. As for now, we will
get her in to outpatient physical therapy. She takes
antibiotics all the time for dental prophylaxis because of her
cardiac valvular disease. She is very pleased. She is starting
to work on increasing her stamina and potentially as she gets
more fit, she will be able to, I am sure walk further faster and
increase her activity levels. At some point in the future, she
may opt to have a similar procedure done on the left hip, but
that is not at all in the cards for this point.
She comes in for L THR.
I would like to see her back in two months' time. She is doing
extremely well. We will check on her ambulatory status at that
point. She should be full weightbear and using just a cane at
this point.
Past Medical History:
Past Medical History: Rheumatic heart disease as a child with
above-mentioned severe aortic stenosis and 4+ mitral
regurgitation, no evidence of any coronary disease to my
knowledge. She also has hypertension. She apparently has had
syncope twice in the past, and of course, has severe heart
murmurs. She has GERD, but no ulcer history and chronic anemia.
History of colon cancer resection [**2132**] and osteoarthritis.
Surgical History: [**2132**] partial colectomy for cancer, no
subsequent problems, [**2139**] left distal radius ORIF.
Social History:
Russian physician, [**Name10 (NameIs) 4183**] to USA in [**2130**].
Lives locally with son and husband. G1, P1 nonsmoker, denies
alcohol use, rarely able to exercise.
Family History:
Non-contributory
Physical Exam:
Afebrile VSS, A/Ox3
LCTA bilaterally
RRR
ABD soft, NTND, +BS
BLE fully NVI distally with 2+ DP pulses and full strength
throughout
Painful and limited ROM of L hip
Pertinent Results:
[**2143-6-4**] 03:57PM TYPE-ART TEMP-37.2 RATES-/14 TIDAL VOL-400
PEEP-0 O2-40 PO2-161* PCO2-42 PH-7.38 TOTAL CO2-26 BASE XS-0
INTUBATED-INTUBATED VENT-SPONTANEOU COMMENTS-PSV 5CM
[**2143-6-4**] 10:54AM TYPE-ART TEMP-34.4 PO2-210* PCO2-49* PH-7.33*
TOTAL CO2-27 BASE XS-0
[**2143-6-4**] 10:54AM LACTATE-1.5 K+-3.6
[**2143-6-4**] 10:54AM freeCa-1.16
[**2143-6-4**] 10:47AM GLUCOSE-163* UREA N-25* CREAT-0.7 SODIUM-141
POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-26 ANION GAP-10
[**2143-6-4**] 10:47AM estGFR-Using this
[**2143-6-4**] 10:47AM CALCIUM-7.9* PHOSPHATE-3.0 MAGNESIUM-2.4
[**2143-6-4**] 10:47AM WBC-9.9 RBC-3.00* HGB-9.6* HCT-28.9* MCV-96
MCH-32.0 MCHC-33.2 RDW-13.5
[**2143-6-4**] 10:47AM PLT COUNT-227
[**2143-6-4**] 09:46AM TYPE-ART PO2-118* PCO2-40 PH-7.38 TOTAL
CO2-25 BASE XS-0 INTUBATED-INTUBATED
[**2143-6-4**] 09:46AM GLUCOSE-171* LACTATE-1.4 NA+-138 K+-3.8
CL--109
[**2143-6-4**] 09:46AM HGB-10.2* calcHCT-31
[**2143-6-4**] 09:46AM freeCa-1.09*
[**2143-6-4**] 08:47AM TYPE-ART PO2-244* PCO2-42 PH-7.39 TOTAL
CO2-26 BASE XS-0
[**2143-6-4**] 08:47AM GLUCOSE-131* LACTATE-1.4 NA+-139 K+-3.2*
CL--107
[**2143-6-4**] 08:47AM HGB-10.7* calcHCT-32
[**2143-6-4**] 08:47AM freeCa-1.14
[**2143-6-6**] 06:30AM BLOOD WBC-7.8 RBC-2.65* Hgb-8.7* Hct-24.4*
MCV-92 MCH-32.7* MCHC-35.5* RDW-14.4 Plt Ct-146*
[**2143-6-5**] 02:28AM BLOOD WBC-7.3 RBC-3.01* Hgb-9.7* Hct-28.5*
MCV-95 MCH-32.1* MCHC-33.9 RDW-14.6 Plt Ct-182
[**2143-6-4**] 10:47AM BLOOD WBC-9.9 RBC-3.00* Hgb-9.6* Hct-28.9*
MCV-96 MCH-32.0 MCHC-33.2 RDW-13.5 Plt Ct-227
[**2143-6-6**] 06:30AM BLOOD Glucose-109* UreaN-14 Creat-0.8 Na-137
K-4.0 Cl-104 HCO3-27 AnGap-10
[**2143-6-5**] 02:28AM BLOOD Glucose-194* UreaN-14 Creat-0.7 Na-137
K-4.0 Cl-108 HCO3-22 AnGap-11
[**2143-6-4**] 10:47AM BLOOD Glucose-163* UreaN-25* Creat-0.7 Na-141
K-3.8 Cl-109* HCO3-26 AnGap-10
[**2143-6-6**] 06:30AM BLOOD Calcium-8.2* Phos-2.2* Mg-2.2
[**2143-6-5**] 02:28AM BLOOD Calcium-8.1* Phos-2.3* Mg-2.0
[**2143-6-4**] 10:47AM BLOOD Calcium-7.9* Phos-3.0 Mg-2.4
[**2143-6-4**] 10:54AM BLOOD Lactate-1.5 K-3.6
[**2143-6-4**] 09:46AM BLOOD Glucose-171* Lactate-1.4 Na-138 K-3.8
Cl-109
[**2143-6-4**] 08:47AM BLOOD Glucose-131* Lactate-1.4 Na-139 K-3.2*
Cl-107
[**2143-6-4**] 09:46AM BLOOD Hgb-10.2* calcHCT-31
[**2143-6-4**] 08:47AM BLOOD Hgb-10.7* calcHCT-32
[**2143-6-5**] 02:40AM BLOOD freeCa-1.12
[**2143-6-4**] 10:54AM BLOOD freeCa-1.16
Brief Hospital Course:
The patient was admitted on [**2143-6-4**] and taken to the operating
room by Dr. [**Last Name (STitle) **] where the patient underwent left hip total
joint arthroplasty. The procedure was well tolerated there were
no complications. Please see the separately dictated operative
report for details regarding the surgery. The patient was
subsequently transferred to the surigical intensive care unit in
stable condition for overnight observation given her heart
history and transferred to the floor the next day.
Overnight, the patient was placed on a IV morphine for pain
control. IV antibiotics were continued for 24 hours
postoperatively for prophylaxis. Lovenox was started the
morning of POD#1 for DVT prophylaxis. Hct was 28.9 and was
transfused 1u PRBC.
On postoperative day 1, the drain was removed without incident.
The patient was weaned off of the IV narcotics and onto oral
pain medications. Xrays of L hip and femur obtained in SICU from
Pt's c/o L thigh pain. Xrays negative. Hct 28.5 and will
recheck the next day.
On postoperative day 2, the Foley catheter was kept for hct
24.4. 2 units RBCS ordered and foley kept in. Pt had pulmonary
edema from 1st unit of R RBC and lasix 10mg iv x1 was not
adequate. Pt c/o shortness of breath. CXR confirmed pulm edema
and lasix 20mg iv x1 given. Pt's breathing better. EKG neg.
Troponin's neg x2.
POD3: The surgical dressing was also removed, and the surgical
incision was found to be clean, dry, and intact without erythema
nor purulent drainage.
During the hospital course the patient was seen daily by
physical therapy. Labs were checked both post-operatively and
throughout the hospital course and repleted accordingly. The
patient was tolerating regular diet and otherwise feeling well.
Prior to discharge the patient was afebrile with stable vital
signs. Hematocrit was stable and pain was adequately controlled
on a PO regimen. The operative extremity was neurovascularly
intact and the wound was benign.
On POD# 3 the patient was discharged to rehab in a stable
condition.
Medications on Admission:
diovan 80', metoprolol 12.5', hctz 12.5', naprosyn 375'',
tylenol, calcium, hydrocodone
Discharge Medications:
1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
2. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO Q6H (every 6 hours) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at
bedtime)) as needed for insomnia.
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) mg Subcutaneous
once a day for 3 weeks: Please take for 3 weeks then start asa
325 po bid x 3 weeks more for a total of 6 weeks anticoaguation.
14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO twice a day for
3 weeks: please start after 3 weeks of lovenox for a total of 6
weeks of anticoagulation.
15. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
18. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One
(1) Packet PO BID (2 times a day) for 3 days.
19. Promethazine HCl 25 mg IV Q6H:PRN nausea
20. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
21. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting
22. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day) for 2 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Osteoarthritis/DDH left hip
Discharge Condition:
stable
Discharge Instructions:
Please seek medical attention if you have any nausea, vomiting,
fever greater than 101.5, chest pain, shortness of breath,
increased pain/redness/drainage from your incision site,
numbness/tingling, or any other concerning symptoms.
Take all medications as prescribed and resume home medications,
please take a stool softener if taking narcotic pain
medications, please taper down pain medication use as tolerated.
No driving nor operating heavy machinery while using narcotic
pain medications.
ANTICOAGULATION: Take lovenox injections (40mg) once a day x 3
weeks and then take aspirin 325 mg [**Hospital1 **] x 3 weeks. [**Month (only) 116**]
discontinue all blood thinners 6 weeks post-operatively.
WOUND CARE: Keep your incision clean and dry. Okay to shower
after POD#5 but do not tub-bath or submerge your incision.
Please place a dry sterile dressing to the wound each day if
there is drainage, leave it open to air. Check wound regularly
for signs of infection such as redness or thick yellow drainage.
Staples will be removed at the first post-op visit.
ACTIVITY: Weight bearing as tolerated to operative leg.
Posterior hip precautions at all times. No strenuous exercise or
heavy lifting until follow up appointment, at least.
VNA (after home): Home PT/OT, dressing changes as instructed,
and wound checks
Please call Dr. [**Last Name (STitle) **]?????? office to confirm your follow-up
appointment for within 10-14 days of surgery.
Physical Therapy:
Activity: Activity as tolerated
Pneumatic boots
Right lower extremity: Full weight bearing
Left lower extremity: Full weight bearing
encourage turn, cough and deep breathe q2hr when awake.
Treatments Frequency:
Site: L hip
Type: Surgical
Dressing: Gauze - dry
Change dressing: Other
Comment: to be changed POD by HO then prn changes
Followup Instructions:
Please call Dr. [**Last Name (STitle) **]?????? office to confirm your follow-up
appointment for within 10-14 days of surgery.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2143-6-17**]
4:30
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2143-7-8**] 10:40
Completed by:[**2143-6-7**]
|
[
"530.81",
"715.35",
"V10.05",
"V43.64",
"396.2",
"428.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"81.51"
] |
icd9pcs
|
[
[
[]
]
] |
10008, 10074
|
5615, 7680
|
343, 408
|
10146, 10155
|
3177, 5592
|
12032, 12468
|
2954, 2972
|
7818, 9985
|
10095, 10125
|
7706, 7795
|
10179, 10890
|
2987, 3158
|
11659, 11855
|
11878, 12009
|
276, 305
|
10902, 11641
|
436, 2181
|
2226, 2752
|
2768, 2938
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,490
| 125,089
|
43448
|
Discharge summary
|
report
|
Admission Date: [**2155-10-28**] Discharge Date: [**2155-11-4**]
Date of Birth: Sex: M
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 40-year-old
male with a history of Crohn's disease status post small
bowel resection in [**2141**] and now with recurrent small bowel
strictures. The patient has a distal ileal disease with
ileal fistulae.
The patient has had increased right upper quadrant pain.
Three weeks ago, a CT showed terminal ileal thickening with a
phlegmon. Small bowel followthrough showed multiple partial
strictures. The patient is currently without fever, chills,
nausea, vomiting, change in appetite. He has had slight
diarrhea. He has been on antibiotics. The patient does
respond well to prednisone and antibiotics for his Crohn's
disease.
PAST MEDICAL HISTORY: His Crohn's was diagnosed in [**2139**].
The patient has a history of gastric ulcers. He has had a
terminal ileum bleed requiring embolization in [**2150**]. In
[**2145**], he had a Dieulafoy lesion cauterized in the stomach.
He has had anal fistulas.
PAST SURGICAL HISTORY: Previous surgery includes 3 small
bowel resections in [**2141**].
HOME MEDICATIONS:
1. Prednisone 40 mg p.o. q.d.
2. 6-mercaptopurine 50 mg p.o. q.d.
3. Pentasa 14 pills per day, currently on hold.
4. Calcium.
5. Prilosec over-the-counter.
6. Levaquin 500 mg p.o. q.d.
7. Flagyl 250 mg p.o. t.i.d.
8. Vitamin B12 shots every month.
ALLERGIES: ZANTAC, WHICH CAUSES A RASH.
PHYSICAL EXAMINATION: The patient in general is alert and
oriented x3, in no acute distress, a healthy-appearing male.
Mucous membranes are moist. Chest is clear to auscultation
bilaterally, with no crackles, wheezes, or rhonchi. Cardiac:
Regular rate and rhythm. No murmurs. Abdomen is soft,
nontender, and nondistended. The patient does have a
supraumbilical hernia just above a midline incision that is
well healed.
HOSPITAL COURSE: The patient was admitted on [**2155-10-28**], taken
directly to the operating room where an ileal resection,
stricturoplasty, and intestinal bypass of the Michelassi type
were performed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1888**] and Dr. [**First Name (STitle) **] [**Name (STitle) **]. The
patient did receive perioperative heparin subcutaneously and
perioperative antibiotics, including Cipro and Flagyl. The
patient tolerated the procedure quite well. He was initially
left n.p.o. and on IV fluids while receiving his
perioperative antibiotics, subcutaneous heparin, and Venodyne
boots for deep vein thrombosis prevention. The patient was
also placed on IV hydrocortisone for steroid stress, which
was tapered over the next couple of days. He was quickly
placed on CellCept, but left on CellCept for an extended
period of time, as it was felt that the patient should show
true signs of bowel function before having diet advanced.
The patient did receive a PCA for pain control, which helped
his pain considerably. Over the next couple of days, the
patient was watched for a return of bowel function, which was
slow to come but did eventually come. He was advanced to a
regular diet starting with clears when it became evident that
the patient had started passing gas and bowel movements. The
patient did have his hydrocortisone weaned down to 20 mg of
prednisone p.o. q.d. His antibiotics were stopped; however,
some erythema began at his incision site, and the patient was
placed on IV Kefzol for treatment of the wound cellulitis.
CONDITION ON DISCHARGE: It is now [**2155-11-4**], and the patient
is being discharged in good condition. He is being
discharged on a regular diet.
DISCHARGE INSTRUCTIONS: He may observe his regular activity,
although he may not lift anything greater than 10 pounds for
6 weeks and he may not drive while on pain medication. He
may take showers but may not take baths. His staples were
left in place and will be taken out in Dr.[**Name (NI) 4999**] office in
followup in approximately 1 week. He is being instructed to
return to the hospital if he experiences chills, fever
greater than 101.5 degrees Fahrenheit, if he experiences
excessive redness, swelling, or tenderness to the wound, or
pus or foul-smelling drainage begins to ooze from it.
DISCHARGE MEDICATIONS: He is also being told that he is not
to restart his home dose of prednisone, but a new dose is
being sent, and that he should not restart his 6-
mercaptopurine, Levaquin, Flagyl, or Pentasa. The patient is
being sent home on new medications. These include:
1. Keflex 500 mg p.o. t.i.d. for 7 days.
2. Prednisone 20 mg p.o. q.d.
3. Percocet 1-2 tablets p.o. q.4h. p.r.n. pain.
4. Prilosec 10 mg p.o. b.i.d.
FINAL DISCHARGE DIAGNOSES: Crohn's disease.
Status post ileocolonic resection, stricturoplasty, and
Michelassi procedure.
Wound cellulitis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7821**], [**MD Number(1) 7822**]
Dictated By:[**Last Name (NamePattern1) 3956**]
MEDQUIST36
D: [**2155-11-6**] 18:01:51
T: [**2155-11-8**] 06:04:27
Job#: [**Job Number 93501**]
|
[
"560.89",
"682.2",
"998.59",
"555.0",
"E878.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.62",
"45.91"
] |
icd9pcs
|
[
[
[]
]
] |
4307, 4717
|
1951, 3530
|
3706, 4283
|
1130, 1197
|
1215, 1507
|
1530, 1933
|
4745, 5132
|
179, 828
|
851, 1106
|
3555, 3681
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,840
| 113,439
|
21391
|
Discharge summary
|
report
|
Admission Date: [**2147-7-25**] Discharge Date: [**2147-7-28**]
Date of Birth: [**2102-4-23**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 25876**]
Chief Complaint:
increased SOB and abdominal girth over the past 3 days with
subjective fevers
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient presented to ED with increased SOB and abdominal girth
over the past 3 days with subjective fevers. She reports
increased nausea with poor po intake but no diarrhea, melena or
hematochezia. She also reports cough productive of bloody sputum
for the last two days. She dnies any dysuria, hematuria,
frequency or urgency.
In the ED she was febrile and hypotensive and was given 4L NS
with improved hypotension but developed respiratory distress.
CXR was c/w PNA with superimposed CHF so she was given 20mg IV
lasix X 2 with good effect. She was transferred to the [**Hospital Unit Name 153**] for
further management.
Pt initially hypotensive in [**Hospital Unit Name 153**], receiving stress dose steroids
until home doses were available. No documented fevers. Pt states
her breathing is now improved.
Past Medical History:
Onc hx:
Initially presented with mole at her left flank which grew and
turned black. She underwent a resection of a 12.5-mm thick
ulcerated melanoma from her left abdominal wall in [**Month (only) 958**] of
[**2145**]. She underwent wide local excision and sentinel node
biopsy, with melanoma present in one of four inguinal sentinel
lymph nodes. On [**2146-5-11**], she underwent complete left inguinal
node dissection, with no melanoma in three remaining lymph
nodes. She was enrolled in intergroup protocol S0008 and was
randomized to the biochemotherapy arm. She received three cycles
of biochemotherapy initiated on [**2146-7-11**]. Following that
therapy, she developed a psychotic depression, which fully
resolved on antidepressant therapy. CT scans in [**Month (only) 116**] showed
possible bilateral pulmonary nodules. PET scans in [**Month (only) **]
confirmed metastatic disease in the lungs, liver, and bone and a
head MRI showed multiple small CNS metastases. Upon
documentation of this CNS metastases, she was referred to
Neuro-Oncology for evaluation. She underwent an LP, which
disclosed no evidence of leptomeningeal disease. Because of
multiple CNS lesions and skull metastasis, she was started on
whole brain radiation in early [**Month (only) 205**]. She completed her treatment
last Wednesday.
Social History:
originally from [**Country 38213**], moved to US with family 2 1/2 years
ago. Worked as cashier. 2 daughters in college and husband.
[**Name (NI) **] [**Name2 (NI) **]/EtOH or drugs.
Family History:
no melanoma
Physical Exam:
T 97.8 HR 120 BP 120/80 RR 18 O2sat 94% on 2L NC
HEENT: PERRL, EOMI O/P clear
CVS: tachycardic, regular, S1, S2
lungs: crackles on L base, fair air entry
Abd: tense, mild diffuse tenderness, no rebound or guarding,
significant ascites present
Extrem: 2+ radial and DP pulses
Neuro: grossly intact
Pertinent Results:
[**2147-7-24**] 11:45PM URINE RBC-<1 WBC-<1 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2147-7-24**] 11:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG
[**2147-7-24**] 11:45PM PLT SMR-VERY LOW PLT COUNT-57*#
[**2147-7-24**] 11:45PM WBC-5.8 RBC-2.85*# HGB-8.6*# HCT-24.4*#
MCV-86 MCH-30.4 MCHC-35.5* RDW-14.0
[**2147-7-24**] 11:45PM NEUTS-69 BANDS-4 LYMPHS-10* MONOS-10 EOS-1
BASOS-0 ATYPS-0 METAS-3* MYELOS-3*
[**2147-7-24**] 11:45PM GLUCOSE-110* UREA N-21* CREAT-0.6 SODIUM-136
POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-28 ANION GAP-15
[**2147-7-24**] 11:45PM ALT(SGPT)-87* AST(SGOT)-54* ALK PHOS-198*
AMYLASE-72 TOT BILI-0.4
[**2147-7-24**] 11:56PM LACTATE-3.2*
[**2147-7-25**] 07:42PM WBC-6.4 RBC-3.20* HGB-9.3* HCT-27.0* MCV-85
MCH-29.1 MCHC-34.4 RDW-14.9
CT: Marked interval progression of metastatic disease -
innumerable new liver mets with hepatomegaly, new adrenal mets,
splenic mets, intraperitoneal seeding with ascites, breast
nodules, lungs mets, diffuse alveloar opacities likely
represents lymphatic spread of tumor with interstitial edema, no
obstruction, focal consolidation in right lower lobe.
Brief Hospital Course:
Hypotension - resolved following initial hydration with 4L IVF
in ED. No further episodes of hypotension. Pt initially on
stress dose steroids, later switched to home dose of decadron
2mg [**Hospital1 **].
Respiratory distress - initial shortness of breath worsened
after IVF but improved after some lasix. CXR consistent with
pneumonia given hx of fevers and cough, but metastatic spread
also possible. Pt remained afebrile in hospital. Started on
levo/flagyl. Pt was chronically oxygen dependent, stable on 4L
per nasal cannula
Ascites - pt tolerating discomfort, does not want therapeutic
tap at this time, likely would reccur quickly.
Anemia: some vague hx of vaginal bleeding. No other known
bleeding. Received 2 units pRBC during hospitalization. No
bleeding noted in hospital.
Depression: Continued on home Zoloft and Risperidone.
Metastatic Melanoma - prognosis dire, after discussion between
hematology/oncology and pt and her family, it was decided that
pt would go home with hospice care.
Contact: daughters [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 56508**] [**Doctor First Name 56509**]
[**Telephone/Fax (1) 56510**]
Discharge Medications:
1. Risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
2. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 11 days.
Disp:*11 Tablet(s)* Refills:*0*
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 11 days.
Disp:*33 Tablet(s)* Refills:*0*
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:*0*
7. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **]
Discharge Diagnosis:
Metastatic Melanoma
Pneumonia
Discharge Condition:
guarded
Discharge Instructions:
Please follow-up with your oncology physician as desired.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 24699**] office as needed with questions.
Completed by:[**2147-7-28**]
|
[
"285.1",
"311",
"198.7",
"197.0",
"486",
"198.5",
"196.8",
"198.3",
"428.0",
"V10.82",
"789.5",
"287.5",
"518.81",
"197.7"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6406, 6457
|
4340, 5497
|
394, 401
|
6531, 6540
|
3140, 4317
|
6646, 6756
|
2795, 2808
|
5520, 6383
|
6478, 6510
|
6564, 6623
|
2823, 3121
|
277, 356
|
429, 1238
|
1260, 2577
|
2593, 2779
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,940
| 107,541
|
27739
|
Discharge summary
|
report
|
Admission Date: [**2185-6-7**] Discharge Date: [**2185-6-17**]
Date of Birth: [**2128-9-11**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
severe pancreatitis
ARDS requiring intubation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
56 y/o transferred from [**Hospital 1562**] Hosp via Med Flight for
hemorrhagic pancreatitis & respiratory failure. Pt originally
admitted to [**Hospital 1562**] Hosp on [**2185-6-2**] from [**Location (un) 3244**] Detox center
following a three week history of binge drinking with epigastric
pain, N/V for 2 days PTA. Dx'd with severe pancreatitis with
hemmorrhagic component. (On coumadin for Afib) requiring 6 u
PRBCs, 6 FFP and plts. Pt intubated at OLH for airway
protection. On [**6-7**] pt transferred to [**Hospital1 18**] for continued care.
Past Medical History:
depression
EtOh at detox
A fib
HTN
Social History:
Married
Hx ETOH abuse (20 oz/day per pt report)
Denies tobacco, IVDA
Family History:
non-contributory
Physical Exam:
On admission to [**Hospital1 18**] SICU:
Patient Intubated and sedated
Coarse bilateral BS
RRR
Abdomen soft with rebound and guarding
Extremeties, Trace Edema.
Now on [**6-17**]
VSS 98.3, 59 112/64 18 100%RA FSBS 66-231
NAD, RRR, Lungs CTA bilaterally,
Abd soft, NT, ND with + BS
Extremeties, no edema noted
Diet advancing to regular, tolerating well
Pertinent Results:
Initial Amylase/Lipase from [**2185-6-3**] [**Telephone/Fax (1) 67692**]
Labs from [**2185-6-7**] 06:16PM
ART PO2-82* PCO2-49* PH-7.35 TOTAL CO2-28 BASE XS-0
GLUCOSE-121* LACTATE-0.9
freeCa-1.12
GLUCOSE-123* UREA N-28* CREAT-1.9* SODIUM-149* POTASSIUM-3.9
CHLORIDE-114* TOTAL CO2-26 ANION GAP-13
ALT(SGPT)-27 AST(SGOT)-68* LD(LDH)-1848* ALK PHOS-177* TOT
BILI-1.8*
AMYLASE-105* LIPASE-254*
ALBUMIN-2.7* CALCIUM-7.7* PHOSPHATE-2.7 MAGNESIUM-2.2
WBC-6.5 RBC-3.43* HGB-10.7* HCT-31.1* MCV-91 MCH-31.3 MCHC-34.4
RDW-15.8*
NEUTS-69 BANDS-2 LYMPHS-11* MONOS-13* EOS-3 BASOS-0 ATYPS-0
METAS-2*
PLT COUNT-172
PT-18.8* PTT-25.8 INR(PT)-1.8* FIBRINOGEN-1224*
CT: [**2185-6-9**] severe pancreatitis w/lg amt fluid/stranding around
the pancreas extending into L paracolic gutter, L ant/post
perirenal space, free fluid in the pelvis,
Labs from [**2185-6-17**]
Na 141 K 4.2 Cl 108 Co2 20 BUN 26 Creat 1.3 glucose 103
Ca: 9.3 Mg: 1.9 P: 4.2
AST: 34 ALT: 47 AP: 127 Tbili: 0.8 Alb: 3.9
[**Doctor First Name **]: 137 Lip: 430
WBC 7.5 Hgb: 11.7 Hct 35.5 Plt 638
PT: 14.1 PTT: 27.8 INR: 1.3
Brief Hospital Course:
57 y/o male with known ETOH abuse, HTN, hyperlipidemia, AFib on
Coumadin/digoxin transferred from [**Hospital 1562**] Hosp after 5 day
admission for hemorrhagic pancreatitis and ARDS. On arrival to
SICU pt was intubated and sedated and was receiving TPN,
imipenem (7 day course). No pressor support. During the one week
ICU course, pt was slowly weaned from vent support, started on
TF and diuresed. Pt did have some renal failure during the
course, but this has since resolved, with current creat at
probable baseline of 1.3. CT showed evidence of severe
pancreatitis with a large amount of fluid and stranding
surrounding the pancreas, extending into the left paracolic
gutter, left anterior and posterior perirenal space, and right
perirenal space. Free fluid is seen extending down into the
pelvis. Assessment of pancreas enhancement is limited, but
appears relatively uniform. No definite thrombus is identified
within the portal and splenic veins. There were also moderate to
large bilateral pleural effusions with associated atelectasis.
Extubation was on [**6-12**], and patient continued to improve and was
transferred to the regular floor on [**6-15**]. Originally pt had a
1:1 sitter which was d/c'd on [**6-16**]. Pt has worked with PT and
has advanced diet. It was felt that he did not require physical
rehab. He required outpatient counseling/work at detox center.
He was discharged home on insulin. He was instructed in how to
check his blood sugars as well as self administer insulin.
He was advised to follow up with PCP as well as an outpatient
gastroenterologist.
Medications on Admission:
Coumadin 5', Digoxin o.125', Lisinopril 40', Librium prn, Librax
0.5',
Effexor XR 150', Lipid 600'
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
3. Insulin Glulisine 100 unit/mL Solution Sig: Ten (10) ubits
Subcutaneous once a day.
Disp:*1 * Refills:*2*
4. Humalog 100 unit/mL Solution Sig: follow sliding scale
Subcutaneous four times a day.
Disp:*1 * Refills:*2*
5. syringes
1 box
refill:2
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] home health
Discharge Diagnosis:
pancreatitis: resolving
Discharge Condition:
good
Discharge Instructions:
Call [**Telephone/Fax (1) 67693**] with increasing abdominal or back pain,
fever,chills, nausea, vomiting or diarrhea.
Followup Instructions:
Call Primary Care physician for appointment in 2 weeks for
management of blood pressure medications
Completed by:[**2185-7-1**]
|
[
"577.0",
"584.9",
"427.31",
"530.6",
"251.8",
"291.81",
"428.0",
"518.0",
"401.9",
"303.01",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62",
"38.91",
"99.15",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5019, 5078
|
2629, 4214
|
358, 364
|
5146, 5153
|
1512, 2606
|
5320, 5450
|
1105, 1123
|
4363, 4996
|
5099, 5125
|
4240, 4340
|
5177, 5297
|
1138, 1493
|
273, 320
|
392, 945
|
967, 1003
|
1019, 1089
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,098
| 158,780
|
18833+56991
|
Discharge summary
|
report+addendum
|
Admission Date: [**2162-3-10**] Discharge Date: [**2162-4-8**]
Date of Birth: [**2116-6-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
worsening lower extremity edema
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 45yo female with HCV cirrhosis, R-sided CHF p/w increasing
bilateral [**Location (un) **], DOE. Recent admit [**Date range (1) 51555**] ([**Doctor Last Name 22583**] [**Location (un) **]). This
admission was for hypotension and lightheadedness. She had a
short stay in the MICU however etiology of hypotension was
unclear, however felt most likely secondary to right sided HF
and possible hypovolemia. However unfortuantely with hydration
she experienced worsening edema for which she got diuretics.
Also had episode of confusion during her stay which was
ultimately found to be caused by a UTI which was treated with
levofloxacin. She was discharged last Thursday with plans for
close follow up with [**Hospital **] clinic. Over the past week the patient
states she has been taking her meds as prescribed however her LE
edema continued to worsen. However she does state that her
weight has not changed from discharge at 264 pounds. Along with
worsening edema she noted onset of SOB this AM. She denies any
chest pain, N/V, diaphoresis, palpitations. No recent fevers,
chills. Denies any sick contacts. [**Name (NI) **] she has been following
low sodium diet and watching her fluid intake.
Past Medical History:
1. Asthma
2. Pulmonary HTN - cathed [**8-/2161**], mean PA pressure 63 mmHg.
Right-
sided filling pressures severely elevated: RA mean 24 mmHg,
RVEDP
24 mmHg). Left sided filling pressures mildly elevated: PCW 20
mmHg.
3. Thrombocytopenia
4. IDDM - unknown duration, on Lispro and NPH at home.
5. RHF - Echo in 7/[**2161**]. EF>55%, Global right ventricular
hypokinesis.
6. Liver cirrhosis - HCV positive Ab, neg VL in [**8-/2161**], not a
transplant candidate due to cor pulmonale. LFTs have been stable
since previous admission in 12/[**2161**].
Social History:
Smoke cigaretes on occasiona, last one 2 days ago. Denies any
etoh, IVDU. Lives alone with her cat.
Family History:
HTN
CAD
Breast CA
Physical Exam:
Gen: Obese female, comfortable, NAD
HEENT: clear OP, mmm, PERRL, EOMI
Neck: supple, no LAD, no thyromegaly, JVD to the ear
Lungs: Poor inspiratory effort and difficult to hear [**3-17**]
obesity. Otherwise clear no crackles, wheezes
Heart: RRR + S1/S2 no m/r/g
Abd: Large edematous pannus that is tender to the touch, soft,
ND, +BS
Ext: 2+ pitting edema in LE foot to sacrum, 2+ DP's
Neuro: A&O times 3, pt appropriate, no signs of delerium, no
asterixis
Pertinent Results:
[**2162-3-10**] 09:55AM WBC-4.3 RBC-2.34* HGB-7.8* HCT-25.4* MCV-109*
MCH-33.5* MCHC-30.9* RDW-16.9*
[**2162-3-10**] 09:55AM PLT COUNT-84*
[**2162-3-10**] 09:55AM NEUTS-50.6 LYMPHS-38.2 MONOS-7.8 EOS-2.6
BASOS-0.8
[**2162-3-10**] 09:55AM GLUCOSE-113* UREA N-13 CREAT-1.4* SODIUM-133
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-24 ANION GAP-10
[**2162-3-10**] 09:55AM ALT(SGPT)-55* AST(SGOT)-123* LD(LDH)-563* ALK
PHOS-80 TOT BILI-4.4*
[**2162-3-10**] 09:55AM ALBUMIN-2.6*
Abdominal US: The liver parenchyma is relatively unremarkable.
The portal vein is patent but has reversed (centrifugal flow).
No evidence of thrombus within the portal vein. The main hepatic
artery is visualized. Left branch of the portal vein is also
patent. The splenic vein and splenomesenteric confluence appears
patent.
There is no evidence of significant ascites. Some
subcutaneous edema and induration is identified, but no clearly
identified fluid collection.
Brief Hospital Course:
45 yo woman w/ h/o HCV cirrhosis, right sided HF, recently d/c
after treatment of orthostatic hypotension, now a/w worsening
LE edema and cough.
1. Cor pulmonale: she has severe right sided heart failure [**3-17**]
pulm HTN, which is responsible for her complaints of peripheral
edema. This has been difficult to control given her concurrent
cirrhosis w/ low albumin. Aggressive diuresis depletes
intravascular volume and deprives RV of high filling volumes
that are needed to maintain cardiac output. There is no
evidence of ACS by EKG and cardiac enzymes. We transitioned her
to PO lasix with success. Her fluid status is very tenuous
therefore if her weight increases, he Lasix may need to be
increased.
2. Pulm HTN: this is likely [**3-17**] portopulmonary HTN. It was
unresponsive to NO2 during cath. There are few remaining
options for treatment in this pt. Dr. [**Last Name (STitle) **] was consulted for
this patient and it was determined that there were no other
therapies with would change this patient's poor prognosis.
3. HCV cirrhosis: She has cirrhosis from HCV and h/o etoh
abuse. She denies any recent ETOH. LFTs have been stable for
months though her synthetic function is comprimised. RUQ
doppler US shows no evidence of ascites or portal thrombosis.
The patient intermittenly becomes encheplpathic and this usually
correlates with her refusal of lactulose. She will continue the
lactulose TID for [**2-14**] BM q day.
4. Coagulopathy: [**3-17**] cirrhosis w/ thrombocytopenia. No evidence
of bleeding though she has had a recent GIB. She should be
transfused for platelets less than 50.
5. Asthma: well controlled w/ advair and albuterol; Continue
current regimin.
6. DM: Her DM was controlled with NPH and regular insulin SS.
7. Anemia: She has h/o hemolytic anemia on last admission in
setting of mycoplasma IgM, now s/p course of levaquin. HCT
remained low on admission. No evidence of active bleeding. She
was transfused 2 units PRBCs during this admission. Her HCT was
stable following this. Her hemolytic workup was negative. This
workup can be continued as an outpatient.
8. Mental Status: The patient has had changes in her mental
status before and during this admission, she had several days
where her mental status was altered. This was very difficult to
assess because even when she was felt to be cleared, she would
continually incoorperative with interviews and exams. When she
was altered, she would responed to questions with often correct
answers, but repeat her answers many times, even after the team
had left the room. These episodes corresponded to times when the
paitent would refuse her lactulose and she would improve with
more lactulose. It was felt to be caused by hepatic
encalholpaty. Though it is very difficult for the patient to
have multiple BM/day, she will need to continue lactulose daily.
Given her diagnoses, her mental status will likely deterioate.
9. Trichomonas infection: The pateitn was found to have
occasinnal trichonomas on a routine UA. She was asked about
sexual contacts but would not coorperate with interviews. She
refused a pelvic exam. She was treated with Flagyl 500 PO BID fo
2 days and will continue this fo 5 days as an outpatient. She
should have a pelvic exam as an outpatient for GC and chalmyidia
screens and preventative health care.
10. Care Plan: The team had multiple discussion with the patient
and her family about her poor prognosis. The patient was not
receptive to the conversations and often said she did not want
to think of these topics and directed us to talk with her
mother. The mother, brother, and sister-in-law are very involved
and understand the patient's prognosis. It was agreed that the
patietn could not take care of herself at home and discharged to
a rehab. The paitnet has not designated a health care proxy and
she does not want to discuss her code status on multiple
attments by the team.
Medications on Admission:
1.Albuterol MDI 1-2 Puffs q6 hr prn
2.Fluticasone-Salmeterol 250-50 mcg 1 inhalation [**Hospital1 **]
3.Pantoprazole 40 mg q12 hr
4.Lactulose 30 ml tid
5.Levofloxacin 500 mg
6.Furosemide 40 mg po qam
7.NPH insulin 25 units qam
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed: ** Do not exceed 2gm/day**.
4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for sbp<100; do not give after 3PM.
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day): hold if having 3 BMs per day .
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day.
8. Insulin NPH Human Recomb 100 unit/mL Syringe Sig: Twenty (20)
units Subcutaneous qAM: Hold if patient not eating.
9. Insulin NPH Human Recomb 100 unit/mL Syringe Sig: Fifteen
(15) units Subcutaneous qPM: Hold if patient not eating.
10. Insulin Regular Human 300 unit/3 mL Syringe Sig: as per RISS
Subcutaneous four times a day: administer per ISS.
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 5 days.
12. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO Every
other Day.
13. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
Roscommon
Discharge Diagnosis:
ETOH and HCV cirrhosis
right sided heart failure
pulmonary hypertension
asthma
diabetes type II
cor pulmonale
Discharge Condition:
good, stable. Fluid status well controlled with PO lasix.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L
You should be having [**3-18**] bowel movements per day.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5265**], M.D. Where: [**Hospital6 29**] REHAB
SERVICES (DYSPNEA) Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2162-3-23**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2162-3-23**] 2:30
Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2162-3-23**]
10:15
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD (PCP) at [**Hospital6 **]. [**4-1**] at 1:30
PM
Name: [**Known lastname 855**],[**Known firstname 9591**] Unit No: [**Numeric Identifier 9592**]
Admission Date: [**2162-3-10**] Discharge Date: [**2162-4-8**]
Date of Birth: [**2116-6-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2339**]
Addendum:
# LGIB: The patient had been ready for discharge and was then
noted to have BRBPR. She underwent colonoscopy which revealed a
blood clot overlying a visible vessel which was thought to be a
bleeding artery. She underwent epinephrine injection and
cauterization. The bleeding was thought [**3-17**] a Dieulafoy's
Lesion. Her hematocrit, though stable when she had the bleeding,
began to decrease from 30 to 27 therefore she was transfused
with 1 PRBC unit with Lasix. She was also tansfused FFP q6
hours and given Vit K, to no avail though, her coagulopathy
persisted and she continued to bleed. She was then taken to a
second colonoscopy which showed continued bleeding with areas of
ulceration, therefore the patient was taken to the OR by
colorectal surgery for ligation of the area under MAC. The
patient then ceased bleeding following this procedure. It was
unclear if she had a [**Name (NI) 9593**] lesion of a bleeding rectal
variocele. If she returns with bleeding, the team should preform
an MRI or endoscopic ultrasound to find out if this is arterial
or venous. She then may benefit from ligation under general
anesteisa.
# Coagulopathy: While the paitent had a GI bleed, she was given
a total of 4 units of FFP and 10mg of Vit K x3 days to correct
her elevated INR. Her coagulopathy is thought to be due to liver
disease, however, she does have a history of hemolysis but did
not appear to have hemolysis this admission. All anticoagulants
should be avoided.
# Mental status: The patient's baseline mental status is alert,
Ox3. She normally lives at home alone and can preform her ADLs,
however she has very little insight into her diseases. During
this admission, there were multiple times when she became
combative, agitated, and confused where she would refuse
medications, namely lactulose, and attempt to leave the
hospital. During one of these periods a code purple was called
as the patient attempted to leave and it was though that she dis
not have the capacity to make this decision since she was
actively having a brisk lower GI bleed. She was then placed in
leather restraints and given haldol.
These epidoses of confusion and agitation were followed three
times by peroids of obtundation. Thourough workups were done
each time to find the etiolgy of these states, including an EEG
which showed severe encephlopathy. She was transferred to the
ICU during the most severe of these periods for airway
protection where she was intubated breifly. She was then
discharged to the floor. It was determined that these were due
to hepatic encephalopathy and could be avoided if she faithfully
took her lactulose. She was also placed on Flagyl to aid in
decreasing her ammonia level.
# Cirrhosis: The patient was started on Aldactone 2 days before
discharge. Her Lasix was decreased to 40mg a day becasue her
blood pressure was lower than her baseline (baseline being 100 -
110 systolic).
# Disposition: The staff stressed that the patient be discharged
to a nursing home or at least her mother's house since she lives
alone. The patient adamatly refused when she was lucid. Her
mental status improved greatly and with a great amount of
teaching by the nursing and medical team, she was felt capable
to go home with close follow-up. VNA will check her HCT QOD and
she has an appointment with her PCP in less than 1 week.
# UTI: After her ICU stay, the patient was found to have a VRE
UTI. She was discharge on 5 days of Linezolid with instructions
to have her CBC checked in 1 week by VNA to monitor her
leukopenia.
Discharge Disposition:
Home with Service
Facility:
Roscommon
[**First Name11 (Name Pattern1) 520**] [**Last Name (NamePattern4) 521**] MD [**MD Number(1) 628**]
Completed by:[**2162-4-20**]
|
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icd9cm
|
[
[
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[
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icd9pcs
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[
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14577, 14775
|
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|
346, 352
|
9651, 9710
|
2792, 3746
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2282, 2301
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9734, 9914
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2316, 2773
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275, 308
|
380, 1576
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12506, 14554
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1598, 2148
|
2164, 2266
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,734
| 165,345
|
10007
|
Discharge summary
|
report
|
Admission Date: [**2133-9-7**] Discharge Date: [**2133-9-17**]
Date of Birth: [**2063-12-22**] Sex: F
Service: INPATIENT MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 69 year-old female
with a past medical history of coronary artery disease status
post coronary artery bypass graft, end stage renal disease,
hypertension, type 2 diabetes, hyperlipidemia, hypothyroid,
paroxysmal atrial fibrillation, peripheral vascular disease.
She was transferred from an outside hospital for evaluation
of chest pain. The patient had a coronary artery bypass
graft to multiple vessels, left anterior descending coronary
artery, obtuse marginal two, obtuse marginal in [**2130**] with
stents placed in the obtuse marginal one, left circumflex,
left main in [**2132-6-28**] and [**2133-2-28**]. On the day
of admission the patient had chest pain radiating to the jaw
with orthopnea and paroxysmal nocturnal dyspnea. The patient
went to the outside hospital and received some nitroglycerin
there and became hypotensive and she was transferred to [**Hospital1 1444**] and found to have an
myocardial infarction by positive troponin. The Coronary
Care Unit team was consulted.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. End stage renal disease on peritoneal dialysis.
3. Diabetes type 2.
4. Hypercholesterolemia.
5. Peripheral vascular disease.
6. Atrial fibrillation.
7. Anemia.
8. Hypothyroid.
9. Hypertension.
10. Claudication.
ALLERGIES: Prevacid.
SOCIAL HISTORY: The patient is married and retired. She
denies alcohol and illicit drug use. Quit tobacco 30 years
ago.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg q day.
2. Plavix 75 q day.
3. Renagel 800.
4. Synthroid 75 q day.
5. Glipizide 10 q day.
6. Vitamin E 400 q day.
7. Ranitidine 150 q day.
8. Lipitor 40 q day.
9. Iron.
10. Neurontin q.h.s.
11. Isosorbide mononitrate 30 b.i.d.
12. Atenolol 60 q day.
13. Amiodarone 200 q day.
PHYSICAL EXAMINATION ON ADMISSION: The patient was afebrile.
Heart rate 62. Blood pressure 90/28. O2 sat 98% on room
air. Respiratory rate 18. The patient was an obese elderly
female lying flat in no acute distress. HEENT anicteric.
Pink conjunctiva. Mucous membranes are moist. No JVD.
Cardiovascular regular rate and rhythm. 2 out of 6 systolic
ejection murmur. No carotid bruits. Respirations clear to
auscultation with a very poor respiratory effort. Abdomen is
obese, distended, slightly tympanic with positive bowel
sounds, but nontender. Extremities were warm with 2+ pulses
and 1+ pedal edema.
LABORATORY FINDINGS AT THE OUTSIDE HOSPITAL: White blood
cell count was 9.6, H&H 12.7 and 35.6. The patient had a CK
of 18, CKMB of less then .5, index 2.8, troponin .06. PT
13.3, INR of 1.2, PTT 22, with normal electrolytes. Repeat
laboratories at [**Hospital1 69**] showed a
white blood cell count of 16, electrolytes within normal
limits. PT 14.2, PTT 48.5, INR 1.3. Liver function tests
all within normal limits. Troponin of .5. Electrocardiogram
showed an irregularly irregular rhythm. The patient was in
atrial fibrillation with normal axis. No Q waves, ST
depressions in V2 through V6 with an incomplete right bundle
branch block. It was read as a nonspecific STT wave changes.
Chest x-ray showed mild congestive heart failure. CTA of the
chest was negative for PE and pneumothorax and just showed
calcified coronary arteries and aorta.
HOSPITAL COURSE: The patient was sent to the catheterization
laboratory for reperfusion. The patient received Integrilin
for 18 hours and placed on Plavix 75 mg q.d. for nine months.
The [**Hospital 228**] hospital course was complicated with vomiting
and severe abdominal pain with elevated amylase and lipase
status post catheterization consistent with pancreatitis.
There were no further cardiovascular complications and the
patient was transferred to the medicine team. CT of the
abdomen then revealed gallstones with no dilation of the
biliary tree. Ultrasound showed gallstones in the
gallbladder. MRCP was deferred due to recent stent and
endoscopic retrograde cholangiopancreatography was not
indicated since this was the first incident of pancreatitis.
The pancreatitis resolved by date of discharge. The patient
was kept NPO and was gently hydrated with intravenous fluids
until discharge. The [**Hospital 228**] hospital stay was also
complicated by a decreased platelet count that resolved with
the discontinuation of heparin. Heparin induced
thrombocytopenia antibody titers were pending on the day of
discharge. Elevated INR and macrocytic anemia were also
noted and should be evaluated in the outpatient setting.
They were not contributory to her hospital stay. The patient
resumed peritoneal dialysis on [**2133-9-16**]. The patient was also
noted to have a skin wound or burn on the back that was due
to a heating pad that she left for too long. The patient's
wound was not infected, but healing slowly and was treated
with neosporin ointment. The patient was also found to have
an elevated TSH indicating insufficient Levothyroxine and was
discharged on an increased dose of levothyroxine to be
followed up as an outpatient.
PROCEDURES PERFORMED: Cardiac catheterization on [**2133-9-7**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Home with VNA Services.
DISCHARGE DIAGNOSES:
1. Myocardial infarction.
2. Pancreatitis.
3. Cholelithiasis.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg q.d.
2. Clopidogrel 75 mg q.d.
3. Levothyroxine 125 micrograms q.d.
4. Vitamin E 400 units q.d.
5. Atorvastatin 40 mg q.h.s.
6. Amiodarone 200 mg q.d.
7. Erythropoietin 500 units three times a week.
8. Sevelamer 800 mg t.i.d.
9. Glipizide 5 mg q.d.
10. Neosporin ointment applied to back wound as needed.
FOLLOW UP: The patient is to follow up with her primary care
physician and cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] appointment for
[**9-29**], with her nephrologist Dr. [**Last Name (STitle) 33481**] on [**10-2**]
and with the gastrointestinal clinic on [**10-5**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Last Name (NamePattern1) 16735**]
MEDQUIST36
D: [**2133-11-4**] 07:24
T: [**2133-11-6**] 10:11
JOB#: [**Job Number 33482**]
|
[
"414.01",
"427.31",
"287.5",
"428.0",
"577.0",
"403.91",
"599.0",
"997.4",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.98",
"99.20",
"37.23",
"36.05",
"88.56",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
5332, 5398
|
5421, 5755
|
1629, 1957
|
3427, 5233
|
5767, 6341
|
176, 1181
|
1972, 3409
|
1203, 1479
|
1496, 1603
|
5258, 5311
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,008
| 145,153
|
32367
|
Discharge summary
|
report
|
Admission Date: [**2115-12-18**] Discharge Date: [**2116-1-10**]
Date of Birth: [**2093-6-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
[**2115-12-18**] Exploratory lap and repair of diaphragmatic injury
[**2115-12-18**] Washout and debridement of left open tibia fracture to
bone; closed reduction left supracondylar femur fracture with
manipulation; closed reduction left proximal tibia fracture with
manipulation; application multiplanar external fixator; IM nail
left femur and closed reduction right wrist fracture with
manipulation.
History of Present Illness:
22-year-old male restrained driver, who was involved in a motor
vehicle crash. He was speaking in the field; was brought to an
area hospital and ultimately intubated electively. He was found
to have a tension pneumothorax, initially treated by needle
decompression followed by placement of a left chest
tube. A chest x-ray suggested the presence of the stomach
within the left chest, supporting the diagnosis of a
traumatic diaphragmatic eventration. He was hemodynamically
stable. He was also noted to have a comminuted closed femur
fracture with intact distal pulses. He was transferred
emergently to [**Hospital1 18**] for further care given his injuries.
Past Medical History:
None
Social History:
Graduate student at Suffock. Patient graduated from [**University/College **]. He is a talented musician.
Family History:
Noncontributory
Physical Exam:
VITALS: T 96.2F, Tm 99.8F, BP 131/89, HR 115, RR 24, Sat 99%RA
GENERAL: Well-appearing, no acute distress
HEENT: Mild anisocoria, mucus membranes moist, no sinus
tenderness
NECK: Supple, trachea midline
CARD: Tachycardic, normal S1/S2, no m/r/g
RESP: Clear to auscultation bilaterally
ABD: Soft, non-distended. Mildly tender to palpation over
surgical scar. No rebound/guarding. Normal bowel sounds.
EXT: LLE in brace, RLE leg wrapped; Right forearm in cast, LUE
wrapped; non-pitting edema of UE, LE
NEURO: Difficult to perform exam. Able to move all extremities,
alert and oriented x 3. Fluent speech that
PSYCH: Denies SI/HI. Endorses occasional visual and auditory
hallucinations (no command auditory hallucinations).
Pertinent Results:
12/12/07CT HEAD W/O CONTRAST
IMPRESSION: No acute intracranial hemorrhage.
.
[**2115-12-18**] CT TORSO WITH INTRAVENOUS CONTRAST
IMPRESSION:
1. Stomach and spleen located within the thoracic cavity, very
concerning for extensive left diaphragmatic rupture, with
retraction.
2. Left lower lobe collapse/consolidation.
3. Patchy opacities predominantly at the right lung base, in the
setting of trauma likely represent parenchymal contusions;
aspiration is another diagnostic consideration.
3. Small amount of intraperitoneal air, an unusual finding in a
setting of blunt trauma, and free fluid, likely related to chest
tube placement, traversing the peritoneal space. While no bowel
injury is seen, this cannot be completely excluded. Comparison
with any CT done prior to the chest tube placement would be most
helpful if available.
.
[**2115-12-18**]. Left elbow film.
IMPRESSION: Extensively comminuted, intra-articular left
olecranon fracture.
.
[**2115-12-18**]. Left leg film. IMPRESSION: Extensively comminuted
fractures of the distal femur and proximal tibia, with displaced
and angulated fractures of the proximal femur and fibula.
.
[**2116-1-1**]. Brain MRI. IMPRESSION: Normal study.
.
[**2116-1-2**] . LENIs. IMPRESSION: No ultrasonographic evidence of
DVT.
.
[**2116-1-1**]. Echo.
IMPRESSION: Normal study. Normal biventricular cavity sizes with
preserved global and regional biventricular systolic function.
No pericardial effusion. Resting tachycardia.
[**2116-1-10**] WBC-9.3 RBC-4.44* Hgb-13.2* Hct-39.4* Plt Ct-844*
[**2116-1-10**] Glucose-163* UreaN-18 Creat-0.7 Na-138 K-4.3 Cl-96
HCO3-31
[**2116-1-10**] ALT-106* AST-23 LD(LDH)-258* AlkPhos-405* TotBili-0.8
[**2116-1-10**] 09:55AM BLOOD Albumin-4.0 Calcium-10.4* Phos-5.3*
Mg-2.0
Brief Hospital Course:
In summary, Mr. [**Known lastname **] is a 22 year old male admitted following
motor vehicle accident for multiple fractures and diaphragmatic
rupture. Hospital course was complicated by delerium, peristent
tachycardia, and transaminitis.
.
S/p MVA. Patient was admitted to the Trauma Service and taken
directly to the operating room for exploratory lap and repair of
his diaphragmatic injury. Orthopedics was consulted given his
multiple bone fractures; he was taken to the operating room for
washout and debridement of left open tibia fracture to bone;
closed reduction left supracondylar femur fracture with
manipulation; closed reduction left proximal tibia fracture with
manipulation; application multiplanar external fixator; IM nail
left femur and closed reduction right wrist fracture with
manipulation. There were no intraoperative complications.
.
Pain. Patient had difficulty with pain control initially. PCA
Dilaudid was initiated and the dose was quickly increased to
0.37 mg. Dilaudid 1-2 mg IV prn for rescue pain was also added
and he did seem to benefit from this. It was discussed with
patient and his mother that at some point long acting narcotics
would likely be initiated for long term pain control. He was
placed on an aggressive bowel regimen. However, patient
developed delerium in setting of opioid use, so opioids were
discontinued and patient was started on ultram. Tylenol is
being avoided due to elevated LFTs. NSAIDs are being avoided
due to impaired bone healing. Opioids are being avoided due to
recent delerium. Pain was adequately controlled at time of
discharge on standing ultram.
.
Delerium. Patient developed delerium during hospitalization.
It was felt to be due to opioid pain medications which were
stopped. Patient was evaluated by neurology and psychiatry.
Vit B12, folate, TSH, RPR within normal limits. LP performed
[**1-1**] showed no evidence of infection. EEG and Brain MRI were
normal. He was placed on standing seroquel at night. Opioids
were avoided. Delerium resolved and patient was alert and
oriented on day of discharged.
.
Elevated transaminases. Likely multifactorial etiology,
including systemic inflammatory response, medications including
Zosyn. LFTs continue to trend down. ALT peaked at 385 on [**1-3**],
AST peaked at 220 on [**12-31**], LDH peaked at 457 on [**1-1**]. Alk
Phos continued to trend up on discharge, likely secondary to
active bone remodeling. Acetaminophen was discontinued on [**1-1**].
Please check LFTs weekly until fully resolved.
.
Thrombocytosis. Patient had elevated platelet count to 1.5
million, likely reactive thrombocytosis due to systemic
inflammatory state due to trauma and multiple operations.
Platelets were trending down and were 1 million at time of
discharge.
.
Tachycardia. Patient had sinus tachycardia post-operatively to
the 150s, that was thought to be pain and stress related. A PE
CT was done and was negative for PE. Metoprolol was started to
prevent tachycardia-induced cardiomyopathy. An echo was done
and was normal. Metoprolol is being titrated down beginning on
[**1-5**]. Goal is to stop metoprolol as HR improves. Overall
tachycardia is improving.
.
Insomnia. Patient reported difficulty sleeping due to
discomfort, multiple braces/casts in place, etc. He was getting
standing seroquel at night with minimal improvement.
Benzodiazepines and ambien were avoided due to delerium. He was
given prn benadryl and standing seroquel. Seroquel should
ultimately be stopped but patient is currently using it for
insomina.
.
Prophylaxis. Patient was maintained on Lovenox daily. S/p
prophylactic IVC filter placement.
.
Communication. Patient and mother [**Telephone/Fax (1) 75595**].
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous QD
().
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
6. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itching.
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q 8H
(Every 8 Hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
s/p Motor vehicle crash
Right pulmonary contusion
Left diaphragmatic rupture
Left olecranon fracture
Left femoral shaft fracture
Left supracondylar femur fracture
Left proximal tibia fracture
Left distal radius fracture
Delirium, resolved
Discharge Condition:
Good. Patient is tolerating oral intake with assistance and able
to work effectively with physical therapy.
Discharge Instructions:
You were admitted to the hospital after your car accident. You
were found to have broken many bones and to have ruptured your
diaphragm. You were treated in surgery for your bone fractures
and your diaphragm rupture and have done well after surgery. You
also became quite confused after your surgery, which was thought
most likely secondary to your strong pain medications. After
your narcotic pain medications were stopped, your confusion
improved greatly.
.
Please take all your medications as prescribed. We have started
you on ultram as needed for pain.
.
If you have any symptoms of fevers, chills, night sweats,
shortness of breath, chest pain, lower extremity swelling, upper
extremity swelling, lightheadedness, or dizziness, please seek
immediate medical attention.
Followup Instructions:
Please follow-up with your primary care doctor Dr. [**First Name4 (NamePattern1) 4597**] [**Last Name (NamePattern1) 16801**].
His address office is: The Medical Group, Inc, [**Last Name (un) **],
[**Apartment Address(1) **], [**Hospital1 **], [**Numeric Identifier 26668**]. Please call him at [**Telephone/Fax (1) 10508**] to
schedule an appointment.
.
Follow up with Dr. [**Last Name (STitle) **], Orthopedics, Thursday [**2120-1-23**]:10 PM. Call [**Telephone/Fax (1) 1228**] if you need to re-schedule your
appointment. Please arrive 20 minutes early. The office is
located on the [**Location (un) **] of [**Hospital Ward Name 23**] Clinical Center on the [**Hospital Ward Name 5074**] of [**Hospital1 **].
.
Follow up with Dr. [**Last Name (STitle) 519**], Trauma/Surgery in [**2115-2-3**] at
10 AM. His office is located on the [**Location (un) 470**] of the [**Hospital Ward Name 23**]
Clinical Center on the [**Hospital Ward Name **] of [**Hospital1 18**]. Please call
[**Telephone/Fax (1) 6554**] if you need to re-schedule.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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icd9pcs
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[
[
[]
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8724, 8804
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4162, 7886
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340, 745
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9106, 9216
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2376, 4139
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1602, 1619
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20,133
| 134,652
|
48149
|
Discharge summary
|
report
|
Admission Date: [**2162-10-22**] Discharge Date: [**2162-10-27**]
Date of Birth: [**2108-12-6**] Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
Dialysis x 3
History of Present Illness:
53F with DMI s/p renal transplant [**2152**] complicated by graft
failure and ESRD with plan to initiate HD, idiopathic dilated
CMP with EF 20% admitted with hyperglycemia. Admitted to [**Hospital1 18**]
[**Date range (1) 101502**] for hypoglycemia during which a right upper
extremity AV graft was placed. Lantus was decreased from 4U [**Hospital1 **]
to 3U [**Hospital1 **] during that admission. At a routine follow-up
appointment at [**Hospital **] Clinic this morning, was noted to be
markedly hyperglycemic (finger stick greater than assay) and was
referred to the lab for additional [**Hospital **] work. Subsequently went
to work, where coworkers noted her to appears tired and unwell.
She took lantus 3U this AM and took 9 units when she checked her
sugar at work and it was greater than assay. She felt fatigued
with a dry mouth and excessive thirst. Endorses recent urinary
frequency. Denies fever, chills, sweats, headache, blurry vision
dizziness, lightheadedness, cough, shortness of breath,
abdominal pain, nausea, vomiting, diarrhea, or dysuria. Called
by her nephrologist Dr. [**First Name (STitle) 805**] who referred her to the ED for
evaluation and treatment of hyperglycemia (671).
In the ED, initial VS 98.8 80 156/71 16 100%RA. CXR showed LLL
PNA. BS 706 Given ceftriaxone 1 g IV, levofloxacin 500 mg IV,
10U regular insulin IV, insulin gtt @ 7 mg/hr, 1/2NS with 1 amp
HCO3 @ 100 cc/hr. Vital signs prior to transfer 98.8 73 150/66
13 98%RA.
Upon arrival in the MICU complains of pain in her RUE fistula
but otherwise feels well.
Past Medical History:
-s/p placement of right upper extremity arteriovenous graft
[**2162-10-19**]
-Type 1 DM, since age 20
-Dilated cardiomyopathy, EF < 20% 4/08 by echo
-Hypertension
-CKD s/p transplant in [**2152**], undergoing evaluation for possible
second transplant
-Hepatitis C, chronic, untreated
-Intracranial right ICA aneurysm, s/p clipping [**2159-5-16**]
-s/p C4-5 and C5-6 anterior decompression and fusion after MVA
[**2157**]
-s/p dickectomy at C6-C7 and fusion in [**2157**], with
instrumentation
removal and reinsertion on [**2159-9-28**]
-Ulnar nerve impingement bilaterally
-S/p Rotator cuff repair
-s/p release of right carpal tunnel
-GERD
-Asthma as a child
-Sleep apnea, unable tolerate CPAP
-s/p right carpal tunnel release
-s/p rotator cuff repair
-Resting tremor
-h/o Pneumonia
-Anemia
-h/o CMV in [**2155**]
Social History:
Divorced, has 2 children and 9 grandchildren. No tobacco, quit
12 years ago after having previously smoked 1ppd x27 years. No
EtOH although previously drank socially.
Family History:
Sister died of [**Name (NI) 101497**], many other family members on maternal side
with diabetes.
Physical Exam:
VITAL SIGNS:
T- 99.4, HR- 72, BP- 137/57, R- 18, SaO2- 97% on RA
PHYSICAL EXAM
GENERAL: Pleasant, well appearing female in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. [**Name (NI) 5674**]. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: [**3-12**] holosystolic murmur heard best at base. Regular
rate and rhythm. Normal S1, S2. JVP= not elevated
LUNGS: Bilateral inspiratory crackles (L>R), good air movement
biaterally. No signs of respiratory distress
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: Trace edema b/l. No calf pain, 2+ dorsalis pedis/
posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**1-8**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Admission Labs:
[**2162-10-21**] 07:35AM WBC-3.7* RBC-4.08* HGB-9.7* HCT-32.4* MCV-80*
MCH-23.9* MCHC-30.0* RDW-17.6*
[**2162-10-21**] 07:35AM NEUTS-71.1* LYMPHS-15.4* MONOS-7.0 EOS-4.9*
BASOS-1.7
[**2162-10-21**] 07:35AM TRIGLYCER-446* HDL CHOL-66 CHOL/HDL-5.9
[**2162-10-21**] 07:35AM CALCIUM-8.1* PHOSPHATE-7.0* MAGNESIUM-2.5
CHOLEST-391*
[**2162-10-21**] 07:35AM GLUCOSE-217* UREA N-73* CREAT-7.3* SODIUM-137
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-22 ANION GAP-15
.
CXR - [**10-22**] - Left lung base opacity concerning for infection.
[**2162-10-22**] 11:56PM [**Month/Day/Year 3143**] WBC-6.9 RBC-4.37 Hgb-10.5* Hct-33.7*
MCV-77*# MCH-23.9* MCHC-31.0 RDW-17.0* Plt Ct-360
[**2162-10-22**] 11:59PM [**Month/Day/Year 3143**] WBC-4.8 RBC-3.85* Hgb-9.4* Hct-29.9*
MCV-78* MCH-24.3* MCHC-31.4 RDW-17.1* Plt Ct-296
[**2162-10-24**] 04:31AM [**Month/Day/Year 3143**] WBC-5.2 RBC-4.09* Hgb-9.8* Hct-31.7*
MCV-78* MCH-24.1* MCHC-31.0 RDW-17.2* Plt Ct-321
[**2162-10-25**] 05:25AM [**Month/Day/Year 3143**] WBC-4.0 RBC-3.92* Hgb-9.4* Hct-30.5*
MCV-78* MCH-23.9* MCHC-30.8* RDW-17.2* Plt Ct-282
[**2162-10-26**] 05:26AM [**Month/Day/Year 3143**] WBC-5.3 RBC-3.76* Hgb-9.3* Hct-29.1*
MCV-78* MCH-24.7* MCHC-31.8 RDW-17.4* Plt Ct-289
[**2162-10-27**] 05:32AM [**Month/Day/Year 3143**] WBC-5.7 RBC-3.72* Hgb-9.2* Hct-28.2*
MCV-76* MCH-24.8* MCHC-32.7 RDW-17.9* Plt Ct-299
[**2162-10-27**] 05:32AM [**Month/Day/Year 3143**] Plt Ct-299
[**2162-10-22**] 11:56PM [**Month/Day/Year 3143**] Glucose-28* UreaN-98* Creat-7.8* Na-137
K-4.4 Cl-103 HCO3-18* AnGap-20
[**2162-10-22**] 11:59PM [**Month/Day/Year 3143**] Glucose-123* UreaN-94* Creat-7.8* Na-134
K-4.7 Cl-103 HCO3-20* AnGap-16
[**2162-10-23**] 04:01PM [**Month/Day/Year 3143**] Glucose-164* UreaN-93* Creat-7.5* Na-131*
K-4.5 Cl-99 HCO3-17* AnGap-20
[**2162-10-24**] 04:31AM [**Month/Day/Year 3143**] Glucose-85 UreaN-101* Creat-8.1* Na-134
K-4.5 Cl-102 HCO3-17* AnGap-20
[**2162-10-24**] 04:07PM [**Month/Day/Year 3143**] Glucose-149* UreaN-103* Creat-8.5*
Na-132* K-4.5 Cl-99 HCO3-18* AnGap-20
[**2162-10-25**] 05:25AM [**Month/Day/Year 3143**] Glucose-158* UreaN-104* Creat-8.2* Na-133
K-3.9 Cl-101 HCO3-18* AnGap-18
[**2162-10-26**] 05:26AM [**Month/Day/Year 3143**] Glucose-269* UreaN-77* Creat-6.5*# Na-135
K-4.4 Cl-98 HCO3-24 AnGap-17
[**2162-10-27**] 05:32AM [**Month/Day/Year 3143**] Glucose-130* UreaN-58* Creat-5.3*# Na-139
K-3.8 Cl-99 HCO3-30 AnGap-14
[**2162-10-25**] 05:25AM [**Month/Day/Year 3143**] Calcium-7.7* Phos-6.9* Mg-2.5
[**2162-10-26**] 05:26AM [**Month/Day/Year 3143**] Calcium-7.4* Phos-4.7*# Mg-2.1
[**2162-10-27**] 05:32AM [**Month/Day/Year 3143**] Calcium-7.9* Phos-4.7* Mg-1.9
[**2162-10-22**] 02:55PM [**Month/Day/Year 3143**] HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2162-10-22**] 11:56PM [**Month/Day/Year 3143**] Vanco-21.3*
[**2162-10-24**] 04:31AM [**Month/Day/Year 3143**] Vanco-14.8
[**2162-10-22**] 02:55PM [**Month/Day/Year 3143**] Digoxin-0.5*
[**2162-10-22**] 11:56PM [**Month/Day/Year 3143**] rapmycn-5.1
[**2162-10-23**] 12:16AM [**Month/Day/Year 3143**] Lactate-1.1
Chest X-Ray ([**10-24**])-
IMPRESSION: Left lower lobe pneumonia.
Brief Hospital Course:
#DKA- The patient was found to be in DKA and was admitted to the
ICU for treatment. Her BS was 706. She was given insulin at
0.1U/kg SC q2h followed by insulin drip @ 5 U/hr (~0.1U/kg/hr) x
2 hrs after SC regimen started to ensure adequate plasma insulin
levels. Her sugars quickly normalized and her anion gap also
corrected quickly also (to 15). Her corrected Na was 136 (given
BS of 706). Cautious fluid resuscitation (D5-1/2NS @ 100 cc/hr)
was initiated given systolic dysfunction. Electrolytes were
closely monitored. K+ stayed within normal limits and her
sodium normalized. [**Last Name (un) **] was consulted.
Patient did well in the ICU. Her insulin drip was discontinued
and she was switched to her home insulin regimen with good
control of her sugars. She was transferred to the floor on
[**10-24**]. Upon transfer to the floor, she was comfortable and
hemodynamically stable. [**Month/Year (2) **] sugar was 149. She denied any
syptoms. While on the floor, her sugars remained under control
with her home regimen. [**Last Name (un) **] continued to follow her. She did
have some elevated AM sugar levels on day 2 on the floor [**First Name8 (NamePattern2) **]
[**Last Name (un) **] recommended increasing her nighttime lantus dose to 5U
(from 4U). She was told to continue this insulin regimen on
discharge. Upon discharge, her sugar was 130. She was
asymptomatic and doing well.
#Pneumonia - Patient found to have probably left lower lobe
pneumonia on chest x-ray. She was hemodynamically stable and
afebrile with no elevated WBC. She denied any shortness of
breath, chest pain, headache, dizziness or abdominal pain. She
was started on vanc and cefepime (day 1- [**10-22**]) empirically
given systemic immunosuppresion, recent hospitalization, &
frequent healthcare contacts. [**Name (NI) **] cultures were drawn with no
growth at time of discharge. Urine cultures were negative and
MRSA screen was also negative. She was switched to PO
levofloxacin (renally-dosed) upon transfer to floor. Her iron
was held given that it can affect absorption of the
levofloxacin. She completed the full course by the time she was
discharged and was not sent home on antibiotics. Her iron was
resumed upon discharge.
#ESRD on HD- She is s/p renal transplant in [**2152**]- now with
rejection. Patient had RUE AV graft placed on [**10-19**]. She was
transferred to the floor with plans to possible dialyze. She
was seen by nephrology team throughout her stay. They decided
to initiate dialysis on [**10-25**]. She received HD each day
(including day of discharge) and tolerated it well. PPD was
planted on [**10-23**] for outpatient dialysis purposes and was
negative. She was continued on her immunosupressants. In
addition, she was started on nephrocaps. She has dialysis
scheduled for [**10-28**] at [**Location (un) **] where she will see her
nephrologist, Dr. [**First Name (STitle) 805**].
#Chronic systolic CHF [**2-8**] idiopathic dilated CMP- Given DKA and
resulting need for gentle hydration, her home lasix was held.
Her beta-blocker, nitrates, aspirin and statin were continued.
IV hydration was discontinued in the ICU. She did demonstrate
some signs of fluid overload on exam once transferred to floor
(inspiratory crackles, pedal edema). She was re-started on her
home dose of lasix. Her fluid status improved daily while on
HD. Given that she was now on HD, she was now able to begin an
ace-inhibitor for her CHF. It was discussed with her
nephrologist and cardiologist who both agreed. Her nifedipine
was discontinued and she was started on lisinopril 5mg by mouth
daily, which she tolerated well. Upon discharge, her lungs
sounded much clearer and her pedal edema had improved. She
denied any shortness of breath, chest pain, headache or
dizziness.
#HTN- Patient was continued on home beta-blocker, calcium
channel blocker, hydralazine and imdur on admission. Lasix was
held given DKA. Given that patient has chronic systolic HF, she
was started on an ace-inhibitor now that she can tolerate it
(given that she is on HD). Her nifedipine was discontinued.
Her [**Month/Day (2) **] pressures were stable and patient remained
asymptomatic.
#FEN: HH/DM/renal diet
#PPX: heparin 5000U SC TID
#CONTACT: HCP are daughter and nephew. Daughter [**Name2 (NI) 61615**] [**Name2 (NI) **]
[**Telephone/Fax (1) 101503**]. Nephew [**Name (NI) **] [**Name (NI) 2427**], [**First Name3 (LF) **]. [**Telephone/Fax (1) 101504**]
Medications on Admission:
1.Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2.Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
3.Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4.Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5.Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6.Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
7.Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8.Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
9.Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10.Sirolimus 1 mg Tablet Sig: Eight (8) Tablet PO DAILY
(Daily).
11.Zemplar 1 mcg Capsule Sig: One (1) Capsule PO Three times a
week.
12.Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
13.Digoxin 125 mcg Tablet Sig: One (1) Tablet PO 1X/WEEK (TU).
14.Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for pain for 7 days.
Disp:*20 Tablet(s)* Refills:*0*
15.Glucagon Emergency 1 mg Kit Sig: One (1) Kit Injection once
a day as needed for Low [**Telephone/Fax (1) **] sugar.
Disp:*1 Kit* Refills:*0*
16.Insulin Glargine 100 unit/mL Solution Sig: Three (3) Units
Subcutaneous twice a day.
17.Novolog 100 unit/mL Solution Sig: One (1) Unit Subcutaneous
four times a day: Please follow sliding scale:
101-140 2 Units; 141-180 3 Units; 181-220 4 Units; 221-260 5
Units; 261-300 6 Units; 301-340 7 Units WITH MEALS. If you are
having a small meal or not eating then use: 141-180 1 Unit;
181-220 2 Units; 221-260 3 Units; 261-300 4 Units; 301-340 5
Units.
18.Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Epogen 10,000 unit/mL Solution Sig: 7000 (7000) units
Injection with HD.
2. Paricalcitol 5 mcg/mL Solution Sig: One (1) mcg Intravenous
3X/week (): with HD.
3. Sirolimus 1 mg Tablet Sig: Eight (8) Tablet PO DAILY (Daily).
4. Pravachol 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO QTUES (every
Tuesday).
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet, Delayed Release
(E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a
day.
12. Zantac 150 mg Tablet Sig: 0.5 Tablet PO once a day.
13. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
14. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
17. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for pain.
18. Insulin
Please continue your sliding scale as shown below- the only
change made while you admitted was to increase your nighttime
lantus dose to 5 units (from 4 units).
-Insulin Glargine 100 unit/mL Solution Sig: 4 units in AM, 5
units at bedtime (Subcutaneous).
-Novolog 100 unit/mL Solution Sig: One (1) Unit Subcutaneous
four times a day: Please follow sliding scale:
101-140 2 Units; 141-180 3 Units; 181-220 4 Units; 221-260 5
Units; 261-300 6 Units; 301-340 7 Units WITH MEALS. If you are
having a small meal or not eating then use: 141-180 1 Unit;
181-220 2 Units; 221-260 3 Units; 261-300 4 Units; 301-340 5
Units.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Diabetic ketoacidosis- resolved, end stage renal
disease on hemodialysis
Secondary: Type I diabetes mellitus, chronic systolic heart
failure
Discharge Condition:
Good. Vital signs stable.
Discharge Instructions:
You were admitted to the MICU for diabetic ketoacidosis. While
in the ICU, you were placed on an insulin drip and your sugars
responded well. You were stablized and transferred to the floor
for continued care. While on the floor, you were started on
hemodialysis, which you tolerated well. You received dialysis
three times with plans to continue it as an outpatient. You
were seen by the renal dietician who educated you on nutrition.
You remained hemodynamically stable and comfortable.
The following medication changes were made:
1. Please start taking lisinopril 5mg by mouth daily
2. Please stop taking your nifedipine now
3. Please continue taking your iron
4. Please start taking nephrocaps- 1 tablet by mouth daily
5. Please stop taking your sodium bicarbonate
6. Please increase your nighttime lantus dose to 5 units
(previously was 4U). Otherwise, please continue your sliding
scale as it was before you were admitted. (Novolog 100 unit/mL
Solution Sig: One (1) Unit Subcutaneous four times a day: Please
follow sliding scale:
101-140 2 Units; 141-180 3 Units; 181-220 4 Units; 221-260 5
Units; 261-300 6 Units; 301-340 7 Units WITH MEALS. If you are
having a small meal or not eating then use: 141-180 1 Unit;
181-220 2 Units; 221-260 3 Units; 261-300 4 Units; 301-340 5
Units)
If you experience any fevers, shortness of breath, chest pain,
sudden weight gain, abdominal pain or any other medically
concerning symptoms, please contact your primary care physician
or go to the emergency department immediately.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
1. Please follow up with your PCP (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) on
Thursday, [**10-28**] at 1:45pm
Location: [**Location (un) 1264**]., [**Location (un) **],[**Numeric Identifier 1265**]
Phone number: [**Telephone/Fax (1) 1260**]
Special instructions if applicable: Dr.[**Name (NI) 101505**] office may
call you at home with a different appt date and time. Please
call above number tomorrow to confirm appt if you do not hear
from Dr.[**Name (NI) 101505**] office.
2. Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10088**] on Thursday,
[**11-4**] at 2:00pm at One [**Last Name (un) **] Place, [**Location (un) 86**] [**Numeric Identifier 718**]
Phone number: ([**Telephone/Fax (1) 4847**]
3. Please follow-up with your nephrologist (Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**])
at dialysis tomorrow ([**10-28**]) at 3:30pm.
Location: [**Location (un) **].
Phone number: [**Telephone/Fax (1) 3637**]
4. Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2162-11-23**] 1:00
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**]
Date/Time:[**2162-11-23**] 2:00
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2162-11-23**] 3:00
Completed by:[**2162-10-27**]
|
[
"327.23",
"E932.3",
"250.13",
"425.4",
"486",
"996.81",
"354.2",
"428.0",
"070.54",
"250.43",
"585.6",
"428.22",
"V45.11",
"781.0",
"285.21",
"V15.82",
"V58.67",
"250.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
15695, 15701
|
7139, 11624
|
275, 289
|
15898, 15927
|
3976, 3976
|
17627, 19056
|
2910, 3008
|
13556, 15672
|
15722, 15877
|
11650, 13533
|
15951, 17604
|
3023, 3957
|
232, 237
|
317, 1872
|
3993, 7116
|
1894, 2709
|
2725, 2894
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,551
| 196,270
|
25747
|
Discharge summary
|
report
|
Admission Date: [**2193-7-7**] Discharge Date: [**2193-7-18**]
Date of Birth: [**2116-8-6**] Sex: M
Service: CSU
CHIEF COMPLAINT: Progressive dyspnea.
HISTORY OF PRESENT ILLNESS: This 76-year-old Greek speaking
gentleman with a past medial history significant for
hypercholesterolemia and chronic obstructive pulmonary
disease presented to an outside hospital on [**7-7**]
complaining of progressively worsening dyspnea on exertion
initially and at the day of presentation at rest. The patient
also complained of generalized weakness and occasional left
sided chest pain. His EKG at that time showed sinus
tachycardia with a rate of [**Street Address(2) 64158**] depressions in 1, 2, F
and V4 through V6, elevations with T-wave inversions in V1
through V3. His initial CK was 147 with a troponin of 0.08.
He was given nitroglycerine as well as Lasix and morphine and
transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for
urgent cardiac catheterization. His cardiac catheterization
revealed an aortic valve area of 0.5 cm squared and 3 vessel
disease in LAD with 80% tubulo stenosis, circumflex with a
mid vessel 70% stenosis, and an RCA with proximal 80%
stenosis. An intraaortic balloon pump was placed and
cardiothoracic surgery team was consulted.
PAST MEDICAL HISTORY: Significant for chronic obstructive
pulmonary disease, benign prostatic hyperplasia, status post
transurethral resection of prostate, hypercholesterolemia.
MEDICATIONS: His medications at home include:
1. Spiriva 18 ug q d.
2. Plavix 75 mg q d
3. Crestor 10 mg q d
4 Budesonide inhaler 2 puffs b.i.d.
1. Buflomedil 600 mg q d.
ALLERGIES: He states an allergy to penicillin.
SOCIAL HISTORY: He currently smokes 1 to 1.5 packs per day x
more than 60 years. Rare alcohol use. Lives with his wife in
the area, visiting with their son.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.9, heart
rate 88, blood pressure 111/54, respiratory rate 20, oxygen
saturations 96% on 4 liters nasal cannula.
GENERAL: In no acute distress. Alert and oriented x 3. He
moves all extremities and follows commands.
HEENT: Pupils are equal, round and reactive to light.
Extraocular muscles intact. Oropharynx is clear. Mucous
membranes moist. Neck is supple with no jugular venous
distention or lymphadenopathy.
HEART: Regular rate and rhythm.
LUNGS: Diffuse inspiratory and expiratory wheezes with rales
in the right base.
ABDOMEN: Soft, nondistended, nontender with normal active
bowel sounds.
EXTREMITIES: Cool and dry with no edema and dopplerable
pulses.
LABORATORY DATA: WBC 10.2, hematocrit 37.6, platelet count
196, PT 54, INR 1.1, sodium 142, potassium 4.1, chloride 103,
CO2 16, BUN 20, creatinine 1.7, glucose 294. Urinalysis has
protein, otherwise negative. EKG - sinus rhythm with normal
intervals. ST depressions in 1, 2, F, V4 through 6,
elevations with Q wave inversions in V1 and V3. Chest x-ray -
hyperinflated lung fields with moderate congestive heart
failure, no effusions or consolidations.
Following cardiac catheterization the patient underwent
carotid studies which showed less than 40% narrowing
bilaterally. The following day the patient was brought to
the operating room. Please see the OR report for full
details.
In summary, the patient had an aortic valve replacement with
No. 21 [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve as well as
coronary artery bypass graft x 3 with left internal mammary
artery to the LAD, saphenous vein graft to the diagonal and
saphenous vein graft to the patent ductus arteriosus. His
bypass time was 190 minutes with cross-clamp time of 145
minutes. He tolerated the operation well and was transferred
from the operating room to the cardiothoracic intensive care
unit. At the time of transfer he was in sinus rhythm at 82
beats per minute with mean arterial pressure of 80. He had
propofol at 20 mics/ kg/ minute, milrinone at 0.5 mics/ kg/
minute, lidocaine at 2 mg per minute. Initially in the
cardiothoracic intensive care unit, the patient had a large
volume of chest tube drainage and after a short period he was
brought back to the operating room for reexploration. At that
time no occult bleeding was found and the patient was re-
wired, stabilized and returned to the cardiothoracic
intensive care unit. He remained hemodynamically stable
throughout that period as well as through his operative day.
On postoperative day 1, given the patient's return trip to
the operating room, it was decided that the patient would
remain sedated throughout the operative night. His FIO2 was
weaned 40% during the course of the night. Following his
return to the intensive care unit, his sedation was
discontinued to assess his neurological status. He awoke and
moved all extremities and became restless and was re-sedated.
On the morning of postoperative day 1, the patient's
intraaortic balloon pump was successfully weaned and
discontinued following which the patient's milrinone infusion
was weaned. During that period the patient had frequent
burst of rapid atrial fibrillation with a heart rate of 120
to 140. He was begun on amiodarone infusion and was attempted
to cardiovert several times without success.
On postoperative day 2, the patient remained in atrial
fibrillation for which he continued to receive amiodarone
infusion. An attempt again was made to cardiovert the patient
following which he had short periods of sinus rhythm but then
generally returned to atrial fibrillation with a heart rate
of 120 to 130. During this time attempts were also made to
lighten the patient's sedation, however each attempt was met
with periods of agitation and desaturation. By postoperative
day 2 when the patient was sedated, he remained
hemodynamically stable, however attempts to wean sedation
were met with patient becoming hemodynamically unstable and
dyspneic associated with periods of agitation. Following each
period of agitation the patient was resedated.
On postoperative day 3, the patient remained in atrial
fibrillation. He was at that point successfully cardioverted
following which he was again weaned from his sedation. The
patient again became agitated and dyspneic, however he
maintained his oxygen saturations with minimal ventilatory
support. Neurology service was consulted at that point to
assess the patient for CVA. He had CT at that time which was
negative for CVA.
On postoperative day 4, the patient remained in sinus rhythm.
His propofol was discontinued. He was placed on Precedex
infusion following which a neuro examination was performed
with his Greek speaking nephew in attendance. At that time
the patient was noted to follow commands, and move all
extremities. He was then successfully weaned from the
ventilator and extubated.
Over the next 24 hours, the patient became less agitated and
more easily reoriented. He remained hemodynamically stable
throughout that period. His chest tubes and temporary pacing
wires were removed, however he was maintained on
cardiothoracic intensive care unit for 2 additional days to
monitor his pulmonary status.
On postoperative day 8, he was transferred to the floor for
continuing postoperative care and cardiac rehabilitation.
Once on the floor, the patient had an uneventful
postoperative course. His activity level was advanced with
the assistance of the physical therapy and nursing staff.
The patient remained in normal sinus rhythm.
On postoperative day 9, it was decided that the following day
he will be stable and ready to be discharged to
rehabilitation center for further postoperative care.
At the time of this dictation the patient's physical
examination was as follows:
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.7, heart
rate 97, in sinus rhythm, blood pressure 124/52, respiratory
rate 20, oxygen saturations 96% on 2 liters nasal prongs. His
weight at the time of discharge was 77.3 kilos.
Preoperatively it was 82 kilos.
NEUROLOGIC: Alert and oriented. Moves all extremities well
and follows commands. Nonfocal examination.
PULMONARY: Scattered rhonchi, otherwise clear.
CARDIAC: Regular rate and rhythm S1 and S2. Sternum is
stable. Incision is clean and dry without drainage or
erythema.
ABDOMEN: Soft and nontender, nondistended with normal active
bowel sounds.
EXTREMITIES: Warm with trace edema.
LABORATORY DATA: White blood cell 8.0, hematocrit 35.8,
platelet count 290, sodium 143, potassium 4.6, chloride 107,
CO 325, BUN 45, creatinine 1.1, glucose 116.
DISCHARGE DISPOSITION: The patient is to be discharged to
rehabilitation.
DISCHARGE DIAGNOSES:
1. Status post AVL with No. 21 [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial
valve as well as coronary artery bypass graft x 3 with
left internal mammary artery to the LAD, saphenous vein
graft to the patent ductus arteriosus and saphenous vein
graft to the diagonal.
2. Hypercholesterolemia.
3. Chronic obstructive pulmonary disease.
4. Benign prostatic hyperplasia, status post transurethral
resection of prostate.
5. Chronic renal insufficiency with baseline creatinine of
1.7.
He is to follow up with his primary care provider [**Last Name (NamePattern4) **] 3 to 4
weeks. He will follow up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], in 3 to 4
weeks and follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] in 4 weeks.
Condition at the time of discharge is good.
DISCHARGE MEDICATIONS:
1. Crestor 20 mg q day.
2. Percocet 5/325 one to two tabs q 4 to 6 hours as needed
for pain.
3. Pulmicort 2 puffs b.i.d.
4. Potassium chloride 20 mEq q d.
5. Colace 100 mg b.i.d.
6. Aspirin 81 mg q d.
7. Protonix 40 mg q d.
8. Amiodarone 400 mg b.i.d x 1 week, then 400 mg q d x 1 week
and then 200 mg q d.
9. Albuterol nebulizer q 6 hours p.r.n.
10. Atrovent nebulizer q 6 hours p.r.n.
11. Amlodipine 5 mg q d.
12. Nicotine patch 14 mg per 24 hours one q d
13. Metoprolol 12.5 mg b.i.d.
14. Lasix 40 mg q d
15. Spiriva inhaler 18 ug q d.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2193-7-18**] 00:04:53
T: [**2193-7-18**] 01:58:28
Job#: [**Job Number 64159**]
|
[
"410.11",
"428.0",
"414.01",
"427.31",
"424.1",
"593.9",
"496",
"E934.2",
"272.4",
"998.11",
"401.9",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"34.03",
"99.05",
"88.72",
"99.07",
"37.61",
"36.15",
"39.61",
"99.04",
"88.56",
"37.23",
"36.12",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8568, 8620
|
8641, 9524
|
9547, 10364
|
7759, 8544
|
152, 174
|
203, 1367
|
1390, 1771
|
1788, 1931
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,712
| 113,186
|
2395
|
Discharge summary
|
report
|
Admission Date: [**2142-2-22**] Discharge Date: [**2142-3-1**]
Date of Birth: [**2100-9-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Transferred from MICU to floor after stay for unresponsiveness,
fever
Major Surgical or Invasive Procedure:
Right central line placement
History of Present Illness:
41 yo m w/ h/o HIV ([**1-15**] aCD4 234), HBV, admitted for failure to
thrive. Partner at bedside significant particpant in history,
states that prior to development of ascites pt weighed approx
125. Prior to paracentesis usually 150. Now down to 130s.
Ascites better controlled on no salt diet. Also having sig
diarrhea- [**1-17**] lactulose as titrated vs imminent
confusion/encephalopathy. Denies f/c/n/v. Admitted for
post-pyloric placement.
Pt had a post pyloric tube placed on [**2-22**] and a theraptuic
paracentesis on [**2-23**] with 3.5 L out. He recevied lactulose
during this time.
Transferred to the MICU on [**2-24**] for unresponsivness to painful
stimuli, hyperkalemia, fever. ABG on admission was
7.51/17/105/14. Lytes were significant for K 7.5 with peaked TW
on EKG. Temp 101.4 rectally. Cultures were drawn, hyperkalemia
treated with D50/insulin/calcium/kayexalate. MICU team felt that
the patient was in sepsis with an alkalosis on top of chonic
metabolic acidosis. Central line placed for resuccitation,
placed on CTX/vanco. for presumed SBP or hosp. acquired infxn.
LP deferred given coagulopathy. Hyperkalemia resolved with
kayexalate. For his liver failure, pt started on vitamin K x 3
days. Renal failure (Cr 3.2) while in MICU. Pt thought to be
hypoperfusing with intravascular dryness. Renal team consulted
and considered hepatorenal syndrome vs. pre-renal renal failure
as etiology. Hyponatremia from diuretics. Anemia is noted to be
a chronic problem from HIV and ESRD, transfused 1 units PRBCS.
Other issues were stable. Pt was called out MS improved. Called
out to the floor for further managment.
Pt states he feels more alert, denies pain. He wants to eat.
Past Medical History:
HIV
Hep B/End Stage Liver Dx
CRI
Anemia
Neuropathy
Tonsillectomy
Paracentesis x 3(last [**12-6**])
Mod Pulm HTN
Heart murmur
Social History:
Works in real estate2-3 cigs/day. 25 pk yr hx. No EtOH. No
drugs. From [**Country 4194**]. Lives with his partner.
Family History:
Mom:DM
No early MIs
Physical Exam:
Temp
BP
Pulse
Resp
O2 sat
Gen - Alert, no acute distress, middle aged thin man
HEENT - PERRL, extraocular motions intact, anicteric, dry MM
with some dried blood near tongue
Neck - no JVD, no cervical lymphadenopathy, triple lumen in
right neck, no erythema or drainage from line site
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, 3/6 SEM murmur rad to axillae, no rubs,
or gallops
Abd - Soft, nontender, distended, with normoactive bowel sounds;
left sided tap sit with small bruise
Back - No costovertebral angle tendernes
Extr - No clubbing, cyanosis, 1+edema to mid shin edema. 2+ DP
pulses bilaterally
Neuro - Alert and oriented x 3, cranial nerves [**1-27**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact, no asterixis
Skin - small red papular rash on lowr neck and chest wall
Pertinent Results:
Labs
[**2-25**] CXR:
The right IJ line has been pulled back and the tip is now in the
superior vena cava. The film is again obscured by motion. No
focal infiltrate is seen. The feeding tube tip is off the film,
at least in the second portion of the duodenum.
[**2-24**] Head CT:
There is no intra or extra-axial hemorrhage, mass effect, shift
of normally midline structures. Differentiation of [**Doctor Last Name 352**]/white
matter is preserved. Sulci, ventricles, and basal cisterns are
all within normal limits. The visualized paranasal sinuses, and
mastoid air cells are well aerated. The surrounding osseous and
soft tissue structures are within normal limits.
IMPRESSION: No intracranial hemorrhage or mass effect.
Brief Hospital Course:
Impression: 41 yo M with h/o HIv, hep B cirrhosis, who was
admitted for FTT s/p post pyloric feeding tube, tap [**2-23**], who
was transferrred to the ICU for unresponsiveness. Pt currently
awake, afebrile, HD stable, with improving renal failure who is
being transferred to the floor awaiting further management of
his liver disease.
Plan:
1. Fever: On admission patient was afebrile. Unclear source as
both initial peritoneal fluid and fluid from diagnostic tap in
ICU were w/o evidence of SBP. Patient defervesced on CTX and
vancomycin. On transfer back to floor was vancomycin and
ceftriaxone were held as no known source had been established.
Culture data remained negative and patient had been afebrile
x48h prior to discharge.
2. Hypotension- hypotensive event likely [**1-17**] lg volume fluid
shift following therapeutic paracentesis. Although only 3L
removed (less than that usually recommended for albumin
replacement), patient has underlying renal disease and thus
could not appropriately buffer redistribution. Hyperkalemia
was likely [**1-17**] to add'l renal hypoperfusion and rapidly resolved
in ICU w/ administration of fluid. Rapidity of resolution not
c/w hepatorenal syndrome. Following fluid administration
patient did well w/o further episodes of hypotension.
3. Hep B cirrhosis: Awaiting transplant for liver and kidney.
Coagulopathy related to cirrhosis. Lactulose was continued for
mgmt of previously diagnosed encephalopathy, vit K x 3 days for
coagulopathy. Patient remained w/ good mental status following
hypotensive event.
4. Acute on CRF: Improving renal function. Pt started on
midodrine, octreotide, albumin in ICU. Discontinued prior to d/c
as renal function had rapidly improved.
5. Anemia: Transfused 2 unit PRBCs. No evidence of ongoing
bleeding.
6. HIV: On HAART, restarted following transfer out of ICU.
Continued on bactrim for ppx.
8. FEN: TF's,
9. PPx: pnuemboots, PPI
10. Code: Full while in house. HCP [**Name (NI) 12395**] [**Name (NI) 12396**].
Medications on Admission:
Bactrim single-strength Mondays,Wednesdays, and Fridays;
atenolol 25 q. day;
lactulose 2 tablespoons twice a day
lamivudine 150 mg every day;
tenofovir 300 mg every-other-day;
Lexiva 700 mg b.i.d.
Neurontin 600 mg b.i.d.
Aldactone 25 q. day;
Mg ox 400 b.i.d.
Reglan 10 t.i.d.;
Procrit 20,000 units qwed;
Mycelex 1 tablet five times per day
Rescriptor 400 mg t.i.d.
furosemide 20 mg q. day;
MVI
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO QMON,WED,FRI ().
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO QOD, START SAT [**2-25**] ().
5. Fosamprenavir Calcium 700 mg Tablet Sig: One (1) Tablet PO
Q12H (every 12 hours).
6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
7. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
8. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
5X PER DAY ().
9. Delavirdine Mesylate 100 mg Tablet Sig: Four (4) Tablet PO
TID (3 times a day).
10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
12. Enfuvirtide 90 mg Kit Sig: One (1) Kit Subcutaneous [**Hospital1 **] ()
as needed for hiv.
13. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig:
Thirty (30) ML PO TID (3 times a day).
Disp:*2700 ML(s)* Refills:*2*
14. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime) as needed.
Disp:*20 Tablet(s)* Refills:*0*
15. Procrit 20,000 unit/mL Solution Sig: One (1) ML Injection
qWED ().
16. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
17. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day: Do not take with Delaviradine.
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
1) post-pyloric tube placement
2) transient hypotension post paracentesis
2) ESLD
3) HIV
4) HBV
Discharge Condition:
Good, afebrile, VSS, tolerating p.o.
Discharge Instructions:
1) Please continue to take your medications as you were
previously
2) Please attend your follow up appointments.
3) Return to medical care if you develop fever, nausea,
vomiting, or abdominal pain.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**]
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-3-7**] 1:20
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
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"285.21",
"584.9",
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"567.2",
"276.2",
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"V49.83",
"571.5",
"276.3",
"263.9",
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"287.5",
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icd9cm
|
[
[
[]
]
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[
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"54.91",
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"99.04"
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icd9pcs
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4087, 6102
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383, 413
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8235, 8273
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3337, 3609
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2437, 2458
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6546, 8016
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8116, 8214
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6128, 6523
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8297, 8496
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2473, 3318
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274, 345
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441, 2141
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3618, 4064
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2163, 2289
|
2305, 2421
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,802
| 113,814
|
42485
|
Discharge summary
|
report
|
Admission Date: [**2149-12-16**] Discharge Date: [**2149-12-19**]
Date of Birth: [**2097-1-25**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
left internal jugular central venous line placement
hemodialysis
History of Present Illness:
52 year old male the past medical history of end-stage renal
disease on hemodialysis, hypertension, anemia, IVDU complicated
by recurrent epidural and hepatitis C who presented to [**Hospital1 18**] ED
from dialysis with altered mental status.
.
His mom notes he has had confusion since midnight. He went to
dialysis this morning and asked repetitive questions. Per
dialysis reports, he was alert and oriented for few minutes and
then would not be oriented to nothing. He vomiting once in
dialysis with no reports of hypoglycemia though he was
hypertensive to 190/132. His ROS is negative for recent fall,
focal weakness, diplopia, chest pain, shortness of breath,
abdominal pain or dysuria. His mom does report having recent
change in his antihypertensives from ... to ...
Hypertensive at the facility: 190/132. He was transferred to
[**Hospital1 18**] ED for futher evaluation and management.
.
In the ED, initial vitals were 97.4 82 188/119 16 100%. He was
noted to have waxing and [**Doctor Last Name 688**] mental status in the ED though
no focal neurological deficit. He was noted to have seizure
after IV labetalol which was described as three minute tonic
clonic with loss of consciousness and 10 minute postictal.. He
was given 2 mg IV ativan. LP attempted but because of
degenerative changes were not able to obtain CSF. Neurology was
consulted who recommended ASA 325mg, MRI brain, 24hr EEG. Ativan
prn sz >3 min 2mg. Keppra 1g IV x1 if repeat sz occurs. Consider
LP, pls get WBC, UA (if he makes urine), tox screen. He was
subsequently transferred to MICU for further evaluation and
management. Vitals prior to transfer were 98.9 72 155.74 12
100%2LNC.
Past Medical History:
1. End-stage renal disease on dialysis, potentially due to
either antibiotic or drug use.
2. Hepatitis C virus.
3. History of multiple soft tissue abscesses as well as spinal
abscesses.
4. Hypertension.
5. Scoliosis.
6. Opioid dependence.
7. Status post left upper arm AV graft excision due to bleeding.
Social History:
He does have one child age 14; both his son and his wife live
in [**State 8842**]. The patient used to work as a carpenter and doing
tiles although currently is on SSI.
Family History:
Brother recently passed away from drinking. No history of kidney
disease in the family.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
Admission labs:
[**2149-12-16**] 09:55AM [**Month/Day/Year 3143**] WBC-3.3* RBC-3.32* Hgb-10.6* Hct-31.0*
MCV-93 MCH-31.9 MCHC-34.1 RDW-13.7 Plt Ct-46*
[**2149-12-16**] 09:55AM [**Month/Day/Year 3143**] Neuts-76.7* Lymphs-16.5* Monos-4.1
Eos-2.6 Baso-0.2
[**2149-12-16**] 07:35AM [**Month/Day/Year 3143**] Glucose-108* UreaN-67* Creat-9.9* Na-139
K-7.1* Cl-92* HCO3-25 AnGap-29*
[**2149-12-16**] 07:35AM [**Month/Day/Year 3143**] ALT-22 AST-39 AlkPhos-95 TotBili-0.2
[**2149-12-17**] 03:20AM [**Month/Day/Year 3143**] Calcium-9.0 Phos-3.8 Mg-2.3
[**2149-12-16**] 01:17PM [**Month/Day/Year 3143**] VitB12-854
[**2149-12-16**] 07:35AM [**Month/Day/Year 3143**] ASA-4.4 Ethanol-NEG Acetmnp-6*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2149-12-16**] 07:50AM [**Month/Day/Year 3143**] Glucose-104 Lactate-1.6 K-6.8*
.
Imaging:
.
CXR (portable AP) [**2149-12-16**]: Mild vascular congestion without
overt edema.
.
[**2149-12-19**]
Echo
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Doppler parameters are most consistent with Grade I
(mild) left ventricular diastolic dysfunction. Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mild symmetric LVH with normal global biventricular
systolic function. Mild diastolic LV dysfunction.
.
Vein Mapping:
IMPRESSION:
1. Patent bilateral brachial and radial arteries with triphasic
flow.
2. Patent but small caliber of bilateral cephalic and basilic
veins with
measurements as above.
3. Subclavian veins could not be imaged due to presence of
dressings
.
EEG: [**12-17**]
IMPRESSION: This is an abnormal routine EEG in wakefulness due
to
continuous left hemispheric slowing maximally seen in the
temporal
region, attenuation of faster frequencies, and absent alpha
rhythm on
the left. These findings are indicative of left hemispheric
cortical and
subcortical dysfunction, maximal in the temporal region. In
addition,
background activity was slow on the right indicative of a
diffuse
encephalopathy of non-specific etiology. No electrographic
seizures or
epileptiform discharges were present. If clinical suspicion for
seizures
is high, a 24 hour recording is recommended to rule out
subclinical left
hemispheric and particularly left temporal seizures.
.
abd US [**12-17**]
IMPRESSION:
1. Enlarged liver without a focal lesion; splenomegaly and
patent portal
vein.
2. Incidental note of a small gallbladder polyp.
3. Small atrophic kidneys.
.
[**2149-12-16**]
CT head
IMPRESSION: No acute intracranial process. Specifically, no
intracranial
hemorrhage detected.
.
Micro:
[**2149-12-16**] 9:48 am [**Month/Day/Year 3143**] CULTURE
**FINAL REPORT [**2149-12-22**]**
[**Year/Month/Day **] Culture, Routine (Final [**2149-12-22**]):
PROPIONIBACTERIUM ACNES.
Anaerobic Bottle Gram Stain (Final [**2149-12-20**]):
Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] ON [**2149-12-20**] AT
2245.
GRAM POSITIVE ROD(S).
[**2149-12-16**] 9:30 am [**Month/Day/Year 3143**] CULTURE SET 1.
**FINAL REPORT [**2149-12-22**]**
[**Year/Month/Day **] Culture, Routine (Final [**2149-12-22**]):
PROPIONIBACTERIUM ACNES.
Anaerobic Bottle Gram Stain (Final [**2149-12-21**]): GRAM
POSITIVE ROD(S).
.
Discharge labs:
[**2149-12-19**] 06:38AM [**Month/Day/Year 3143**] WBC-5.4 RBC-3.96* Hgb-12.3* Hct-36.4*
MCV-92 MCH-31.2 MCHC-33.9 RDW-13.8 Plt Ct-81*
[**2149-12-16**] 09:55AM [**Month/Day/Year 3143**] Neuts-76.7* Lymphs-16.5* Monos-4.1
Eos-2.6 Baso-0.2
[**2149-12-19**] 06:38AM [**Month/Day/Year 3143**] Plt Ct-81*
[**2149-12-19**] 06:38AM [**Month/Day/Year 3143**] Glucose-94 UreaN-35* Creat-6.5*# Na-140
K-4.8 Cl-99 HCO3-28 AnGap-18
Brief Hospital Course:
52 year old male the past medical history of end-stage renal
disease on hemodialysis, hypertension, anemia, IVDU complicated
by recurrent epidural and hepatitis C who presented to [**Hospital1 18**] ED
from dialysis with altered mental status.
.
# Altered mental status: The patient presented with confusion
that improved after admission. Non-contrast CT head negative.
Initially there was concern for a CNS infection, so LP was
attempted. LP was unsuccessful, and the patient received 1 dose
of vancomycin and ceftriaxone before antibiotics were d/c'ed.
Neurology was consulted, and felt that the Ddx included
hypertensive encephalopathy versus benzo withdrawal or seizures.
Patient was admitted to the MICU and his mental status improved.
On reevaluation by neurology, it was felt that an MRI and LP
were no longer needed and they recommedned a 20 minute EEG.
This showed diffuse L sided slowing, with no epileptiform
features. When called out to the floor he was AAO x 3 and
responding to questions appropriately. Pt's mental status
remained stable throughout the rest of hospitalization. Given
history of benzodiazepine use and abrupt stop, very well could
have been benzodiazepine withdrawal seizures. Neurology did not
want to start pt on anti-epileptic at this time. He will follow
up with neuro in one month to be re-evaluated.
.
# Hypertensive urgency: The patient had hypertension and severe
headache. He was initially treated with labetolol, but this was
stopped due to bradycardia. In the MICU, he was transitioned to
a nicardipine gtt, with improvement in [**Hospital1 **] pressure. On HD
day, he was transitioned to captopril 25mg PO tid with bp of
140s/90s. On the floor pt was started on lisinopril 10mg daily
and amlodipine 5mg daily, with adequate bp control.
.
# Headache: The patient complained of a severe headache. This
responded best to clonazepam and oxygen. Neurology recommended
verapamils for vascular headache. However, his headaches
ultimately improved by time of discharge.
.
# Seizure: The patient was noted to have seizure activity in the
emergency department. 20-minute EEG showed diffuse slowing on
the left. Patient had no further seizures. See above.
.
# Pancytopenia: Unclear etiology. Obtained RUQ U/S to evaluation
for cirrhosis in setting of known hepatitis C.
.
# Opioid dependence: The patient attends a methadone clinic as a
outpatient, where his methadone dose is 140 mg daily. He was
maintained on this dose and discharged with a letter to his
methadone clinic.
.
# ESRD: HD was performed on admission and on HD 2. MS [**First Name (Titles) **] [**Last Name (Titles) **]
pressures improved with HD. Vein mapping was scheduled to be
performed on [**2149-12-18**], so we did it in hospital instead. At the
request of the renal team we also checked an echocardiogram to
see if heart failure could be contributing to his hypervolemia
or if this was purely from ESRD. Echo revealed normal
ventricular function without any wall motion abnormalities and
an EF > 55%
.
FC
.
Transitional:
needs follow up for [**Date Range **] cultures
follow up in neuro clinic one month
Medications on Admission:
CALCIUM ACETATE 667 mg [**1-23**] capsules with meals daily
CLONAZEPAM 1 mg po qdaily
METHADONE 140 mg daily per methadone clinic
Trazodone
Iron
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for headache. Tablet(s)
2. calcium acetate 667 mg Capsule Sig: [**1-23**] Capsules PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. clonazepam 1 mg Tablet Sig: One (1) Tablet PO qAM for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
4. methadone 40 mg Tablet, Soluble Sig: 3.5 Tablet, Solubles PO
DAILY (Daily).
5. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
7. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*7 Tablet(s)* Refills:*0*
9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
10. clonazepam 1 mg Tablet Sig: One (1) Tablet PO qPM as needed
for anxiety for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
metabolic encephalopathy
new onset seizure
Hypertension
ESRD
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 taking care of you. You were admitted to the
hospital for mental status changes and seizures. Your mental
status changes improved after hemodialysis. We believe that
your mental status changes were either caused by a post-ictal
state (which means confusion after a seizure), or from metabolic
encephalopathy which is related to your renal disease. The
neurology team evaluated you and think that your seizure could
have been caused by withdrawal from clonazepam. At this time,
we are not yet starting any anti-epileptic medications. We have
arranged for follow up in the neurology clinic here, the
information is below. Please do not drive or operate any heavy
machinery for six months or until a neurologist or your PCP
gives you clearance to drive.
.
During this hospitalization you also had high [**Known lastname **] pressure,
which likely contributed to some of your headaches. We are
starting several medications for this. Please see the
information below.
.
We have made the following changes to your home medications:
START: Lisinopril 10mg tab. One tablet by mouth once daily
START: amlodipine 5mg tab. one tablet by mouth once daily
CHANGE: Clonazepam from 1mg once daily to 1mg twice daily
START: folate and thiamine supplements
.
Followup Instructions:
PCP [**Name Initial (PRE) **]:Thursday, [**12-25**] @ 2:20pm for 40min
appointment
Name:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 91953**],MD
Location: [**Hospital6 5242**] CENTER
Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 798**]
Department: NEUROLOGY
When: WEDNESDAY [**2150-1-21**] at 1 PM
With: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name **] [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMODIALYSIS
When: SATURDAY [**2149-12-20**] at 7:30 AM
Department: TRANSPLANT CENTER
When: FRIDAY [**2150-1-9**] at 8:00 AM
With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: TRANSPLANT SOCIAL WORK
When: FRIDAY [**2150-1-9**] at 9:00 AM [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**]
|
[
"585.6",
"070.54",
"287.5",
"349.82",
"780.39",
"304.01",
"403.91",
"V45.11",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11998, 12004
|
7647, 7903
|
292, 358
|
12109, 12109
|
3301, 3301
|
13588, 14871
|
2583, 2673
|
10967, 11975
|
12025, 12088
|
10797, 10944
|
12260, 13328
|
7203, 7624
|
2688, 3282
|
13346, 13565
|
231, 254
|
386, 2052
|
3317, 7186
|
12124, 12236
|
2074, 2380
|
2396, 2567
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,211
| 186,942
|
27059
|
Discharge summary
|
report
|
Admission Date: [**2199-2-4**] Discharge Date: [**2199-2-8**]
Date of Birth: [**2156-2-4**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Stab wounds
Major Surgical or Invasive Procedure:
Bronchoscopy
Esophagogastroduodenoscopy
Laryngoscopy
Swallow Study
History of Present Illness:
43 y/o M transferred from OSH for self-inflicted stab wounds to
neck. Pt. apparently stabbed himself 11 times in the neck in a
suicide attempt. After stabbing himself he went to his cousin's
home and cousin called EMS. Pt. also reported that he took some
advil and aspirin. At scene, pt. w/ GCS 14. Pt. was electively
intubated in flight and put in a c-collar. Pt. found to have
multiple zone 2 neck wounds.
Past Medical History:
HIV+
Depression
Drug Use
Hepatitis C
Social History:
Drug abuse
Alcohol abuse
Marital difficulty
Family History:
Non-contributory
Physical Exam:
99.1 97 112/66 100% intubated
HD: no lac, PERRLA
Neck: in c-collar; multiple 1 cm lacerations ant neck, palp
carotids w/ no bruits, mild crepitus anterior neck
Face: intubated, no lacerations
Back: no step offs
chest: b/l breath sounds, CTA b/l
Abd/Pelvis: NTND soft, pelvis stable
Rectal: no gross blood, nl tone
Ext: + pulses
Pertinent Results:
CXR ([**2-4**]):Subcutaneous emphysema in the neck around the
trachea. No acute
cardiopulmonary process. Irregularity of distal clavicle on the
single view. There is clinical concern for injury, dedicated
clavicular views can be obtained.
CT/CTA:IMPRESSION:
1. Extensive cervical subcutaneous emphysema centered primarily
around the
trachea. Although no definite defect is observed, this may
represent a
tracheal or less likely esophageal injury.
2. Laceration in right thyroid lobe. Diffuse hematoma is
observed along the anterior neck.
3. Occlusion of the right vertebral artery from the C6 through
C2 to C3
levels. Given the osseous defect only in the posterior aspect of
the right C6 foramen transversarium and the presence of rounded
metallic densities in the C6 and C5 foramen, this vertebral
artery occlusion is felt less likely to be related to the
current stabbing and may have been secondary to a prior trauma
such as a gunshot wound.
4. No definite evidence of acute arterial injury.
5. Orogastric tube coiled within the mouth and pharynx.
The right foramen transversarium is small,
indicating that the right vertebral artery was developmentally
small in the neck. I see only a "nubbin" of right vertebral
artery arising from the right subclavian artery. The origin of
the metallic densities in the right foramina transversaria is
unclear. It is not clear, also, whether there was flow in the
right cervical vertebral artery before the current incident.
CXR ([**2-5**])
Pneumomediastinum at the thoracic inlet and subcutaneous
emphysema in the neck have improved. There is no pneumothorax or
pleural effusion. Heart size normal. ET tube in standard
placement. Nasogastric tube passes into the upper stomach.
Swallow study: No evidence of leak from pharynx to esophagus
EGD: wnl
Bronchoscopy: wnl
[**2199-2-7**] 06:15AM BLOOD WBC-5.9 RBC-3.05* Hgb-11.3* Hct-32.4*
MCV-106* MCH-37.1* MCHC-35.0 RDW-13.2 Plt Ct-189
[**2199-2-7**] 06:15AM BLOOD Plt Ct-189
[**2199-2-7**] 06:15AM BLOOD Glucose-82 UreaN-9 Creat-0.8 Na-139 K-3.7
Cl-101 HCO3-30 AnGap-12
[**2199-2-7**] 06:15AM BLOOD ALT-114* AST-103* AlkPhos-51 Amylase-65
TotBili-0.5
[**2199-2-7**] 06:15AM BLOOD Lipase-19
[**2199-2-7**] 06:15AM BLOOD Albumin-3.5 Calcium-8.7 Phos-2.4* Mg-1.9
[**2199-2-7**] 06:15AM BLOOD Ammonia-36
[**2199-2-7**] 06:15AM BLOOD Free T4-0.9*
Brief Hospital Course:
Pt. was transferred from OSH for multiple self-inflicted stab
wounds to zone 2 of the neck. Pt. transferred from OSH.
Intubated in [**Location (un) **]. GI and vascular were consulted.
Neuro: some difficulty controlling pain at first, but eventually
pt. had pain relief w/ cepacol throat lozenges, percocet,
ibuprofen and clonidine patch.
CV: no acute issues
GI: Pt. had an EGD that did not reveal any evidence of
esophageal injury. A bronchoscopy was performed with ? of a
tracheal ring injury, but may have been secondary to intubation.
Pt. had a swallow study that did not show any evidence of
extravasation. Pt. had a laryngosopcy by ORL who felt that
subcutaneous air was the result of stab wounds and not due to
perforation of trach/esoph. A swallow study was performed after
this with no evidence of extravasation. Pt. with some elevated
liver enzymes - unclear if rxn to tylenol vs. hepatitis C (Ab
+). The LFTs should be monitored by his PCP as an outpatient.
Pt's diet was slowly advanced and pt. was tolerating regular
diet.
Respiratory: A CXR revealed subcutaneous emphysema. A
bronchoscopy was performed with a ? of a suprerficial tracheal
ring injury, but this was small and felt to be secondary to
intubation.
Vascular: vascular surgery was consulted. A CT torso and CTA
were performed to look for vascular injury. There did not
appear to be any inury. There was a small vertebral artery
occlusion with evidence of old metal object (bullet). Vascular
and radiology reviewed the films and did not feel that the
occlusion was acute.
ID: Pt. originally given zosyn and then was switched to kefzol.
Pt. d/c w/ 1 week of keflex. Pt. with HIV who is unclear about
his medications. Pt's PCP was [**Name (NI) 653**] about these medications
and pt. was re-started on his HIV medications prior to
discharge.
Toxicology: Pt. ingested unknown quantities of aspirin and
tylenol. He was not acidotic and no bicarb was needed. Pt. had
supportive care.
Psychiatry: Pt. was followed by psychiatry throughout his
hospitalization. Pt. was put on a CIWA scale for withdrawal,
but did not require this. Pt. was put on 3 days of
folate/thiamine. Section 12 was placed by psychiatry. It was
decided that pt. would benefit from inpatient psychiatric care
given suicide attempt. Pt. given haldol and ativan PRN
agitation and did not require a lot. Social work also followed
the patient given his substance abuse history.
Pt. was medically cleared and transferred to [**Hospital1 **] 4 for psych
care
Medications on Admission:
HIV medications
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
2. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 4 days.
3. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6
hours) as needed for agitation/anxiety.
4. Haloperidol 1 mg Tablet Sig: 1-2 Tablets PO BID (2 times a
day) as needed for agitation.
5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
6. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
PRN (as needed) as needed for sore throat.
7. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet
PO BID (2 times a day).
8. Nelfinavir 625 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. Wound Care
Please put bacitracin ointment on wound and cover with a dry
sterile dressing once a day.
10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4, [**Hospital1 18**]
Discharge Diagnosis:
Suicide attempt
Neck Wounds
Aspirin and Tylenol Ingestion
Depression
Discharge Condition:
Good
Discharge Instructions:
You need to take your medications as directed.
Call your doctor or return to the ER for severe pain, inability
to swallow, difficulty breathing, shortness of breath, nausea,
vomiting, fevers, chills or any other changes in your medical
condition that concern you.
Followup Instructions:
You need to follow up in trauma clinic in the next 2 weeks. You
can call [**Telephone/Fax (1) 6449**] to make an appointment.
You need to follow up with your psychiatrist regularly.
You need to follow up with your primary care physician regarding
your hepatitis status, HIV, liver lab tests and general care.
|
[
"862.29",
"965.4",
"305.00",
"965.1",
"309.0",
"070.70",
"E950.0",
"276.2",
"V08",
"E956",
"305.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"33.22",
"45.13",
"96.04",
"31.42"
] |
icd9pcs
|
[
[
[]
]
] |
7206, 7271
|
3714, 6237
|
323, 392
|
7384, 7391
|
1354, 3691
|
7705, 8020
|
972, 990
|
6303, 7183
|
7292, 7363
|
6263, 6280
|
7415, 7682
|
1005, 1335
|
272, 285
|
420, 835
|
857, 895
|
911, 956
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,238
| 105,805
|
6686
|
Discharge summary
|
report
|
Admission Date: [**2133-2-18**] Discharge Date: [**2133-3-1**]
Date of Birth: [**2051-11-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Bactrim / Morphine
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Recurrent right pneumothorax
Major Surgical or Invasive Procedure:
[**2133-2-20**]: Video-assisted thoracoscopic right apical
blebectomy and mechanical and chemical (1 gram doxycycline)
pleurodesis.
[**2133-2-25**]: Right 4gram talc pleurodiesis.
History of Present Illness:
Mr. [**Known lastname 25501**] is a 81 year-old male with COPD. He presented to [**Hospital 25502**] Hospital, [**Location (un) 8117**] NH on [**2132-2-11**] for increased shortness of
breath. A chest film revealed a right pneumothorax, a chest tube
was placed to suction, on [**2133-2-11**] pleurodesis with 1 gm Doxy was
done, resolution of pneumothorax by chest film, RLL infiltrates
were also seen, sputum culture grew pseudomonas treated with
Zosyn changed to Fortaz. He was discharged on [**2133-2-13**]. He
returned to the ED on [**2-17**] with decreased oxygen saturation and
increased respiratory effort. He was admitted, chest film today
showed recurrent right apical pneumothorax a chest tube was
placed and he transferred to [**Hospital1 18**] for further management.
Past Medical History:
Right Lower lobe lung nodule s/p R VATs wedge for Squamous cell
[**7-/2128**]
Left pneumothorax s/p L VATs blebectomy pleurodesis [**7-/2129**]
Severe chronic obstructive pulmonary disease on home 02 3L
Parkinson's disease
Hypertension
Diverticulosis
Associated lower GI Bleed
Right lower lobe pneumonia
PSH: R VATS wedge resection [**7-/2128**], L VATS
blebectomy/pleurodesis
[**2129**], Bowel perforation [**2100**], right inguinal hernia repair,
right
shoulder dislocation
Social History:
heavy smoking history-quit in 25 yrs ago
married, lives in [**Location 8117**], works in financial services
Family History:
Lung and cardiac disease
Physical Exam:
VS: 67.2 90 111/61 20 91%4L
General: 81 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1,S2 no murmur/gallop or rub
Resp: decreased breath sounds with bibasilar crackles no wheezes
GI: bowel sounds positive, abdomen soft
non-tender/non-distended.
Extr: warm no edema
Incision: Right VATs site clean dry intact. no erythema or
discharge
Skin: bilateral earlobes 1 cm x 1 cm stage II. Coccyx Stage I
Neuro: awake, alert, oriented, slurred speech
Pertinent Results:
[**2133-2-27**] 07:25AM BLOOD WBC-8.3 RBC-3.31* Hgb-10.4* Hct-30.4*
MCV-92 MCH-31.5 MCHC-34.3 RDW-14.3 Plt Ct-267
[**2133-2-26**] 07:45AM BLOOD WBC-7.4 RBC-3.48* Hgb-11.2* Hct-32.6*
MCV-94 MCH-32.2* MCHC-34.4 RDW-14.1 Plt Ct-299
[**2133-2-18**] 05:13PM BLOOD WBC-10.7 RBC-4.03* Hgb-12.9* Hct-37.3*
MCV-93# MCH-31.9 MCHC-34.5 RDW-14.1 Plt Ct-337
[**2133-2-27**] 03:05PM BLOOD Glucose-107* UreaN-18 Creat-0.7 Na-131*
K-4.0 Cl-95* HCO3-28 AnGap-12
[**2133-2-27**] 07:25AM BLOOD Glucose-103* UreaN-16 Creat-0.6 Na-131*
K-4.0 Cl-95* HCO3-28 AnGap-12
[**2133-2-23**] 01:58AM BLOOD Glucose-109* UreaN-24* Creat-0.6 Na-135
K-3.8 Cl-98 HCO3-31 AnGap-10
[**2133-2-18**] 05:13PM BLOOD Glucose-110* UreaN-25* Creat-0.7 Na-132*
K-4.7 Cl-94* HCO3-33* AnGap-10
[**2133-2-27**] 03:05PM BLOOD Mg-2.1
CXR:
[**2133-2-27**]: There is a minimal right basal air collection in the
pleural
space. No clear apical pneumothorax is identified. Unchanged
opacities at
the left lung base and the entire right lung, but both lungs
show signs of
improved aeration. No newly occurred parenchymal opacities.
Normal size of
the cardiac silhouette.
[**2133-2-26**]: Unchanged appearance of parenchymal opacity at the
bases of the right upper lobe and the atelectasis at both lung
bases. Minimal right pleural effusion cannot be excluded.
Unchanged size of the cardiac
silhouette. No interval appearance of new parenchymal opacities.
[**2133-2-25**]: 1. Very small right-sided hydropneumothorax with chest
tube in unchanged position.
2. Heterogeneous opacification of the right lung with focal
opacity in the right upper lobe. It is difficult to entirely
exclude pneumonia but the
appearance could be seen with post-operative changes including
atelectasis.
3. Severe emphysema.
[**2133-2-19**]: FINDINGS: Very small right apical pneumothorax is
present with a basilar right chest tube in place. Postoperative
changes are present within the right mid lung with surgical
chain sutures. Upper lobe bullous emphysema is present as well
as a mid and lower lung predominant interstitial process,
possibly representing acute interstitial edema superimposed on
underlying emphysema.
Chest CT:
[**2133-2-26**]: No pulmonary embolus seen. Extensive distortion of the
pulmonary
architecture consistent with the patient's known emphysema.
Areas of
consolidation along suture lines within the dependent lungs are
likely
atelectasis secondary to recent surgery.
[**2133-2-18**]: 1. Right-sided chest tube with minimal anterior
right-sided pneumothorax.
2. Right middle lobe solid, ground-glass nodules, new since the
prior
examination. Given the patient's underlying severe diffuse
emphysematous
disease, these nodules warrant followup in three months.
3. Severe atherosclerotic disease of the aorta, and coronary
vessels.
4. Gallstones. Ventral mesh, intact.
Brief Hospital Course:
Mr. [**Known lastname 25501**] was admitted for right recurrent apical pneumothorax
on [**2133-2-18**]. He was taken to the operating room by Dr.
[**Last Name (STitle) **] on [**2133-2-20**] for a right Video-assisted thoracoscopic
right apical blebectomy and mechanical and chemical (1 gram
doxycycline) pleurodesis. He was extubated in the operating
room and transferred to the PACU. While in the PACU he
desaturated to the mid 80's his PCO2 was 77%. He transferred to
the intensive care unit for observation. He was slightly
confused, with two chest tubes to wall suction for over 48
hours. The patient was transferred to the floor on [**2133-2-23**].
Below is a systems review of his hospital course.
Neuro: The patient's Parkinson's medications were continued. His
PCP and geriatrics followed him while in house. He developed
delirium in the ICU. Geriatrics was consulted followed him
throughout his hospital course and recommended, continue his
home dose of Ativan 0.5 [**Hospital1 **] and Seroquel 12.5 for acute
agitation. No Haldol since would make his Parkinson worse.
Ultram and acetaminophen, Lidoderm patch for pain. No morphine
secondary to confusion with this narcotics. His delirium
improved.
Pulmonary: Pulmonary toilet with incentive spirometry,
nebulizers, and mucolytics were continued. The patient had a
good productive yellow cough. The patient's oxygen saturations
were kept in the low 90's initially with shovel mask transition
ed to 4 L Nasal cannula. On [**2133-2-26**] his saturations decreased
a Chest CT was negative for Pulmonary Embolism.
Chest-tubes: On POD 3, the anterior chest tube was discontinued
with posterior chest tube kept to water seal. CXR was stable,
however small leak persisted. gram right talc pleurodesis and
chest tubes to wall suction for 48 hours. The chest tube was
clamped on [**2133-2-27**] follow-up chest film showed no pneumothorax.
The chest tube was removed.
Serial chest films: see above report.
CV: He was found to tachycardic in the ICU and low-dose
beta-blocker was started. He converted to PO with HR 70-90's.
Once stabilized the beta-blocker was titrated off given his
history of severe COPD. His home dose of felodipine of 5 mg was
continue on admission but decreased to 2.5 mg to allow BP
greater than 110 for cerebral perfusion.
Abd: Stool softeners were given throughout his stay. The
patients diet was advanced and tolerated, however he had poor
appetite. Ensure supplemental shakes were continued. The patient
had adequate bowel movements.
GU/renal: Foley was removed following surgery. Initially he had
low urine output responded to fluid bolus. Hyponatremia with
Na+ 131. monitored closely.
ID: no fevers or leukocytosis.
Heme: HCT stable 30-33.
Prophylaxis: SCD's and SQ heparin were instituted for VTE
prophylaxis.
Disposition: he was followed by physical therapy who recommended
rehab. He was discharged to [**Hospital 11729**] Hospital Rehab in [**Location (un) 8117**]
NH on [**2133-3-1**]. He will follow-up with Dr. [**Last Name (STitle) **] as an
outpatient.
Medications on Admission:
Symbicort 160/4.5 2 puffs twice daily
Guaifenesin 600 mg [**Hospital1 **]
Carbidopa/levodopa 25-250 twice daily
Omeprazole 40 mg daily
Tiotropium bromide 1 capsule daily
Felodipine 5 mg daily
Naprosyn 500 twice daily
Acetylcysteine & albuterol nebs QID
PRN: Senna, Ativan 0.5 Q6, MSO4 0.5 SL Q4, [**2-27**] IV Q4, bisacodyl
10
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) SQ
Injection TID (3 times a day).
3. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO BID (2 times a
day) as needed for SOB.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
6. carbidopa-levodopa 25-250 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ML
Miscellaneous Q6H (every 6 hours) as needed for wheezing: mix
with albuterol to prevent bronchospasm.
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) mL Inhalation Q4H (every 4 hours) as
needed for wheezing/SOB.
11. felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO DAILY (Daily): increase to
5 mg as BP tolerates.
12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
13. lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
14. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
15. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical once a day: Right shoulder.
Discharge Disposition:
Extended Care
Facility:
St. [**Hospital **] Hospital Rehabilitation Unit
Discharge Diagnosis:
Right apical recurrent pneumothorax s/p right apical blebectomy
with pleurodiesis.
Right Lower lobe lung nodule s/p R VATs wedge for Squamous cell
[**7-/2128**]
Left pneumothorax s/p L VATs blebectomy pleurodesis [**7-/2129**]
Severe chronic obstructive pulmonary disease on home 02 3L
Parkinson's disease
Hypertension
Diverticulosis
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 greater than 101.5, chills
-Increased shortness of breath, cough or chest pain
-Incision develops drainage
-Chest tube site remove dressing Saturday and cover with a
bandaid until healed.
-Should site drain cover with a clean dry dressing and change as
needed
-Shower daily. Wash incision with mild soap, rinse, pat dry
-Oxygen titrate to maintain saturations 88-90%
Followup Instructions:
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2133-3-17**] 2:00 [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] [**Location (un) **].
Chest X-ray [**Location (un) **] radiology 30 minutes prior to your
appointment.
Completed by:[**2133-3-1**]
|
[
"401.9",
"427.89",
"276.1",
"V49.87",
"492.0",
"293.0",
"285.9",
"V46.2",
"V10.11",
"V15.82",
"512.8",
"276.2",
"332.0",
"V14.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"34.92",
"34.6",
"34.21",
"99.21",
"32.20"
] |
icd9pcs
|
[
[
[]
]
] |
10433, 10508
|
5387, 8455
|
313, 496
|
10886, 10886
|
2548, 5364
|
11560, 11886
|
1952, 1979
|
8833, 10410
|
10529, 10865
|
8481, 8810
|
11071, 11537
|
1994, 2529
|
245, 275
|
524, 1309
|
10901, 11047
|
1331, 1810
|
1826, 1936
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,774
| 114,990
|
29155
|
Discharge summary
|
report
|
Admission Date: [**2177-11-6**] Discharge Date: [**2177-11-10**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Back pain x 5 days
Major Surgical or Invasive Procedure:
EVAR [**2177-11-6**]
History of Present Illness:
[**Age over 90 **] year old female with known aortic abdominal aneurysm of 5.4
cm in size presents with 5 days of back pain. It started out as
her feeling lethargic and just not herself. She then had
bilateral hip pain that seemed to travel to her back. She has
been in constant pain. She denies fever, chills, night sweats,
nausea, vomiting, constipation, or diarrhea. She has a known
AAA
which has been asymptomatic for the last 3 years and followed by
Dr [**First Name (STitle) **]. She went to [**Hospital3 **] where a CT scan showed
that there some stranding around the aneurysm and slight
increase of size to 5.5 compared to about 1 year and half ago.
She denies chest pain and shortness of breath.
Past Medical History:
Macular degeneration, legally blind, thoracoabdominal aneurism,
hypertension, hyperlipidemia, history of colon cancer
Past Surgical History: Appendectomy, colon resection for colon
cancer, hysterectomy, cataract surgery, tonsillectomy
Social History:
Lives in an retirement home. Independent of all her activities.
She drinks one [**Doctor Last Name 6654**] a night. She denies tobacco.
Family History:
N/C
Physical Exam:
Vital Signs: HR 79 BP 136/66 RR 16 O2 Sat 98% RA
General: No acute distress
Cardiovascular: regular rate and rhythm
Lung: clear to auscultation bilaterally
Abdomen: soft, nondistended, nontender
Extremities:
palpable femoral pulses bilaterally
right DP and PT are dopplerable
Left DP is dopplerable but PT was not dopperable
Wound: Groin sites CDI. No hematoma, no bleed
Pertinent Results:
[**2177-11-9**] 06:08AM BLOOD WBC-10.0 RBC-3.65* Hgb-10.8* Hct-31.5*
MCV-86 MCH-29.6 MCHC-34.3 RDW-14.9 Plt Ct-175
[**2177-11-9**] 06:08AM BLOOD Plt Ct-175
[**2177-11-9**] 06:08AM BLOOD Glucose-103 UreaN-19 Creat-1.1 Na-136
K-4.0 Cl-101 HCO3-27 AnGap-12
[**2177-11-7**] 01:20AM BLOOD CK(CPK)-71
[**2177-11-9**] 06:08AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.0
[**2177-11-7**] 08:44AM BLOOD Type-ART pO2-100 pCO2-32* pH-7.47*
calTCO2-24 Base XS-0
[**2177-11-7**] 08:44AM BLOOD Glucose-133* Lactate-0.6 K-3.3*
[**2177-11-7**] 08:44AM BLOOD O2 Sat-97
Brief Hospital Course:
[**2177-11-6**]
Emergently sent by [**Location (un) **] from [**Hospital1 **] to [**Hospital1 18**] for
symptomatic AAA. Having one week of abdominal and back pain.
Esmolol and sodium bicarb gtt initiated. Evaluation by Attending
Vascular Surgeon on arrival to ED and CT scan reviewed. Patient
was a DNR/DNI and agreed to possible intervention. Taken to the
OR for an endovascular AAA repair. Tolerated procedure without
complications. Transferred to the CVICU post-op. Propofol and
nitro gtts overnight for BP control. Intubated overnight.
[**2177-11-7**]
Extubated and weaned off drips. Vitals and labs stable.
Transferred to VICU. Diet advanced. OOB to chair.
[**2177-11-8**]
No acute events. Labs and vitals stable. Foley DC'ed. PT
screened and cleared for home with Physical Therapy. Pain
management. Lasix given for fluid overload with symptomatic lung
crackles.
[**2177-11-9**]
No acute events. Ambulated with PT. Tolerating regular diet.
[**2177-11-10**]
Stable overnight. DC home with VNA and Physical therapy.
Follow-up with Dr. [**Last Name (STitle) **] in [**3-18**] weeks.
Medications on Admission:
Lisinopril 10 mg PO Daily, Crestor 10 mg PO Daily, Aspirin 40.5
mg PO Daily, calcium, vitamin D, vitamin C, Multiple vitamins,
Omega 3
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Please call PCP for refills [**Last Name (LF) **],[**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] [**Telephone/Fax (1) 52051**].
Disp:*30 Tablet(s)* Refills:*2*
6. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
AAA
PMH:
legally blind
hypertension
hyperlipidemia
DNR/DNI
Discharge Condition:
Stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm (AAA) Discharge
Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**2-16**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**4-20**] weeks for
post procedure check and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2177-12-2**] 12:00
Completed by:[**2177-11-10**]
|
[
"441.4",
"401.9",
"276.6",
"V10.05",
"369.4",
"272.4",
"362.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"39.71"
] |
icd9pcs
|
[
[
[]
]
] |
4380, 4439
|
2456, 3548
|
281, 304
|
4542, 4551
|
1890, 2433
|
7158, 7343
|
1475, 1480
|
3733, 4357
|
4460, 4521
|
3574, 3710
|
4575, 6578
|
6604, 7135
|
1209, 1304
|
1495, 1871
|
223, 243
|
332, 1045
|
1067, 1186
|
1320, 1459
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,565
| 193,799
|
5151
|
Discharge summary
|
report
|
Admission Date: [**2142-8-30**] Discharge Date: [**2142-9-11**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
altered mental status, fevers
Major Surgical or Invasive Procedure:
lumbar puncture, PICC
History of Present Illness:
85 year-old female with seizures, CHF (right sided), pulmonary
HTN, atrial fib, rheumatic heart disease s/p mechanical MVR,
severe TR, HTN, presents with fever, hypotension, seizures. She
has been at [**Hospital **] rehab recovering from a SBO surgery in the
spring and has been slowly worsening. She had a seizure 2 weeks
ago and was started on Keppra. Two days ago, her keppra dose was
decreased for a high peak and somnalence. On [**8-29**], she was
febrile to 102.8. She has had continued ventilator requirement.
.
In the ED, initial vs were: T 105.4 P 82 BP 96/60 R O2 sat 100.
She was hypotensive to 70s/40s from baseline 90s/60s but
responded to 2 L IVF. Exam showed unresponsive cachectic woman
with warm basilar ralles and cuts in teeth and mouth c/w
seizure. Guiac (+) stool. EKG showed new lateral downsloping st
depressions. ED doctor discussed code status with son, who
confirmed DNR, moving to CMO but wanted a last hurrah. Family
did not want a LP because it was too invasive and did not want a
CT scan because they did not want any surgeries to correct what
might be found. She was given Acetaminophen 650mg x2,
Piperacillin-Tazob, Vancomycin 1g, Acyclovir, Aspirin 600mg
Supp. Prior to transfer, vitals were HR 77 BP 81/49, RR 33
ovebreathing vent, sat 97% on RR 10, TV 359 PEEP 5, FiO2 40%.
Past Medical History:
Seizure disorder, noted in [**2080**], prior to this episode last
seizure in [**2123**], was on dilantin in past but had been taken off.
Cerebellar infarcts
Pancreatic cyst
Diabetes
Mitral valve disease s/p MVR with mechanical valve
Severe tricuspid regurgitation (3+)
Aortic regurgitation (1+)
History of rheumatic fever
Chronic atrial fibrillation
Congestive heart failure
Iron deficiency anemia
Hypertension
CCY
Left inguinal hernia
Social History:
Lives at [**Hospital **] rehab. No alcohol. No cigarette smoking.
Family History:
Non-contributory.
Physical Exam:
Vitals: T:102 BP: 95/52 P:84 R:24 O2:99 on 350/10/5/.4
General: Cachectic, ill-appearing woman.
Neuro: Unresponsive to voice or touch. Blinks to threat, does
not track. PERRL. No spontaneous movements. No withdrawal to
pain. No tremor. Negative babinski.
HEENT: Sclera anicteric, MMM, jaw contracted, tongue eroded by
bite.
Neck: supple, JVP not elevated, no LAD
Lungs: Good air movement bilaterally. Bibasilar rhonchi.
CV: irregularly irregular, mechanical heart sounds.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, G-tube C/D/I
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Multiple pressure ulcers on back
Pertinent Results:
[**2142-8-30**] 04:30PM BLOOD WBC-13.0* RBC-3.79*# Hgb-11.2*#
Hct-34.6*# MCV-91 MCH-29.4 MCHC-32.2 RDW-17.5* Plt Ct-309
[**2142-8-30**] 04:30PM BLOOD Neuts-79.4* Lymphs-15.9* Monos-3.9 Eos-0
Baso-0.8
[**2142-8-30**] 04:30PM BLOOD PT-20.8* PTT-60.7* INR(PT)-1.9*
[**2142-8-30**] 04:30PM BLOOD Glucose-145* UreaN-63* Creat-1.5* Na-149*
K-4.6 Cl-115* HCO3-25 AnGap-14
[**2142-8-30**] 04:30PM BLOOD ALT-42* AST-90* CK(CPK)-71 AlkPhos-211*
TotBili-0.7
[**2142-8-31**] 01:50PM BLOOD Digoxin-2.6*
[**2142-8-31**] 01:49PM BLOOD Phenyto-14.3
[**2142-9-11**] 04:47AM BLOOD WBC-7.2 RBC-2.71* Hgb-8.5* Hct-25.7*
MCV-95 MCH-31.4 MCHC-33.1 RDW-20.0* Plt Ct-144*
[**2142-9-11**] 04:47AM BLOOD Neuts-79.7* Lymphs-11.8* Monos-5.4
Eos-2.8 Baso-0.2
[**2142-9-11**] 04:47AM BLOOD PT-29.1* PTT-69.3* INR(PT)-2.9*
[**2142-9-11**] 04:47AM BLOOD Glucose-134* UreaN-33* Creat-1.2* Na-140
K-4.1 Cl-102 HCO3-31 AnGap-11
[**2142-9-11**] 04:47AM BLOOD ALT-11 AST-32 LD(LDH)-299* AlkPhos-161*
TotBili-0.5
[**2142-9-11**] 04:47AM BLOOD Albumin-2.5* Calcium-8.8 Phos-3.4 Mg-2.1
[**2142-9-11**] 04:47AM BLOOD Digoxin-0.7*
Blood Culture, Routine (Final [**2142-9-5**]): NO GROWTH.
URINE CULTURE (Final [**2142-8-31**]): NO GROWTH.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2142-9-1**]): Feces
negative for C.difficile toxin A & B by EIA.
GRAM STAIN (Final [**2142-8-31**]): >25 PMNs and <10 epithelial
cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE
ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2142-9-2**]): OROPHARYNGEAL FLORA
ABSENT. Due to mixed bacterial types ( >= 3 colony types) an
abbreviated workup will be performed appropriate to the isolates
recovered from this site.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
GRAM NEGATIVE ROD #2. SPARSE GROWTH.
GRAM NEGATIVE ROD #3. SPARSE GROWTH.
[**2142-9-4**] 9:12 pm CSF;SPINAL FLUID Source: LP 3. GRAM STAIN
(Final [**2142-9-5**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2142-9-8**]): NO
GROWTH.
VIRAL CULTURE (Preliminary): No Virus isolated so far.
[**2142-9-4**] 9:12 pm CSF;SPINAL FLUID Source: LP 3.
GRAM STAIN (Final [**2142-9-5**]): NO POLYMORPHONUCLEAR LEUKOCYTES
SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made
by cytospin method, please refer to hematology for a
quantitative white blood cell count..
FLUID CULTURE (Final [**2142-9-8**]): NO GROWTH.
VIRAL CULTURE (Preliminary): No Virus isolated so far.
CXR [**2142-8-30**] IMPRESSION: There may be small bilateral pleural
effusions. Overall, however, no acute pulmonary process is
identified.
CT head [**2142-8-30**] IMPRESSION: Relatively stable head CT examination
compared with [**2142-6-14**]. No CT evidence of acute cortical
stroke or hemorrhage. Incidental findings as above.
MRI head [**2142-8-30**] IMPRESSION: 1. Diffuse hyperintensities in the
white matter indicate extensive changes of small vessel disease,
which have progressed since the previous MRI of [**2136-10-19**].
2. Ventriculomegaly and prominence of temporal horns which in
presence of
choroidal fissure widening is secondary to atrophy.
3. Chronic blood products in the left cerebellum indicate
previous hemorrhage
with bilateral small chronic cerebellar infarcts.
4. No evidence of acute infarct seen.
5. No evidence of abnormal parenchymal enhancement.
[**9-6**] MRI head
FINDINGS: Extensive periventricular and subcortical
hyperintensities are
identified with moderate ventriculomegaly and prominence of
temporal horns. Hyperintensities are also seen in the pons and
middle cerebellar peduncles. There is an area of chronic blood
products in the left cerebellum. There is no acute infarct seen.
No midline shift identified. Coronal images demonstrate
bilateral hippocampal atrophy with widening of the choroidal
fissures. No intrinsic signal abnormalities are seen within the
hippocampus. The hyperintensity seen on the superior aspect of
the right hippocampus appears to be due to enhancement of the
choroid plexus as the FLAIR images appear to have been obtained
following gadolinium administration.
Coronal MP-RAGE images demonstrate no evidence of abnormal
parenchymal
enhancement. There is mild diffuse pachymeningeal enhancement
seen, which is a nonspecific finding and could be related to
prior lumbar puncture. IMPRESSION:
1. Diffuse hyperintensities in the white matter indicate
extensive changes of small vessel disease, which have progressed
since the previous MRI of [**2136-10-19**].
2. Ventriculomegaly and prominence of temporal horns which in
presence of
choroidal fissure widening is secondary to atrophy.
3. Chronic blood products in the left cerebellum indicate
previous hemorrhage with bilateral small chronic cerebellar
infarcts.
4. No evidence of acute infarct seen.
5. No evidence of abnormal parenchymal enhancement.
6. Diffuse pachymeningeal enhancement is identified which is a
nonspecific
finding and could be due to prior lumbar puncture.
Brief Hospital Course:
Assessment and Plan: This is an 85 y/o female with right sided
heart failure, pulmonary HTN, atrial fib, rheumatic heart
disease s/p mechanical MVR, HTN, seizure disorder who presents
with fevers, hypotension and altered mental status.
.
# Goals of care: Patient was made comfort measures only after
discussion with family. No escalation of care, DNR. All
medications were discontinued except lorazepam and morphine.
.
# Altered mental status/seizures/CNS infection: The patient had
a remote history of seizure disorder which had been stable until
2 weeks prior to presentation. The patient had a seizure and was
started on keppra, however, her mental status has been declining
since that time. The patient developed a fever and worsening of
mental status and presented to [**Hospital1 18**] for work up. At [**Hospital1 18**] the
patient was febrile and was found to be in nonconvulsive status
epilepticus. An lumbar puncture at that time was declined by the
family. The patient was started empirically on acyclovir,
ampicillin, vancomycin and cefepime. Neurology was consulted and
discontinued keprra and started dilantin with ativan for
breakthrough seizures. The patient also was started on
continuous EEG. The option of LP was reevaluated with son and he
was agreeable. The patient had a CT head which showed no
increased ICP. Her INR was reversed and an LP was performed
without complications. HSV PCR was negative so we discontinued
acyclovir. The LP was somewhat abnormal without organisms so
cefepime, vancomycin and ampicillin were continued for treatment
of infectious meningitis for a total course of 14 days. EEG
showed that the patient was seizing intermittently and Keppra
was added. The EEG showed some improvement with no clinical
improvement. Eventually depakote was added. The patient
continued to have seizures despite antibiotic treatment, three
anticonvulsives and boluses of ativan. Goals of care were
discussed with family and the decision was made to make patient
CMO. Plans were arranged to transport patient back to rehab
facility for comfort care. After discussion with neurology all
antiepileptics were discontinued and patient was given standing
ativan.
.
# Infection: The patient presented with SIRS criteria with
fevers, leukocytosis. The patient also had mild hypotension. The
patient was given IVF to increase MAP. The patient was
pan-cultured and initially no LP was done per family wishes. The
patient was started on cefepime and vancomycin for coverage. As
per above, LP was done which was somewhat abnormal. The patient
was started on ampicillin and acyclovir, with acyclovir being
discontinued once PCR results returned. Hemodynamic status
improved.
.
# Chronic respiratory failure: The patient presented on a
ventilator with a trach. She was continued on her home settings
with good oxygenation. ABG's and CXR were done in changes with
clinical status, which was stable.
.
# Afib with RVR: The patient had a history of atrial
fibrilation, which continued during her hospitalization. She was
continued on anticoagulation with coumadin, which was reversed
for her LP. She was then put on a heparin drip until her
coumadin was back to goal. Digoxin levels were measured, which
were elevated and causing EKG changes. The digoxin was re-added
once levels were at appropriate range. The patient initially had
her beta blocker held due to hypotension. This was added once
her hemodynamics improved.
.
# EKG changes: The patient presented with lateral ST depression.
This was suggestive of demand ischemia vs digoxin toxicity. Her
digoxin was held. Aspirin, statin were continued and
beta-blockers as tolerated. EKG and CE were trended.
.
# Anemia: The patient has a baseline anemia. She had an acute
drop in hct with no obvious sign of bleed. She had a CT of her
torso, which showed a hematoma in her thigh but no signs of
retroperitoneal bleed. She was transfused pRBC and had serial
hct, which were stable throughout the rest of the
hospitalization. Hemolysis labs were negative.
.
# Mechanical valve: The patient was anticoagulated with coumadin
or heparin during her stay.
.
# Diabetes: Continued on insulin sliding scale.
.
# Acute renal failure: The patient had pre-renal ARF in setting
of hypotension. Resolved with fluids.
.
# FEN: The patient became volume overload secondary to IVF. She
was given lasix to diurese.
Medications on Admission:
Vancomycin 1gm daily started [**8-29**]
Zosyn 3.375 g QID started [**8-29**]
Flagyl 500 mg TID
Darbopeotin alfa 25 mcg SC Th, hold for Hg > 12
Digoxin 0.25 mg PO DAILY (Daily) PEG TUBE.
Ferrous sublate 325 mg [**Hospital1 **]
Keppra 250 mg [**Hospital1 **] (started [**8-29**])
Magnesium Oxide 400 mg TID
Metoprolol Tartrate 50 mg PO QID PEG TUBE
Omeprazole 40 mg PO daily
KCl 40 mEq daily
Senna 17.2 mg [**Hospital1 **]
Thiamine HCl 100 mg PO DAILY PEG TUBE.
Warfarin 10 mg PO Once Daily at 4 PM PEG TUBE.
Tylenol 650 mg Q6hrs
Miconazole nitrate topical [**Hospital1 **]
Atrovent 0.5 mg q6hrs
Discharge Medications:
1. Lorazepam 2 mg IV Q6H
2. Morphine Sulfate 1-2 mg IV Q2H:PRN comfort
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary
1. Subclinical status epilepticus
Secondary
Seizure disorder, noted in [**2080**], prior to this episode last
seizure in [**2123**], was on dilantin in past but had been taken off.
Cerebellar infarcts
Pancreatic cyst
Diabetes
Mitral valve disease s/p MVR with mechanical valve
Severe tricuspid regurgitation (3+)
Aortic regurgitation (1+)
History of rheumatic fever
Chronic atrial fibrillation
Congestive heart failure
Iron deficiency anemia
Hypertension
CCY
Left inguinal hernia
Discharge Condition:
Patient was discharged in stable condition.
Discharge Instructions:
1. The patient was admitted for fever and seizures. She was
treated with multiple anti-seizure medications and antibiotics
for her seizures with limited success. After discussion with her
family, she was converted to comfort measures only with
cessation of all medications except for standing ativan 2 mg IV
Q6H and prn morphine.
2. As above, the patient was converted to comfort measures only.
Followup Instructions:
Please follow-up with the palliative care service at [**Hospital 100**]
Rehab for hospice.
|
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icd9cm
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[
[
[]
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[
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icd9pcs
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[
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13067, 13133
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7966, 12326
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292, 315
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|
2979, 7943
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|
2132, 2199
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,339
| 104,882
|
37463+58150
|
Discharge summary
|
report+addendum
|
Admission Date: [**2107-10-21**] Discharge Date: [**2107-10-25**]
Date of Birth: [**2020-2-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Coronary Artery Disease
Major Surgical or Invasive Procedure:
CABG X4 (LIMA-LAD, SVG-OM, PDA,PLD) on [**2107-10-21**]
History of Present Illness:
87 year old male, known to our service (see H&P from [**2107-8-12**]),
who sustained an STEMI in [**2107-7-24**]. A bare metal stent was
placed to the RCA at that time. A TTE on [**2107-8-13**] showed inferior
hypokinesis and an EF of 35-40%. He was seen by cardiac surgery
and was considering CABG at the time of discharge however wanted
to wait for the time being. Since that time he has felt quite
well and has been symptom free. He walks 20 minutes daily
without issue. He was seen by Dr. [**Last Name (STitle) 911**] in consultation and it
was recommended that he would be best served with going forward
with surgical revascularization. Recent echo showed left
ventricular
wall motion abnormalities and overall left ventricular systolic
function that are significantly improved compared to prior echo.
He presented for surgical discussion.
Past Medical History:
Glaucoma
Mechanical fall c/b left proximal ulnar fracture [**4-/2105**]
Mild cognitive impairment
Left peroneal impairment
Prostate Cancer s/p TURP and Lupron therapy 12 years ago
GERD
Past Surgical History:
s/p TURP
Past Cardiac Procedures:
[**2107-8-12**] s/p BMS to RCA
Social History:
Race: Caucasian
Last Dental Exam: 3 months ago
Lives with: alone
Contact: [**Name (NI) 84169**] (son) Phone #[**Telephone/Fax (1) 84170**]
Occupation:retired
Cigarettes: Smoked no [x] yes []
Other Tobacco use: Never
ETOH: < 1 drink/week [x] [**3-1**] drinks/week [] >8 drinks/week []
Illicit drug use: Denies
Family History:
The patient has a twin brother who has a history of heart
disease and heart failure
Physical Exam:
Pulse: 59 Resp: 16 O2 sat: 100/RA
B/P 140/75
Height: 5'8" Weight: 75.7 kgs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur []
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] No Edema
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:1+ Left:1+
DP Right:1+ Left:1+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right:1+ Left:1+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2107-10-24**] 05:40AM BLOOD Hct-28.5*
[**2107-10-23**] 06:15AM BLOOD WBC-9.7 RBC-3.15* Hgb-9.2* Hct-27.9*
MCV-89 MCH-29.3 MCHC-33.1 RDW-15.1 Plt Ct-128*
[**2107-10-22**] 02:37AM BLOOD WBC-10.0 RBC-3.26* Hgb-9.6* Hct-28.8*
MCV-88 MCH-29.4 MCHC-33.3 RDW-14.8 Plt Ct-126*
[**2107-10-21**] 07:27PM BLOOD Hct-29.0*
[**2107-10-24**] 05:40AM BLOOD UreaN-25* Creat-1.2 Na-132* K-4.3 Cl-100
[**2107-10-23**] 06:15AM BLOOD Glucose-108* UreaN-22* Creat-1.2 Na-135
K-4.1 Cl-103 HCO3-26 AnGap-10
[**2107-10-22**] 02:37AM BLOOD Glucose-149* UreaN-19 Creat-1.3* Na-136
K-4.8 Cl-108 HCO3-22 AnGap-11
[**2107-10-21**] 12:17PM BLOOD UreaN-19 Creat-1.2 Na-141 K-4.3 Cl-114*
HCO3-22 AnGap-9
[**2107-10-21**] TTE
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is low normal (LVEF
50-55%). with borderline normal free wall function. There are
simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. Mild (1+)
mitral regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is paced, on no inotropes.
Preserved biventricular systolic fxn.
Trace MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta intact.
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on **** where the patient underwent *********.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. ***** was used
for surgical antibiotic prophylaxis. POD 1 found the patient
extubated, alert and oriented and breathing comfortably. The
patient was neurologically intact and hemodynamically stable on
no inotropic or vasopressor support. Beta blocker was initiated
and the patient was gently diuresed toward the preoperative
weight. The patient was transferred to the telemetry floor for
further recovery. Chest tubes and pacing wires were
discontinued without complication. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD **** the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged ***** in good
condition with appropriate follow up instructions.
Medications on Admission:
ATORVASTATIN 80 mg tablet 1 tablet(s) by mouth daily
CLOPIDOGREL [PLAVIX] 75 mg tablet once a day
LISINOPRIL 5 mg by mouth once a day
METOPROLOL SUCCINATE [TOPROL XL] 25 mg tablet,extended release 1
Tablet(s) by mouth once a day
NITROGLYCERIN [NITROSTAT] - Nitrostat 0.4 mg sublingual tablet
1 tablet(s) sublingually as directed PRN
TIMOLOL MALEATE - Dosage uncertain
ASPIRIN 325 mg tablet,delayed release 1 Tablet(s) by mouth once
a day
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*100 Tablet Refills:*0
2. Atorvastatin 80 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Metoprolol Tartrate 50 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 50 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*1
5. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days
Hold for K+ > 4.5
RX *potassium chloride 20 mEq 1 by mouth daily Disp #*1 Tablet
Refills:*0
6. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
7. Timolol Maleate 0.25% 1 DROP BOTH EYES [**Hospital1 **]
8. Furosemide 20 mg PO DAILY Duration: 7 Days
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
9. Lisinorpil 5 mg po daily
10. Plavix 75 mg po daily
Discharge Disposition:
Extended Care
Facility:
TBA
Discharge Diagnosis:
Coronary Artery Disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. 1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**First Name (STitle) **] on [**2107-11-22**] at 2:30pm
Cardiologist: Dr. [**Last Name (STitle) 911**] [**2107-11-16**] at 3:20pm ([**Hospital Ward Name 23**] 7)
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**4-28**] weeks [**Telephone/Fax (1) 2010**]
**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:[**2107-10-25**] Name: [**Known lastname 2793**],[**Known firstname **] Unit No: [**Numeric Identifier 13382**]
Admission Date: [**2107-10-21**] Discharge Date: [**2107-10-25**]
Date of Birth: [**2020-2-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 265**]
Addendum:
The patient was admitted to the hospital and brought to the
operating room on [**2107-10-21**] where the patient underwent Coronary
artery bypass graft x4: Left internal mammary artery to left
anterior descending artery, saphenous vein graft to obtuse
marginal and posterior descending artery and posterior left
ventricular branch. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable on no inotropic or vasopressor support. All narcotics
were stopped due to post op confusion. 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. He did have a brief
episode of atrial fibrillation POD2 night, for which he was
bolused with Amiodarone. He converted to sinus rhythm and
remained in sinus for the remainder of his hospital course. His
Lopressor was titrated up and Lisinopril was restarted for blood
pressure and rate control. Chest tubes and pacing wires were
discontinued without complication. Plavix was resumed at the
time of discharge per Dr [**Last Name (STitle) 677**] with history of RCA stent in
7/[**2107**]. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. His confusion
had cleared by the time of discharge. On POD 4, the patient was
ambulating with assistance, the wound was healing well and pain
was controlled with Tylenol. The patient was discharged to
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Rehab at Foxhill in good condition with appropriate
follow up instructions.
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*100 Tablet Refills:*0
2. Atorvastatin 80 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Metoprolol Tartrate 50 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 13383**] *metoprolol tartrate 50 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*1
5. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days
Hold for K+ > 4.5
RX *potassium chloride 20 mEq 1 by mouth daily Disp #*1 Tablet
Refills:*0
6. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
7. Timolol Maleate 0.25% 1 DROP BOTH EYES [**Hospital1 **]
8. Furosemide 20 mg PO DAILY Duration: 7 Days
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
9. Lisinopril 5 mg PO DAILY
10. Clopidogrel 75 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
TBA
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2107-10-25**]
|
[
"285.9",
"427.31",
"293.9",
"V10.46",
"412",
"365.9",
"V45.82",
"414.01",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
11607, 11758
|
4019, 5117
|
335, 393
|
6634, 6850
|
2637, 3996
|
7774, 10647
|
1909, 1995
|
10670, 11584
|
6587, 6613
|
5143, 5583
|
6874, 7751
|
1498, 1565
|
2010, 2618
|
272, 297
|
421, 1268
|
1290, 1475
|
1581, 1893
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,910
| 115,657
|
13213
|
Discharge summary
|
report
|
Admission Date: [**2153-3-10**] Discharge Date: [**2153-4-5**]
Service: Plastics
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 40291**] is an 86-year-old
gentleman with a history of laryngeal cancer, status post
laryngectomy, right radical neck dissection, with
postoperative radiation therapy two years ago, with a second
course of radiation therapy for question of a recurrence.
The patient has since developed an orocutaneous fistula which
has been resistant to local wound care and an advancement
flap.
The patient now presents with a large orocutaneous fistula
anteriorly to the left neck measuring approximately 7 cm X
8 cm with saliva and purulent discharge. The patient was
noted to have a large volume of bleeding from the wound
earlier in the day, at which time the patient was transferred
to the [**Hospital1 **] for further evaluation.
PAST MEDICAL HISTORY:
1. Laryngeal cancer.
2. Coronary artery disease.
PAST SURGICAL HISTORY:
1. Laryngectomy.
2. Radical neck dissection.
3. G-tube placement.
4. Aortic valve replacement.
MEDICATIONS ON ADMISSION: Coumadin 2.5 mg p.o. Monday
through Friday and 5 mg p.o. on Saturday and Sunday, Roxicet
elixir for pain
PHYSICAL EXAMINATION ON PRESENTATION: At the time of
admission, the patient was awake and alert, in no apparent
distress. He was afebrile with stable vital signs. On head
and neck, his cranial nerve examinations were all intact.
There was a 7-cm X 8-cm orocutaneous fistula anteriorly over
the left neck with saliva and purulent discharge extruding
from the wound. The laryngeal stoma was intact. The airway
was secured. His lungs were clear to auscultation
bilaterally. His heart had a regular rate and rhythm. His
abdomen was soft, nontender, and nondistended. A G-tube
secured in place.
HOSPITAL COURSE: Because of the nature of this wound, and
near exposure of the left carotid artery, Neurosurgery was
consulted for angiography to rule out any carotid bleeding
given this patient's history of a large amount of blood
extruding from the wound. The angiography was performed, and
there was no sign of any pseudoaneurysm, dissection, or
extravasation.
An incidental finding was noted on CT. The patient had
bilateral subdural hematomas. At the time of admission, the
patient's INR was 2.9, and he was being anticoagulated for
his prosthetic aortic valve. At this point, the patient
began receiving blood products to reverse his INR in
anticipation of the patient needing surgical correction for
his neck as well as potential subdural hematomas. While this
was being done, the patient developed congestive heart
failure but rapidly responded to Lasix and did not require
any ventilatory support.
On hospital day five, the patient had been adequately
reversed and was taken to the operating room by the
Otolaryngology team where he underwent biopsies of the
margins to insure there was no remaining cancer prior to
placement of a flap for closure of this wound. Biopsy
results of the wound were negative for any remaining signs of
malignancy.
At this point, it was decided by the Neurosurgery team that,
despite the patient's subdural hematomas, the patient was
suffering no neurologic compromise. There were no radiologic
findings to suggest midline shift, and it was decided at this
point that the patient would be of significant risk and of
decreased benefit with the hematomas.
Over the next several days the patient was seen by the
Physical Therapy team and the Nutrition team as the patient
was prepared for operative repair of his orocutaneous
fistula.
On [**3-26**], the patient was taken to the operating room where
he underwent left pectoralis myocutaneous skin flap for
closure of the orocutaneous fistula. The patient tolerated
the procedure well, and there were no perioperative
complications. The patient was taken to the Surgical
Intensive Care Unit overnight for observation and monitoring
of flap. The patient had no problems in the immediate
perioperative period and was therefore transferred to the
floor on postoperative day one.
At this point, the patient's tube feeds were restarted, and
the patient was begun on his home medications as well as
restarted on heparin and Coumadin while waiting for the
patient to become adequately anticoagulated in the setting of
his prosthetic aortic valve. The patient was also treated
with penicillin and Ancef postoperatively.
The patient's pectoralis donor site was initially managed
with a bulb suction drain. Over the next couple of days, the
patient continued to do well. His rotational flap continued
to thrive, with the only concern being that the level where
his tracheostomy appeared to be causing some necrosis at the
level of the right lateral inferior aspect of the flap.
Otolaryngology was consulted, and it was decided the patient
did not need a tracheostomy as the patient had a very mature
stoma. After the tracheostomy was removed, the patient
continued to do well; and, again, the flap continued to
thrive.
On postoperative day six, the patient developed a large left
chest wall hematoma and had to be taken to the operating room
for evacuation. The bulb suction drain which had been
draining the chest wound had been discharged two days
previously. The drainage output from the drain prior to it
being removed had been less than 15 cc per day for the two
previous days prior to it being removed. Again, the patient
tolerated evacuation well with no perioperative
complications. The patient did receive 2 units of packed red
blood cells, as the patient's hematocrit during this bleeding
episode had dropped to 26. The patient responded
appropriately increasing his hematocrit to 30.
Over the next two days, the patient continued to rapidly
improve. He was seen by the Physical Therapy Department and
began ambulating with assistance. From a nutritional
standpoint he continued to do well on his tube feeds.
On postoperative day nine, the patient had a barium swallow
performed which revealed no signs of any leakage or
persistent orocutaneous fistula. At this point, the patient
was begun on soft solids, and swallow consultation was
obtained. Also at this time, the patient's antibiotics were
changed from penicillin and Ancef to clindamycin, and the
patient was deemed medically stable and ready for discharge
to a rehabilitation facility.
CONDITION AT DISCHARGE: The patient was stable at the time
of discharge. His orocutaneous skin flap was doing well.
DISCHARGE STATUS: The patient was to be discharged to an
acute rehabilitation facility.
MEDICATIONS ON DISCHARGE:
1. Clindamycin 300 mg per G-tube q.i.d.
2. Acetaminophen 325 mg to 650 mg per G-tube q.4-6h. p.r.n.
3. Ascorbic acid 500 mg per G-tube b.i.d.
4. Tocopheryl 400 IU per G-tube q.d.
5. Zinc sulfate 220 mg per G-tube q.d.
6. Metoprolol 25 mg per G-tube b.i.d.
7. Albuterol 1 to 2 puffs per stoma q.4h. p.r.n. for
wheezing.
8. Artificial Tears 1 to 2 drop OU p.r.n.
9. Coumadin 2.5 mg p.o. q.d. Monday through Friday and 5 mg
p.o. q.d. on Saturday and Sunday.
10. Dulcolax per G-tube b.i.d.
11. Roxicet elixir 5 mL to 10 mL per G-tube q.4-6h. p.r.n.
12. G-tube feedings with ProMod fiber full strength at 80 cc
per hour with a plan to wean the tube feeds as the patient's
oral intake is gradually increased.
DISCHARGE FOLLOWUP: The patient was to see Dr. [**First Name (STitle) **] in
clinic in one week for followup.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8332**], M.D. [**MD Number(1) 8333**]
Dictated By:[**Last Name (NamePattern1) 40292**]
MEDQUIST36
D: [**2153-4-4**] 18:03
T: [**2153-4-5**] 09:12
JOB#: [**Job Number 40293**]
RP [**2153-4-5**]
|
[
"V45.81",
"998.6",
"V44.1",
"428.0",
"427.31",
"E878.8",
"432.1",
"998.12",
"V43.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.43",
"86.74",
"86.04",
"88.41",
"42.24",
"86.22",
"01.24"
] |
icd9pcs
|
[
[
[]
]
] |
6592, 7317
|
1089, 1795
|
1813, 6366
|
962, 1062
|
6381, 6565
|
7338, 7726
|
120, 865
|
887, 939
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,878
| 180,800
|
25229
|
Discharge summary
|
report
|
Admission Date: [**2151-9-5**] Discharge Date: [**2151-10-11**]
Date of Birth: [**2129-7-26**] Sex: M
Service: SURGERY
Allergies:
Propofol
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p Gunshot Wound to Abdomen
Major Surgical or Invasive Procedure:
s/p Exploratory Laporotomy/Small Bowel Resection x2 [**2151-9-5**]
s/p Repair Left Iliac Artery [**2151-9-5**]
s/p Exploratory Laparotomy and Openeing of Abdomen for ?
Compartment [**2151-9-9**]
s/p Partial Closure of Abdomen
s/p Tightening of Abdominal Closure/Open Tracheostomy [**2151-9-20**]
s/p Abdomonal Closure/Open Gastostomy Tube [**2151-9-24**]
History of Present Illness:
22 yo male, s/p gun shot wound to left lower quadrant;
transferred from [**Hospital 48825**] hospital and taken to the operating
room immediatley for exploratory laparotomy and repair of left
iliac artery.
Past Medical History:
None
Social History:
Resides in [**Hospital1 487**] with his family.
Family History:
Noncontributory
Pertinent Results:
[**2151-9-5**] 10:34PM LACTATE-1.9
[**2151-9-5**] 10:11PM GLUCOSE-114* UREA N-23* CREAT-1.6* SODIUM-142
POTASSIUM-4.1 CHLORIDE-115* TOTAL CO2-20* ANION GAP-11
[**2151-9-5**] 10:11PM CALCIUM-8.0* PHOSPHATE-3.3 MAGNESIUM-2.4
[**2151-9-5**] 10:11PM WBC-7.3 RBC-3.20* HGB-9.7* HCT-27.2* MCV-85
MCH-30.5 MCHC-35.8* RDW-15.0
[**2151-9-5**] 10:11PM PLT COUNT-138*
[**2151-9-5**] 10:11PM PT-13.5* PTT-31.4 INR(PT)-1.2
[**2151-9-5**] 10:34PM TYPE-ART TEMP-37.9 PO2-109* PCO2-35 PH-7.39
TOTAL CO2-22 BASE XS--2
CT RECONSTRUCTION [**2151-9-7**] 4:55 PM
CT T-SPINE W/O CONTRAST; CT RECONSTRUCTION
Reason: s/p trauma
[**Hospital 93**] MEDICAL CONDITION:
22 year old man s/p gunshot wound
REASON FOR THIS EXAMINATION:
s/p trauma
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Status post gunshot wound.
No prior studies are available for comparison.
TECHNIQUE: Multidetector CT scanning of the thoracic spine was
obtained without administration of intravenous contrast. Coronal
and sagittal reformations were also obtained.
FINDINGS: There are no fractures identified. The vertebral body
heights and disc spaces are preserved. There is normal
alignment. The visualized elements and spinal canal is within
normal limits. Note is made of an endotracheal tube and NG tube
which appear to be positioned appropriately. The visualized
portions of the lung are remarkable for a partially visualized
dependent consolidations and bilateral pleural effusions. High
density material is also noted surrounding the visualized
portions of the left kidney, which could be consistent with
hemorrhage.
CT RECONSTRUCTIONS: The above findings were confirmed with
coronal and sagittal reformations.
IMPRESSION: No evidence of thoracic spine fracture. Abnormal
chest findings. Please refer to the above discussion.
CHEST (PORTABLE AP) [**2151-9-7**] 7:34 PM
CHEST (PORTABLE AP)
Reason: ? penumonia
[**Hospital 93**] MEDICAL CONDITION:
22 year old man s/p gunshot wound.
REASON FOR THIS EXAMINATION:
? penumonia
INDICATION: Status post gunshot wound.
CHEST X-RAY, PORTABLE AP: Comparison made to prior study of two
days earlier. There is an endotracheal tube with tip 2.8 cm from
the carina. A nasogastric tube is positioned with tip in the
stomach. There is a right subclavian central venous line with
tip in the right atrium. There is no pneumothorax. The
cardiomediastinal silhouette is within normal limits. There is a
small left pleural effusion. Bilateral patchy perihilar
opacities are present. Air bronchograms are seen. These are new
from the prior study.
IMPRESSION:
1. Right subclavian central venous line with tip in the right
atrium. This may be withdrawn 2-3 cm for optimal positioning in
the lower superior vena cava.
2. Patchy bilateral perihilar opacities, concerning for
pneumonia or aspiration.
CT HEAD W/O CONTRAST [**2151-9-7**] 4:54 PM
CT HEAD W/O CONTRAST
Reason: s/p trauma
[**Hospital 93**] MEDICAL CONDITION:
22 year old man s/p gunshot wound
REASON FOR THIS EXAMINATION:
s/p trauma
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Status post gunshot wound.
No prior studies are available for comparison.
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is no intraparenchymal hemorrhage. There is no
shift of normally midline structures, mass effect, or
hydrocephalus. The [**Doctor Last Name 352**]-white differentiation is preserved. The
ventricles, sulci, and cisterns are felt to be within normal
limits for patient age. The visualized osseous structures are
within normal limits. The paranasal sinuses are remarkable for
rounded mucosal thickening within the bilateral maxillary
sinuses with associated air- fluid levels as well as air-fluid
levels within the ethmoid sinuses and sphenoid sinuses. There is
diffuse soft tissue swelling in the subcutaneous tissues most
pronounced near the cranial vertex.
IMPRESSION:
1. No intracranial hemorrhage or mass effect.
2. Diffuse surrounding soft tissue swelling.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 63191**],[**Known firstname **] [**2129-7-26**] 22 Male [**-5/3163**]
[**Numeric Identifier 63192**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 44437**]/dif
SPECIMEN SUBMITTED: PROXIMAL SMALL BOWEL.
Procedure date Tissue received Report Date Diagnosed
by
[**2151-9-5**] [**2151-9-7**] [**2151-9-9**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/cma??????
DIAGNOSIS
Proximal small bowel segments, two:
1. Multiple perforations, with hemorrhage and focal
coagulation, consistent with gunshot wounds.
2. The margins are free of disease.
Clinical: Gunshot wound left lower quadrant of abdomen.
Gross: The specimen is received fresh labeled with "[**Known lastname **],
[**Known firstname 1790**]" and the medical record number and "proximal small
bowel" and consists of an unoriented 26.3 cm segment of small
bowel with a diameter that averages 2.5 cm. Both margins are
stapled. The serosal surface contains a 8.0 x 3.0 cm area of
erythema/hemorrhage that comes to within 0.5 cm of the stapled
margin. In addition, there are four areas of serosal disruption
with leakage of bowel content measuring 2.6 cm in greatest
dimension and coming to within 1.0 cm of the nearest stapled
margin. There is a separate 2.5 cm segment of small bowel with
two stapled margins. The serosal surface contains a 1.0 x 0.5
cm area that is erythematous and appears disrupted and grossly
to be leaking bowel contents. Sections are submitted as
follows: A = representative sections of margins of larger
segment, B = representative sections of serosal hemorrhage. C =
representative sections of area of apparent perforation, D =
representative sections of uninvolved mucosa, E = representative
sections of smaller segment, including area of apparent
perforation. Gross photographs are taken.
CT HEAD W/O CONTRAST [**2151-10-8**] 8:35 PM
CT HEAD W/O CONTRAST
Reason: compare to prior.
[**Hospital 93**] MEDICAL CONDITION:
22 year old man s/p GSW, multiple injuries, propofol infusion
syndrome with cerebral edema now with persistent blurry vision
and gait unsteadiness.
REASON FOR THIS EXAMINATION:
compare to prior.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 22-year-old male who is status post gunshot wound
and multiple injuries. The patient developed propofol infusion
syndrome with cerebral edema. Now has persistent blurry vision
and gait abnormalities.
COMPARISONS: Comparison is made to [**2151-9-4**].
TECHNIQUE: CT of the head without IV contrast.
FINDINGS: There is no evidence of intracranial hemorrhage, mass
effect, shift of normally midline structures, major vascular
territory infarcts. The [**Doctor Last Name 352**]- white matter differentiation is
preserved. There is interval decrease in the amount of edema
located in the bilateral occipital lobes medially to the atria
of the lateral ventricles. No new areas of edema are seen. The
ventricles are stable in size. Interval removal of the right
frontal bone.
BONE WINDOWS: The paranasal sinuses, mastoid air cells and
middle ears are normally aerated.
IMPRESSION: Interval slight decrease in bilateral occipital lobe
edema. There is also interval decrease in the small fluid
collection along the tentorium, which is now seen on series 2,
image 12 and measures 9x5 mm.
ABDOMEN (SUPINE & ERECT) [**2151-10-6**] 10:14 AM
ABDOMEN (SUPINE & ERECT)
Reason: distension/ileous? obstruction?
[**Hospital 93**] MEDICAL CONDITION:
22 year old man with trach & cycling tube feeds with high
residual and occasion emesis and occasional severe abd pain
REASON FOR THIS EXAMINATION:
distension/ileous? obstruction?
ABDOMEN TWO VIEWS
History of tube feeds with high residual, intermittent vomiting
and severe abdominal pain with distention.
G-tube overlies left upper quadrant. Gas is present throughout
the colon, and there is no free intraperitoneal gas. There are a
few loops of moderately gas distended small bowel in the upper
abdomen, which are not identified on the prior contrast study of
[**2151-9-30**]. Significance uncertain in relation to
possible partial small-bowel obstruction. Surgical staples are
present in the right lower quadrant and metallic fragment
consistent with bullet overlies LV4 as previously noted.
Correlate clinically and with followup as indicated to
reevaluate the moderately gas distended proximal small bowel
loops.
CHEST (PA & LAT) [**2151-10-6**] 2:26 PM
CHEST (PA & LAT)
Reason: evidence aspiration?
[**Hospital 93**] MEDICAL CONDITION:
22 year old man with s/p possible aspiration yesterday
REASON FOR THIS EXAMINATION:
evidence aspiration?
CLINICAL HISTORY: Cough, fever, evaluate for aspiration.
Chest PA and lateral.
A tracheostomy tube is present. Infiltrates are present in the
lingula and in the right lower lobe consistent with aspiration.
The effusions which were present on the prior chest x-ray have
resolved.
IMPRESSION: Right lower lobe and lingular infiltrates.
UNILAT LOWER EXT VEINS LEFT [**2151-9-30**] 3:54 PM
UNILAT LOWER EXT VEINS LEFT
Reason: ABDOMEN WOUND, LEG PAIN, EVAL FOR DVT
[**Hospital 93**] MEDICAL CONDITION:
22 year old man s/p GSW to LLQ c iliac artery laceration now
with L medial thigh pain
REASON FOR THIS EXAMINATION:
DVT
INDICATION: Status post gunshot wound to left lower quadrant
with iliac artery laceration, now with left medial thigh pain.
UNILATERAL LOWER EXTREMITY VEINS: The left common femoral,
superficial femoral, and popliteal veins all demonstrate normal
patency, color flow and Doppler waveform with normal
compressibility, augmentation and respiratory variation. No
intraluminal thrombus is identified.
IMPRESSION: No evidence of deep vein thrombosis.
SMALL BOWEL ONLY (GASTROGRAF) [**2151-9-30**] 2:29 PM
SMALL BOWEL ONLY (GASTROGRAF)
Reason: assess functionality of G-tube & possible other
pathology re
[**Hospital 93**] MEDICAL CONDITION:
22 year old man with s/p gsw and multiple abd
surgeries--trached, g-tube placement but putting out much fluid.
Please perform small bowel follow through with contrast through
G-tube
REASON FOR THIS EXAMINATION:
assess functionality of G-tube & possible other pathology
related to high G-tube output
HISTORY: Status post gunshot wound with multiple abdominal
surgeries, increased G-tube output.
PROCEDURE/FINDINGS: Pulmonary scout film demonstrates multiple
midline surgical staples as well as a bullet lodged within the
pelvis. A gastric tube is demonstrated with the tip in the left
upper quadrant. 150 cc of gastrografin was injected through the
patient's G-tube under direct fluoroscopic guidance. Contrast
was noted to opacify the stomach which appeared non-dilated and
normal. There is no evidence of contrast extravasation. Contrast
flowed freely from the stomach into the duodenum and proximal
loops of jejunum. The small bowel loops appeared normal in
caliber and mucosal pattern. No evidence of obstruction was
identified. Because of the patient's agitation, passage of
contrast into more distal loops of small bowel could not be
observed and the study was terminated.
IMPRESSION: No evidence of gastric or proximal small bowel
obstruction. No contrast extravasation.
Brief Hospital Course:
Patient admitted to the trauma service. His brief hospital
course by systems is as follows:
Neurologic- Patient with low GCS score of 7 on admission; head
CT scan revealed cerebral edema. An ICP bolt was deferred
initially due to coagulopathy; it was later placed on HD 7; his
pressures were elevated; daily head CT scans were followed.
Neurology was [**Hospital 4221**] for ? anoxic brain injury, recommended
holding sedation to see if patient would awaken; initially he
did not as quickly as hoped for. EEG was done also to rule out
non-convulsive status; an MRI was not obtainable at that time
because of the ICP bolt. After lengthy ICU stay patient did
awaken and was transferred to the regular nursing unit.
Ophthalmology was [**Hospital 4221**] for blurred vision; felt likely
optic neuropathy OS of unclear etiology and hemianopic field
defect secondary to questionable occiptial lobe pathology. It is
recommended that he follow up with [**Hospital **] Clinic
after discharge.
Cardiac-Cardiology [**Hospital 4221**] for RBBB, felt not ischemia in
origin, most likely secondary to toxic metabolic effect. A TEE
was performed which was unremarkable. It was recommended that
antibiotics and antifungal therapy continue. He was started on
beta blocker during his early hospital stay for rate control; he
is being discharged to home on 25 mg [**Hospital1 **] Lopressor. His blood
pressure will be followed at home via home visiting nurse; at
his next Trauma Clinic follow up it will be determined whether
he will need to continue with this therapy. There is no history
of HTN or other cardiac disease in patient's PMH. Vascular
surgery was [**Hospital1 4221**] for decreased pulse left lower extremity;
ABI's were recommended. He was prophylaxed with Lovenox.
Respiratory-Patient developed ARDS; mechanically vented on PEEP.
He was taken to the operating room on [**2151-9-20**] for open
tracheostomy; his tach was downsized to a 6.0 prior to his
discharge with plans to pull his trach at his next Trauma Clinic
follow up. He does not require oxygen therapy at this time.
Gastrointestinal-He was directly taken to the operating room
where he underwent exploratory laparotomy for his injuries.
Postoperatively his abdominal pressures were high, he was later
taken back to the operating room for Abdominal Compartment
Syndrome; his abdomen was left open. He was later taken back to
the OR for closure of his abdomen. He was started on TPN early
during his hospital stay. A percutaneous gastrostomy was
eventually placed in the operating room after his abdominal
complications were stabilized. Nutrition was [**Date Range 4221**] for tube
feeds. Speech and Swallow were also involved for his swallowing
issues; his diet was upgraded to soft solids; his tube feedings
were stopped once calorie counts revealed he was taking in
adequate nutrition by mouth. His abdominal staples were
discontinued prior to his discharge. He is being discharged home
on a PPI.
Genitourinary-Renal was [**Date Range 4221**] for ARF felt secondary to
rhabdomyolysis and volume overload. CVVH was initiated during
his ICU stay. He is currently making urine; his Foley catheter
was discontinued.
Musculoskeletal-Orthopedics was [**Date Range 4221**] for ?Compartment
Syndrome; felt low suspicion and recommended to follow patient
clinically. There were no further issues.
Integumentary-Wound Nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] for patient's
sacral ulcer; he is being discharged home with daily dressing
changes.
ID-Patient with intermittent fever spikes during his
hospitalization; he was initially treated with Vanco, Meropenem,
Caspofungin and Flagyl. With subsequent fever spikes,he was
cultured and treated with the appropriate antibiotics.
Social-Social work was [**Last Name (Titles) 4221**] early on for patient/family
coping; several family meetings were held to discuss patient's
progress.
Rehab-Physical and Occupational therapy were [**Last Name (Titles) 4221**] early on
and have worked very closely with patient. He is currently
ambulating with a walker; a leg splint is being recommended to
help with balance.
Medications on Admission:
None
Discharge Medications:
1. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic PRN (as needed).
Disp:*30 ML's* Refills:*2*
2. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
3. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
6. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
s/p Gun Shot Wound to abdomen
Multiple Small Bowel Perforations
Mesenteric Lacerations
Left Iliac Artery Avulsion
Adult Respiratory Distress Syndrome
Propofol Infusion Syndrome
Discharge Condition:
Stable
Discharge Instructions:
1.Follow up in Trauma, Neurosurgery and [**Hospital 8095**] Clinic after
your discharge from hospital.
2.Return to Emergency room if you develop fevers/chills,
increased abdominal pain or tenderness, nausea, and/or
vomitting.
Followup Instructions:
1.Follow up in Trauma Clinic in [**2-4**] weeks, call [**Telephone/Fax (1) 6439**] for
an appointment.
2.Follow up in [**Hospital 8095**] Clinic in 2 weeks, call [**Telephone/Fax (1) 253**]
for an appointment.
3.Follow up with Dr [**First Name (STitle) **] in the Behavioral-Neurology:
[**Telephone/Fax (1) 1690**]; call for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2151-10-20**]
|
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icd9cm
|
[
[
[]
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[
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"54.72",
"88.72",
"54.4",
"99.15",
"39.31",
"38.93",
"96.6",
"45.61"
] |
icd9pcs
|
[
[
[]
]
] |
17476, 17559
|
12382, 16521
|
297, 654
|
17780, 17789
|
1034, 1657
|
18064, 18565
|
998, 1015
|
16576, 17453
|
11078, 11260
|
17580, 17759
|
16547, 16553
|
17813, 18041
|
229, 259
|
11289, 12359
|
682, 889
|
911, 917
|
933, 982
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,551
| 138,746
|
17010
|
Discharge summary
|
report
|
Admission Date: [**2175-5-3**] Discharge Date: [**2175-5-11**]
Date of Birth: [**2100-11-6**] Sex: M
Service: Cardiac Surgery
HISTORY OF PRESENT ILLNESS: This is a 74-year-old gentleman
who was seen in the [**Hospital3 3583**] Emergency Room with a
1-month complaint of progressive shortness of breath,
exertional left and right arm pain radiating to the chest,
associated with shortness of breath, reporting pain resolving
with rest. At the outside hospital, the patient ruled in for
a non-Q-wave myocardial infarction with peak troponin levels
of 2.6. Electrocardiogram showed inferior T wave
abnormalities.
The patient was transferred to [**Hospital1 188**] for cardiac catheterization.
PAST MEDICAL HISTORY:
1. Gastroesophageal reflux disease.
2. Arthritis.
3. Status post right knee arthroscopic surgery.
4. History of esophageal cancer; status post
esophageal/partial gastrectomy in [**2156**].
5. History of sternal fracture.
6. History of esophageal stricture; status post multiple
esophageal dilatations.
7. Remote alcohol abuse; quit in [**2156**].
8. Remote tobacco use; quit in [**2158**].
ALLERGIES: No known drug allergies.
MEDICATIONS ON DISCHARGE: (Preoperative medications
included)
1. Aspirin 81 mg p.o. once per day.
2. Protonix 40 mg p.o. once per day.
3. Lopressor 25 mg p.o. four times per day.
4. Lipitor 10 mg p.o. once per day.
MEDICATIONS ON TRANSFER: The patient was transferred from
the outside hospital on heparin and nitroglycerin drips.
HOSPITAL COURSE: The patient was taken to the Cardiac
Catheterization Laboratory on [**2175-5-3**]. Cardiac
catheterization showed normal left ventricular systolic
function, with a 50% left main lesion, 80% ostial/proximal
left anterior descending artery lesion, 50% ostial circumflex
lesion, and 80% complex right coronary artery lesion.
Cardiothoracic Surgery was consulted, and it was decided that
the patient was a candidate for cardiac surgery.
The patient was to the operating room on [**2175-5-4**] for a
coronary artery bypass graft times three with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**]. The patient had a left internal mammary artery to
left anterior descending artery, saphenous vein graft to
obtuse marginal, and saphenous vein graft to right posterior
descending artery. Please see the Operative Note for further
details.
The patient was transferred to the Intensive Care Unit
postoperatively in stable condition. The patient was weaned
and extubated from mechanical ventilation on the first
postoperative evening.
On postoperative day one, the patient complained of bilateral
arm numbness and weakness which was not the same as his
preoperative angina. The patient had an electrocardiogram
which was unchanged. This sensation was thought to be due to
positioning during surgery, and the sensation gradually
improved over the next couple of days. The patient remained
hemodynamically stable on no cardiac medications. On
postoperative day one, the patient was started on Lopressor.
The chest tube were removed on postoperative day two. The
pacing wires were removed without incident on postoperative
day two. The patient began ambulating in the Intensive Care
Unit. The patient remained in the Intensive Care Unit for a
couple of extra days due to lack of floor bed availability.
The patient was transferred from the Intensive Care Unit to
the floor on postoperative day four. On the evening of
postoperative day four, the patient had a temperature of
101.8. The patient was pan-cultured. As of the day of
discharge, his urine culture was negative. His sputum
culture grew oropharyngeal flora. His blood cultures were
pending, and his chest x-ray was without infiltrate.
The patient was encouraged to use his incentive spirometer,
and the fever defervesced. The patient did not have any
further elevated temperatures.
On postoperative day five, the patient had a 5-beat run of
tachycardia which was presumed to be a ventricular
tachycardia. The patient had an electrocardiogram done at
this time which was negative for any ischemic changes. The
patient had an echocardiogram done which showed grossly
normal left ventricular function. The patient had no further
ventricular tachycardia.
The patient remained hemodynamically stable and was cleared
for discharge to home on postoperative day seven.
CONDITION AT DISCHARGE: Temperature maximum of 97, heart
rate was 70 (sinus rhythm without ectopy), blood pressure was
115/59, respiratory rate was 18, and oxygen saturation was
97% on room air. The patient's weight on [**5-11**] was 77.1
kilograms. Preoperatively, the patient weighed 75.6
kilograms.
PERTINENT LABORATORY VALUES: White blood cell count was 6.1,
hematocrit was 28.6, and platelet count was 295. Sodium was
137, potassium was 5, chloride was 101, bicarbonate was 27,
blood urea nitrogen was 20, creatinine was 1.1, and blood
glucose was 88. Prothrombin time was 13.2 and partial
thromboplastin time was 36.6.
A chest x-ray from [**5-8**] only showed small bilateral
pleural effusions.
PHYSICAL EXAMINATION: The patient was neurologically awake,
alert and oriented times three. The examination was
nonfocal. Strength in the upper and lower extremities was
equal bilaterally. Heart was regular in rate and rhythm
without rubs or murmurs. The lungs were decreased at the
posterior bases without wheezes or rhonchi. Abdominal
examination revealed the abdomen was soft, nontender, and
nondistended. Positive bowel sounds. The patient had a bowel
movement. The patient was tolerating a regular diet.
External incision and Steri-Strips were intact. The sternum
was stable. The incisions was clean and dry without
erythema. The left leg vein harvest site revealed
Steri-Strips were intact without erythema or drainage. The
extremities had 1 to 2+ pitting edema.
MEDICATIONS ON DISCHARGE:
1. Lopressor 50 mg p.o. twice per day.
2. Lasix 20 mg p.o. twice per day (times seven days).
3. Potassium chloride 20 mEq p.o. twice per day (times
seven days).
4. Percocet 5/325 one to two tablets p.o. q.4h. as needed.
5. Colace 100 mg p.o. twice per day.
6. Protonix 40 mg p.o. once per day.
7. Niferex 150 mg p.o. once per day.
8. Vitamin C 500 mg p.o. twice per day.
9. Enteric-coated aspirin 325 mg p.o. once per day.
10. Lipitor 10 mg p.o. once per day.
DISCHARGE STATUS: The patient was to be discharged to home.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with Dr. [**Last Name (STitle) 5310**] on [**5-22**] at 4:45 p.m.
2. The patient was to call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office and
follow up with Dr. [**Last Name (STitle) 70**] in four to six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 28087**]
MEDQUIST36
D: [**2175-5-11**] 11:24
T: [**2175-5-11**] 11:37
JOB#: [**Job Number 47841**]
|
[
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] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
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"88.56",
"37.22",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
5903, 6454
|
1527, 4394
|
6538, 7121
|
5117, 5876
|
6469, 6505
|
172, 712
|
1418, 1509
|
734, 1171
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,958
| 179,773
|
15245
|
Discharge summary
|
report
|
Admission Date: [**2155-4-24**] Discharge Date: [**2155-4-30**]
Date of Birth: [**2110-1-7**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
45 yo male Type II DM complicated by neuropathy, HTN,
antiphospholipid antibody syndrome complicated by stroke in
[**2139**], chronic R foot osteomyelitis w/ recent debridement who has
had 4d of fatigue, and increasing lower extremity edema. The
patient has not taken his home medications for the past four
days. The patient also complains of nonproductive cough. The
patient endorses orthopnea. The patient denies fever, chills,
chest pain or chest pressure.
Upon arrival to the emergency department, initial vitals were:
97.8 80 196/82 18 100%. The patient had crackles throughout
lungs, an elevated JVD and + S4, with significant lower
extremity edema. Labs were significant for UA w/out infection,
lactate 1.1, WBC 6.4 Hct 33.2, plt 196, Na 141, K 3.4, Cl 101,
CO2 27, BUN 16, Cr 0.9, glucose 222. BNP 4235. CXR demonstrated
likely multifocal pneumonia with superimposed mild pulmonary
edema and small bilateral pleural effusions. While in the
emergency department, the patient acutely decompensated with
desaturation reportedly to 56% on 2L NC and SBPs in 170s. The
patient was placed on a non-rebreather and improved to 98%. The
patient had a CXR that showed much worsening pulmonary edema.
Presumed to be flash pulmonary edema, the patient received 40mg
IV lasix and nitro drip started (SBP 170s at the time). Also
received morphine. The patient was started on 750mg
levofloxacin. The cardiology service was consulted in the ED,
and the patient was transferred to the CCU.
Vitals on transfer were BiPAP HR 82 160/80 100% RR 18. Upon
arrival to the CCU: initial vitals were 90 171/82 95% on 50%
aerosol mask
REVIEW OF SYSTEMS
On review of systems, he denies any prior history hemoptysis,
black stools or red stools. He denies recent fevers, chills or
rigors.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, palpitations, syncope or
presyncope.
Past Medical History:
1. Antiphospholipid Antibody Syndrome
2. h/o CVA due to Antiphospholipid antibody syndrome ([**2139**]), on
warfarin: manifested as right-sided paralysis with aphasia, no
residual symptoms
3. Insulin-Dependent Diabetes Mellitus: FSBS mostly in the high
200s at home
4. Hypertension: VNA tells him that his blood pressure is
well-controlled at home
5. Depression: did not pursue any medical care [**1-2**] depression
[**2150**] [**2152**]. Has been treated with Celexa successfully since
[**2153-7-1**]. Had one suicide attempt as teenager with drink
vodka. Used to cut wrists, last time in [**2141**]. Had SI and
hopelessness in [**2145**].
6. Degenerative disk disease: moderately large disc protrusions
at L5-S1 and L4-L5
7. Abscess on right buttock, I+D'ed [**2147**], grew MRSA, treated
with vancomycin
8. right leg cellulitis [**2149**], treated with Keflex
9. Acne
10. Rosacea
Social History:
Occasional alcohol use with 2-3 drinks/month but prior h/o binge
drinking, h/o marijuana use, no tobacco use now, rare social
smoking in remote past, no history of IV drug use, divorced and
has a daughter. Not sexually active now, bisexual, questionable
adherence to protection. Has BA in Theology.
Family History:
Alzheimer's in mother, diagnosed at 68 years old. Father
deceased from MI at 58 years old, had CVA a few years prior to
that. Father's side of the family with several men w/CVA and MI
Physical Exam:
Physical Exam on Admission:
VS: 98.2 90 171/82 95% on 50% aerosol mask
GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, JVD till midway up the neck.
CARDIAC: RR, normal S1, S2 with S4 present.
LUNGS: Resp were unlabored, no accessory muscle use; bilateral
crackles [**12-2**] way up lung fields, no wheezes or rhonchi.
ABDOMEN: Soft, NT. Abdominal distension. Right hypochondrial
fullness suggestive of hepatomegaly. Abd aorta not enlarged by
palpation. No abdominial bruits.
EXTREMITIES: 1+ LE edema b/l
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
.
Physical Exam on Discharge:
VS Tm/Tc:98.4/97.9 HR:68-78 BP: 78-156/62-78 RR:20 02 sat:98% RA
In/Out: Last 24H: 2750/3300
Weight: (97.4) 108.2 on admission
exam unchanged
Pertinent Results:
ADMISSION LABS:
[**2155-4-24**] 04:00PM BLOOD WBC-6.4 RBC-3.83* Hgb-11.0* Hct-33.2*
MCV-87 MCH-28.7 MCHC-33.1 RDW-16.3* Plt Ct-196
[**2155-4-24**] 04:00PM BLOOD Neuts-78.2* Lymphs-12.8* Monos-5.5
Eos-3.4 Baso-0.1
[**2155-4-24**] 07:43PM BLOOD PT-14.9* PTT-26.1 INR(PT)-1.4*
[**2155-4-24**] 04:00PM BLOOD Glucose-222* UreaN-16 Creat-0.9 Na-141
K-3.4 Cl-101 HCO3-27 AnGap-16
[**2155-4-24**] 04:00PM BLOOD Calcium-8.7 Phos-2.8 Mg-1.8
[**2155-4-24**] 04:00PM BLOOD Ferritn-63
[**2155-4-24**] 10:03PM BLOOD Type-ART FiO2-96 O2 Flow-10 pO2-71*
pCO2-42 pH-7.47* calTCO2-31* Base XS-6 AADO2-581 REQ O2-94
Intubat-NOT INTUBA
[**2155-4-24**] 04:11PM BLOOD Lactate-1.1
[**2155-4-24**] 10:03PM BLOOD Glucose-195*
[**2155-4-24**] 10:03PM BLOOD O2 Sat-93
.
IMAGING:
CXR [**2155-4-24**]: Multifocal pneumonia with superimposed mild
pulmonary edema and small bilateral pleural effusions.
.
CXR [**2155-4-24**]: Compared to the previous radiograph, there is an
increase in
severity of the bilateral parenchymal opacities, with newly
appeared
consolidations in the retrocardiac lung areas that are likely
atelectatic in nature. The size of the cardiac silhouette is
unchanged. No pneumothorax.
.
LE DOPPLER: No DVT of the bilateral lower extremity.
.
CXR [**2155-4-25**]: As compared to the previous radiograph, there is a
mild decrease in extent and severity of the pre-existing
parenchymal opacities. The heart continues to be large. There
is ongoing blunting of the left costophrenic sinus, so that the
presence of a minimal left pleural effusion cannot be excluded.
No other changes. Mild bilateral basal atelectasis.
.
CXR [**2155-4-26**]: There are bilateral pleural effusions, left greater
than right, which have increased since the previous study.
There is decrease in the pulmonary interstitial prominence since
the previous study. There is unchanged cardiomegaly. There are
no pneumothoraces.
.
ECHO [**2155-4-29**]:
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Mild PA systolic hypertension.
PERICARDIUM: No pericardial effusion.
.
Conclusions
The left atrium is moderately 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. 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 no pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal global and regional biventricular systolic function. Mild
pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2155-2-13**],
the findings are similar.
Brief Hospital Course:
Mr. [**Known lastname **] is a 45 year old male with history of Type II
diabetes (DMII) complicated by neuropathy, hypertension,
antiphospholipid antibody syndrome complicated by stroke in
[**2139**], chronic right foot osteomyelitis w/ recent debridement who
presented with 4d of fatigue, tightness of abdomen and
increasing lower extremity edema, found to have a heart failure
exacerbation.
.
# Acute diastolic heart failure (dCHF): His prior echo in [**Month (only) 958**]
[**2154**] showed LVEF >55% so CHF is likely diastolic in nature.
Trigger for exacerbation could be medication noncompliance
leading to volume overload and hypertension, especially since
the patient admitted that he frequently self-dosed his blood
pressure medications. Patchy opacities on CXR were suggestive
of pneumonia, so pt was treated for this initially with
levofloxacin, vancomycin, cefepime. Initial cardiac enzymes were
negative, and pt also had a recent stress test that was
negative. PE was also considered given patient's history of
antiphospholipid syndrome. His [**Doctor Last Name **] score for PE was 1.5, which
is a low probability. He had no pleuritic signs or clinical
symptoms of DVT. Nonetheless, obtained LE dopplers which were
neg for DVT bilaterally. Pt was aggressively diuresed with IV
lasix drip and his pulm edema and oxygenation improved. The
patchy opacities that were read as possible pneumonia also
improved, making this diagnosis unlikely. Other infectious work
up neg, including blood and urine cx and urine legionella ag.
Antibiotics were stopped on hospital day 4 due to low suspicion
for pneumonia. He was maintained on an IV nitroglycerin drip to
keep his SBP between 110-140 while in the ICU and then
transitioned to an oral regimen. On discharge, his medication
regimen consisted of torsemide 20mg daily, lisinopril 40mg
daily, amlodipine 10mg and carvedilol 12.5mg [**Hospital1 **]. He was
continued on ASA 81mg daily and pravastatin 40 mg daily.
.
# Hypertension: pt hypertensive on admission with SBP 160s-170s.
Patient has not been taking medications for > 3 days. He was
placed on nitro drip to keep pressures down. He was restarted on
his home meds of amlodipine and lisinopril. His atenolol was
changed to carvedilol for better control of BP as well as beta
blockade for heart failure. His medications were titrated as
needed and on discharge his regimen consisted of torsemide 20mg
daily, lisinopril 40mg daily, amlodipine 10mg and carvedilol
12.5mg [**Hospital1 **].
.
# Orthostatic hypotension: Patient was orthostatic the last 2
days of his admission and his creatinine on the day of discharge
was up to 1.7 from 0.9 on admission. It was felt that he was
overdiuresed with torsemide during the admission. Please
recheck Cr at follow-up and adjust his dose of torsemide as
needed to avoid overdiuresis.
.
# DMII: Patient w/ longstanding DMII (15yrs), complicated by
peripheral neuropathy, stroke, gastroparesis, autonomic
neuropathy. Patient on lantus 52 qhs, and novolog pre-breakfast,
lunch and dinner. Patient had not been taking insulin for the
past three days on admission. Glucose level 222 in ED. He was
restarted on insulin glargine with insulin humalog sliding scale
while in house.
.
# Anti-phospholipid Syndrome: Has history of stroke. INR
subtherapeutic at 1.4 on admission; had not taken coumadin for
last 4 days. High risk for thrombus formation, so bridged with
heparin to coumadin and restarted pt on coumadin and adjusted
dose as indicated. On discharge, coumadin dose was 7 mg daily
and INR was 2.7.
.
# Chronic osteomyelitis: Patient was on Keflex PO q6h as
outpatient, but was started on Cefepime as above for HCAP so
Keflex was held initially. Due to low suspicion for pneumonia,
cefepime was stopped and he was placed back on keflex. He
completed his course prior to discharge. Has follow-up
scheduled with ID outpatient.
.
TRANSITIONAL ISSUES:
- Please assist with diet teaching for heart failure, ie. low
salt and medication compliance. Please help weigh him every day
- Please monitor INR, goal is [**1-3**] for antiphospholipid syndrome,
life-long
- Please recheck Cr at follow-up and adjust his dose of
torsemide as needed to avoid overdiuresis.
Medications on Admission:
AMLODIPINE 10 mg Tablet PO qd
ATENOLOL 100 mg Tablet PO qd
CEPHALEXIN 500 mg PO q6h
CITALOPRAM 20 mg PO qd
INSULIN ASPART [NOVOLOG] 10, 14, 16 U with meals
INSULIN GLARGINE [LANTUS] 46 U at bed time
LISINOPRIL 40 mg PO qd
Terazosin 5mg qhs
PANTOPRAZOLE 40 mg PO qd
PRAVASTATIN 40 mg PO qd
WARFARIN 7 mg PO qd
Medications - OTC
Vitamin D [**2142**]
Vitamin B12 500
Metamucil qd
Discharge Medications:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
3. cephalexin 500 mg Capsule Sig: One (1) Capsule PO four times
a day.
4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. insulin glargine 100 unit/mL Solution Sig: Forty Six (46)
units Subcutaneous at bedtime.
6. lisinopril 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. pravastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. warfarin 2 mg Tablet Sig: 3.5 Tablets PO once a day.
Disp:*105 Tablet(s)* Refills:*2*
10. cholecalciferol (vitamin D3) 2,000 unit Capsule Sig: One (1)
Capsule PO once a day.
11. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
13. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
acute on chronic Diastolic congestive heart failure.
secondary diagnosis:
diabetes mellitus
antiphospholipid syndrome
orthostasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the [**Hospital1 69**]
with congestive heart failure. This is fluid overload that is
caused by a stiff heart from long standing high blood pressure.
You were started on a diuretic to prevent the fluid from coming
back and some new medicines to optimize the pumping function of
your heart. You will need to check your weight every morning
before breakfast and call Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] your weight has increased
more than 3 pounds in 1 day or 5 pounds in 3 days. You will also
need to cut down on the salt in your diet an read the labels on
foods carefully. You can eat [**2142**] mg of salt per day but no
more. You can also try taking your medicines at different times
if you feel lightheaded or dizzy.
You should continue to take all of your medications as you
previously had, except for the following:
1. Stop taking Atenolol, take carvedilol instead to lower your
heart rate and blood pressure
2. Take lisinopril at bedtime instead of the morning
3. STOP taking terazosin
4. Increase the warfarin to 7mg daily
5. Start taking torsemide to get rid of extra fluid.
Followup Instructions:
Department: Primary Care
When: Thursday [**5-1**] at 3:00 PM
With: [**Last Name (LF) **],[**First Name3 (LF) **] A. [**Telephone/Fax (1) 43944**]
Where: [**Hospital 778**] health Center
.
Department: INFECTIOUS DISEASE
When: FRIDAY [**2155-5-2**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13125**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: GASTROENTEROLOGY
When: FRIDAY [**2155-6-6**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: PODIATRY
When: MONDAY [**2155-6-9**] at 1:40 PM
With: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2155-5-30**] at 11:20 AM
With: [**Name6 (MD) **] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES, HEART FAILURE CLINIC
When: Monday [**5-12**] at 9am
With: [**Last Name (LF) 437**], [**Name8 (MD) 449**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
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71,397
| 185,248
|
47706
|
Discharge summary
|
report
|
Admission Date: [**2131-9-28**] Discharge Date: [**2131-10-3**]
Date of Birth: [**2073-9-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
UGIB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Name13 (STitle) 90262**] is a 58 y.o. M with hepatitis C cirrhosis c/b
gastric and esophageal varices, recently admitted in [**8-5**] at
[**Hospital 8**] Hospital for gastric variceal bleed s/p sclerotherapy,
admitted to CHA on [**2131-9-27**] after having 2-3 days of BRBPR and
generalized weakness. He stated that he was dizzy, lightheaded,
and feeling very weak. He had 3 BRBPR BMs / day. This has
happened once before. Also endorsed chills, chest pain, SOB,
and abdominal pain during this period of time. He also vomited
1-2 times red blood.
.
On admission to CHA, pt was noted to have signs of active
VS on admission to OSH ICU: HR 77 BP 112/61 RR 12 100% 2 L
NC. At CHA, he was admitted to the ICU and given 5 pRBCs total.
He had an EGD today, which showed stigmata of esophageal
variceal bleeding s/p 12 bands. He was on octreotide and
protonix gtt. Currently, his Hct is 33. Pt then noted to be
nauseous and has not had his methadone in [**2-28**] days. Concern for
acute opioid withdrawal, so he was given IV morphine as well as
60 mg methadone elixir. He was also given compazine, zofran, 2
mg ativan. Never intubated and [**Name8 (MD) **] MD, never hemodynamically
unstable even with low Hct. After banding, pt was started on
ertapenem. The patient is being transferred to [**Hospital1 18**] for
possible TIPS.
.
Currently, he complains of some mild abdominal pain; however,
tells me that it is 0/10 pain. He also has some nausea
currently.
.
ROS:
(+) chills, sore throat, cough, SOB, chest pain, abdominal pain,
nausea, vomiting, diarrhea, BRBPR, melena, dysuria, ? hematuria
Past Medical History:
Hepatitis C Type 1A cirrhosis since age of 20 c/b gastric and
esophageal varices - recently admitted in [**8-5**] for gastric
variceal bleed s/p sclerotherapy
Alcohol abuse
Cardiac murmur
History of IV drug use
History of meningitis
Anemia
Pancytopenia
Social History:
He is retired post office worker. Lives alone in apt in [**Location (un) 3786**].
He has parents in their 80s. Estranged from parents who live in
[**State 108**]. Reportedly, stopped drinking 20 years ago. 5
cigarettes / day for last 20 years. History of heroin use,
IVDU. Currrently adherent to methadone clinic at [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Clinic - 125 mg methadone daily.
Family History:
Mom has history of TB, father history of stroke. No known
bleeding d/o in family.
Physical Exam:
Vitals - T: 99.1 BP: 147/66 HR: 92 RR: 15 02 sat: 92% 4 L
NC
GENERAL: ill appearing, older than stated age
HEENT: slightly icteric, EOMI, PERRL, MMM, pink conjunctivae, no
cervical LAD
CARDIAC: RRR, no m/r/g
LUNG: decreased BS at bases but poor inspiratory effort, no
wheezes
ABDOMEN: NT, slightly distended, did not reproduce fluid wave or
shifting dullness
EXT: 2+ DP bilaterally, no c/c/e, + asterixis
NEURO: A&O to full name, birth date, [**Hospital1 18**], [**Last Name (un) 2753**] as President
DERM: no rashes, spider angioma
Pertinent Results:
Imaging:
CXR PA/Lat [**9-30**]:
FINDINGS: As compared to the previous radiograph, there are
persistent
interstitial markings, notably at the bases of the lungs,
potentially
consistent with pulmonary edema. A persistent right basal
opacity has not
changed in size. The opacity could represent pneumonia or
atelectasis. In
the interval, the right jugular line has been removed. There is
no evidence
of pneumothorax. Unchanged bilateral apical thickening.
.
[**2131-9-6**] ABDOMINAL ULTRASOUND:
FINDINGS: The liver has a nodular appearance but no focal liver
lesion is identified. There is no biliary dilatation seen. The
portal vein is patent with hepatopetal flow. No gallstones are
identified within the gallbladder. The gallbladder wall is
slightly thickened but this is likely due to underlying liver
disease. The midline structures are obscured from view by
overlying bowel. The spleen is enlarged measuring at least 19
cm. There is no hydronephrosis. The right kidney measures 12.0
cm and the left kidney measures 10.5 cm. A small amount of
ascites is seen in the perihepatic space and in the lower
quadrants.
IMPRESSION:
1. Nodular hepatic architecture but no focal liver lesion
identified.
2. Splenomegaly.
3. Trace of ascites.
.
OSH EGD [**2131-8-16**]: Grade III Esophageal Varices, Gastric Varices
s/p sclerotherapy.
.
LABS:
[**2131-9-28**] 08:57PM BLOOD WBC-9.8# RBC-3.61* Hgb-10.5* Hct-31.9*
MCV-88 MCH-29.1 MCHC-32.9 RDW-19.1* Plt Ct-54*
[**2131-9-29**] 01:54AM BLOOD WBC-8.4 RBC-3.49* Hgb-10.2* Hct-31.1*
MCV-89 MCH-29.2 MCHC-32.9 RDW-19.0* Plt Ct-49*
[**2131-9-30**] 02:53AM BLOOD WBC-4.3 RBC-3.33* Hgb-9.7* Hct-30.5*
MCV-91 MCH-29.1 MCHC-31.8 RDW-18.6* Plt Ct-51*
[**2131-10-1**] 05:10AM BLOOD WBC-4.5 RBC-3.34* Hgb-9.8* Hct-30.8*
MCV-92 MCH-29.4 MCHC-31.9 RDW-18.6* Plt Ct-59*
[**2131-10-2**] 05:10AM BLOOD WBC-7.7# RBC-3.67* Hgb-10.7* Hct-33.9*
MCV-92 MCH-29.1 MCHC-31.5 RDW-18.3* Plt Ct-86*
[**2131-10-3**] 05:05AM BLOOD WBC-9.4 RBC-3.95* Hgb-11.3* Hct-35.8*
MCV-91 MCH-28.6 MCHC-31.6 RDW-18.1* Plt Ct-120*
[**2131-9-28**] 08:57PM BLOOD Neuts-86.5* Lymphs-8.5* Monos-5.0 Eos-0
Baso-0.1
[**2131-9-28**] 08:57PM BLOOD PT-16.6* PTT-30.2 INR(PT)-1.5*
[**2131-9-29**] 01:54AM BLOOD PT-16.9* PTT-30.6 INR(PT)-1.5*
[**2131-9-29**] 05:52PM BLOOD PT-17.4* PTT-32.4 INR(PT)-1.6*
[**2131-9-30**] 02:53AM BLOOD PT-17.6* PTT-33.1 INR(PT)-1.6*
[**2131-10-1**] 05:10AM BLOOD PT-18.2* PTT-36.3* INR(PT)-1.6*
[**2131-10-2**] 05:10AM BLOOD PT-18.8* INR(PT)-1.7*
[**2131-10-2**] 05:10AM BLOOD PT-18.8* INR(PT)-1.7*
[**2131-9-28**] 08:57PM BLOOD Glucose-112* UreaN-17 Creat-0.8 Na-139
K-4.1 Cl-106 HCO3-29 AnGap-8
[**2131-9-29**] 01:54AM BLOOD Glucose-147* UreaN-18 Creat-0.8 Na-139
K-4.0 Cl-106 HCO3-27 AnGap-10
[**2131-9-30**] 02:53AM BLOOD Glucose-110* UreaN-14 Creat-0.8 Na-140
K-3.3 Cl-108 HCO3-28 AnGap-7*
[**2131-10-1**] 05:10AM BLOOD Glucose-153* UreaN-11 Creat-0.8 Na-140
K-3.7 Cl-110* HCO3-27 AnGap-7*
[**2131-10-2**] 05:10AM BLOOD Glucose-153* UreaN-10 Creat-0.8 Na-141
K-4.0 Cl-110* HCO3-24 AnGap-11
[**2131-10-3**] 05:05AM BLOOD Glucose-87 UreaN-11 Creat-0.9 Na-138
K-3.5 Cl-105 HCO3-26 AnGap-11
[**2131-9-28**] 08:57PM BLOOD ALT-19 AST-22 LD(LDH)-206 AlkPhos-63
TotBili-6.0* DirBili-4.3* IndBili-1.7
[**2131-9-29**] 01:54AM BLOOD ALT-20 AST-22 LD(LDH)-226 AlkPhos-63
TotBili-4.8* DirBili-3.3* IndBili-1.5
[**2131-9-30**] 02:53AM BLOOD ALT-18 AST-16 AlkPhos-62 TotBili-1.8*
[**2131-10-1**] 05:10AM BLOOD ALT-16 AST-13 AlkPhos-65 TotBili-1.6*
[**2131-10-2**] 05:10AM BLOOD TotBili-2.1*
[**2131-9-28**] 08:57PM BLOOD Albumin-2.6* Calcium-7.5* Phos-2.9 Mg-2.2
[**2131-9-29**] 01:54AM BLOOD Albumin-2.6* Calcium-7.4* Phos-3.0 Mg-2.2
[**2131-9-30**] 02:53AM BLOOD Calcium-7.7* Phos-2.2* Mg-2.0
[**2131-10-2**] 05:10AM BLOOD Calcium-7.7* Phos-3.1 Mg-1.7
[**2131-10-3**] 05:05AM BLOOD Calcium-7.8* Phos-3.6 Mg-1.6
[**2131-9-29**] 05:51PM BLOOD HBsAg-NEGATIVE
[**2131-9-28**] 09:11PM BLOOD Lactate-2.0
[**2131-9-28**] 09:11PM BLOOD Type-CENTRAL VE pO2-51* pCO2-44 pH-7.41
calTCO2-29 Base XS-2 Comment-GREEN TOP
[**2131-9-29**] 01:54AM URINE Color-Brown Appear-Clear Sp [**Last Name (un) **]-1.027
[**2131-9-29**] 01:54AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-MOD Urobiln-8* pH-6.0 Leuks-TR
[**2131-9-29**] 01:54AM URINE RBC-10* WBC-6* Bacteri-NONE Yeast-NONE
Epi-0
[**2131-9-29**] 01:54AM URINE Mucous-RARE
[**2131-9-29**] 01:46AM ASCITES WBC-72* RBC-1195* Polys-25* Lymphs-18*
Monos-48* Atyps-1* Mesothe-3* Macroph-5*
[**2131-9-29**] 01:46AM ASCITES TotPro-0.2 Glucose-128 LD(LDH)-44
Albumin-LESS THAN
Blood Cx [**9-28**] and [**9-29**] NGTD
Peritoneal Fluid Cx [**9-29**] NGTD
Urine Cx [**9-29**] NGTD
Brief Hospital Course:
58 y.o. M with hepatitis C cirrhosis c/b gastric and esophageal
varices, recently admitted in [**8-5**] at [**Hospital 8**] Hospital for
gastric variceal bleed s/p sclerotherapy, admitted to [**Hospital 8**]
hospital on [**2131-9-27**] with a variceal bleed that was banded; he
was subsequently resuscitated with 5 units PRBCs and transferred
to [**Hospital1 18**] for further hemodynamic monitoring. He was initially
admitted to the ICU but remained hemodynamically stable with
stable Hcts and was transferred to the Liver service for further
management.
.
# Variceal bleed: The patient was admitted to the MICU from
[**Hospital **] hospital after variceal banding. He remained
hemodynamically stable with stable HCTs. He was treated with IV
pantoprazole and octreotide, as well as sucralfate and
ceftriaxone. He did not require any transfusions while
inpatient, and had no repeat episodes of melena. He was
transitioned to po PPI and antibiotics, with a plan for 7 day
course to end on [**2131-10-5**]. At discharge, he was given an
appointment for repeat banding of his esophageal varices on
[**2131-10-11**].
.
# Hepatitis C Cirrhosis: The patient's cirrhosis is currently
decompensated given his gastric and esophageal varices. While
inpatient, he remained oriented and appropriate, with no
asterixis or other indications of encephalopathy. Additionally,
he remained afebrile with no leukocytosis or other indication of
SBP. He was treated with lactulose, rifaximin, nadolol and
diuretics. He was discharged with close outpatient followup for
his liver disease with Dr. [**Name (NI) **].
.
# Opioid Use: History of IVDU, now on methadone maintenance,
confirmed dose with outpatient methadone program at 125 mg
daily. The patient was initially treated with a decreased dose
of methadone due to concerns regarding his hemodynamic stability
following significant variceal bleed. He was restarted on his
home dose of 125 mg daily on [**2131-10-2**]. His last dose of
methadone 125 mg was dispensed on [**2131-9-27**] at 8am.
.
# Dyspnea: The patient was initially dyspneic in the MICU, with
variable O2 saturation. A CXR showed persistent prominent
interstitial markings, compatible with mild pulmonary edema with
one area concerning for pneumonia versus atelectasis. This was
felt likely to be atelectasis or a small area of pneumonitis
from hematamesis and likely aspiration during variceal bleed.
He was empirically covered for bacterial pneumonia with his
course of cefpodoxime.
.
# Nausea: Was initially nauseous, possibly secondary to opioid
withdrawal given that pt had not received methadone in [**2-28**] days
prior to presentation at OSH. He was treated with prn compazine
and zofran, with some relief. He was then restarted on home
dose of methadone, with resolution of nausea.
.
# Thrombocytopenia: Felt to be secondary to chronic liver
disease, remained stable throughout hospitalization and did not
require transfusion.
.
# Depression/Anxiety: The patient had no clinical signs of
hepatic encephalopathy while inpatient, and was continued on
lactulose and rifaximin. He did report some recent memory loss
and feeling "foggy." Additionally, he also endorsed symptoms of
depression and remained oriented without no signs of delerium.
He was counseled regarding the role of antidepressant therapy,
and declined current treatment. Additionally, he was maintained
on his home dose of clonazepam for anxiety, with good effect.
Medications on Admission:
HOME MEDICATIONS:
Albuterol MDI 2 puffs q6 hours prn sob
Iron sulfate 325 mg po BID
Klonopin 2 mg po qhs
Lactulose 15 ml po daily
Lasix 40 mg po daily
Methadone 125 mg po daily
Nadolol 20 mg po BID
Protonix 40 mg po BID
Spirinolactone 100 mg po daily
.
MEDICATIONS ON TRANSFER:
Octreotide gtt at 50 mcg/hour
Protonix gtt at 8 mg/hour
NS at 125 cc/hour
Zofran 4 mg IV q6 hours prn
Morphine 4 mg IV q3 hours - hold for sedation
Ertapenem 1 gm IV daily
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): take to have three to 5 bowel movements per day.
Disp:*4050 ML(s)* Refills:*2*
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for low back pain.
3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 3 days: please take separately from other
medications.
Disp:*12 Tablet(s)* Refills:*0*
4. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
6. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 4 doses.
Disp:*8 Tablet(s)* Refills:*0*
11. Methadone 10 mg Tablet Sig: 12.5 Tablets PO DAILY (Daily).
12. Nadolol 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 10 days: then decrease to 7mg
patch for 2 weeks.
Disp:*10 Patch 24 hr(s)* Refills:*0*
14. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) d24 hours
Transdermal once a day: for two weeks after completing
prescription for 14mg patch, do not smoke while wearing this
patch.
Disp:*14 0* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis:
HCC cirrhosis
Esophageal varices s/p banding
Discharge Condition:
Good; hemodynamically stable, ambulating with assistance,
tolerating POs.
Discharge Instructions:
You were admitted to the hospital because of bleeding from your
esophageal varices. You were initially admitted to [**Hospital 8**]
hospital, where you were given blood transfusions and underwent
endoscopy with banding of your varices. You were transferred to
[**Hospital1 18**] for further management of of your varices. You have been
treated with medications to decrease your blood pressure, and to
prevent future bleeding. It is very important that you return
to have your varices evaluated in the next week. An appointment
has been made for you.
.
Please take all medications as directed on discharge from the
hospital. If you have any questions or concerns please do not
hesitate to contact your primary care physician, [**Name10 (NameIs) **] liver
doctor, or to call the hospital at ([**Telephone/Fax (1) 100750**].
.
It is extremely important that you call 911 immediately if you
have another episode of bleeding. Please call your doctor or
return to the ED if you experience any fever, chills, shortness
of breath or other complaints.
Followup Instructions:
1. Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2131-10-5**] 9:00 -> This is your liver transplant
follow-up appointment.
2. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK
Date/Time:[**2131-10-5**] 10:00 -> Transplant social worker appointment
3. Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2131-10-11**] 12:30
-> Appointment for endoscopy for varices.
|
[
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"305.1",
"456.8",
"304.01",
"789.59",
"507.0",
"285.9",
"571.5",
"300.4",
"482.9",
"292.0",
"518.0",
"571.2",
"284.1",
"456.20",
"486",
"287.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
13691, 13749
|
8012, 11458
|
319, 326
|
13857, 13933
|
3350, 7989
|
15031, 15541
|
2693, 2777
|
11958, 13668
|
13770, 13770
|
11484, 11484
|
13957, 15008
|
2792, 3331
|
11502, 11737
|
275, 281
|
354, 1968
|
13789, 13836
|
11762, 11935
|
1990, 2244
|
2260, 2677
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,772
| 150,411
|
17133
|
Discharge summary
|
report
|
Admission Date: [**2187-11-1**] Discharge Date: [**2187-11-7**]
Date of Birth: [**2124-3-20**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Morphine
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known firstname **] [**Known lastname 34909**] is a 63 year old woman with history of MVR on
coumadin, dCHF (EF 55%), and COPD on 3L NC who presents to the
ED from pulmonology clinic with significant hypoxia with
exertion (73% on 3L NC).
.
In the ED, initial vs were: T [**Age over 90 **] F,P 64, BP 122/82, RR 20, O2
sat 94% on 8L NC. EKG was unchanged compared to baseline and
without ischemic changes. Labs were significant for BNP 3077
(baseline 800), INR 9.5, Cr 1.2 (baseline), lactate 4.0. CXR
showed interstitial edema and bilateral pleural effusions.
Patient was given nebulizers, solumedrol 125mg IV without
significant improvement in her symptoms. Due to significant
desaturations to 70's% with exertion she was admitted to the
ICU.
.
On the floor, patient appears comfortable. She denies any recent
change in her baseline shortness of breath. She reports only
being able to ambulate a few yards before needing to rest at her
baseline. She admits to over a month of increased fatigue,
daytime sleepiness, nausea, and headaches. She believes overall
she has lost weight in the last year but reports currently
feeling swollen and admits to increased feet edema. She admits
that she does not take her lasix on days that she is going
leaving her house because of her frequent need to urinate on her
lasix dose. She reports missing 3 days of lasix in the last
week.
.
She denies fevers, chills, abdominal pain, chest pain, wheezing,
[**Age over 90 **], diarrhea, dysuria, sick contacts, increased [**Name2 (NI) **],
diaphoresis, lightheadedness, change in vision, loss of
consciousness, focal weakness.
Past Medical History:
Morbid obesity BMI > 54
CAD s/p PCI [**2171**] (stent LAD), [**2179**], [**2182**] (stent RCA), [**2186**]
COPD on 3L NS
presumed sleep apnea
diastolic dysfunction EF% 55%
mitral valve replacement [**8-/2182**]
fibromyalgia
CRI baseline creatinine 1.2
Pulmonary HTN
Patent Foramen Ovale
Social History:
She lives alone, is on disability, previously worked at
[**Company 2676**],
no asbestos or TB exposure. She quit smoking in [**2179**] after
smoking a pack per day for 35 to 40 years. She denies any
illicit drug use. She drinks occasional alcohol. There are no
birds or pets at home.
Family History:
Both of her parents are deceased. Her father had emphysema and
her mother died of ovarian cancer at age 72.
Physical Exam:
Vitals: T: 97.6 BP: 191/74 P: 72 R: 14 O2: 93% 5L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to assess given habitus, no LAD
Lungs: Good air movement, decreased breath sounds at bilateral
bases, crackles in bottom two thirds of lung fields, no wheezes,
no stridor
CV: Regular rate and rhythm, mechanical S1,, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, bilateral nonpitting edema,
no clubbing, cyanosis
By discharge on [**11-7**], her weight was 291 lbs, her lungs were
clear, albeit with diminished air entry throughout. Non pitting
edema both legs.
Pertinent Results:
[**2187-11-1**] 06:13PM LACTATE-4.0*
[**2187-11-1**] 06:05PM GLUCOSE-114* UREA N-20 CREAT-1.2* SODIUM-135
POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-25 ANION GAP-16
[**2187-11-1**] 06:05PM estGFR-Using this
[**2187-11-1**] 06:05PM proBNP-3077*
[**2187-11-1**] 06:05PM WBC-10.8 RBC-4.40 HGB-9.8* HCT-33.1* MCV-75*
MCH-22.3* MCHC-29.7* RDW-19.1*
[**2187-11-1**] 06:05PM NEUTS-64.7 LYMPHS-26.9 MONOS-5.4 EOS-2.6
BASOS-0.4
[**2187-11-1**] 06:05PM PLT COUNT-343
[**2187-11-1**] 06:05PM PT-79.3* PTT-40.8* INR(PT)-9.5*
[**2187-11-1**] 05:35PM URINE HOURS-RANDOM
[**2187-11-1**] 05:35PM URINE UCG-NEG
[**2187-11-1**] 05:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2187-11-1**] 05:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
CXR:
FINDINGS: The lateral view is nondiagnostic due to respiratory
motion. The
technologist notes the patient was unable to stay still for the
lateral.
There is blunting of the bilateral costophrenic angles
suggesting bilateral effusions. Pulmonary vascular
indistinctness is evident. There is mild prominence of the
intralobular septate. No definite focal consolidation is seen.
There is evidence of prior valve surgery. The cardiac silhouette
is markedly enlarged consistent with cardiomegaly. Please note
multiple prior studies are available, the most recent, however,
dating [**2182-9-18**]. The visualized osseous structures
reveal mild multilevel degenerative disease throughout the
thoracic spine and marked degenerative changes noted at
bilateral acromioclavicular joints.
IMPRESSION: Mild interstitial edema, likely cardiogenic in
etiology given
underlying cardiomegaly. Small bilateral pleural effusions.
ECHO: The left atrium is moderately dilated. The right atrium
is moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is 10-15mmHg.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated with normal free wall contractility. There is
abnormal septal motion/position. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. A bileaflet
mitral valve prosthesis is present. The mitral prosthesis
appears well seated, with normal leaflet/disc motion and
transvalvular gradients. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2186-12-20**],
the degree of AR and pulmonary hypertension detected has
decreased
Brief Hospital Course:
63 year old woman with history of MVR on coumadin, dCHF (EF
55%), and COPD on 3L NC who presents to the ED from pulmonology
clinic with significant hypoxia with exertion (73% on 3L NC).
.
# Acute on chronic diastolic CHF: The likely cause of her
hypoxia and respiratory distress given edema on exam and CXR,
lack of infectious symptoms, or wheeze. She has poor adherence
to her home lasix dose. She was aggressively diuresed in the
ICU with improvement in her symptoms. No antibiotics or
steroids were given. There was no evidence of acute ischemia or
PE. She was transferred to the floor. She diuresed very well
to lasix 60mg IV per day. Echo was performed which showed well
positioned mitral valve and a small decrease in her pulmonary
hypertension. Systolic fraction at 55%, suggesting her sx are
still from diastolic dysfunction with perhaps some right sided
heart failure as well. Her weight on day of discharge was 291
lbs, after having received only lasix 120 mg po daily; if
patient watches her salt and water intake, this dose of lasix
appears to be sufficient for her.
# Acute renal failure: Improved with diuresis. creatinine 1.2
on discharge
# MVR/Supratherapeutic INR: Patient s/p MVR [**Hospital3 9642**] [**2182**] for
severe MR. INR 9.5 on presentation. Patient denied recent use
of antibiotics or taking additional doses. She does admit to
recent initiation of Cymbalta which may have increased her INR.
No evidence of active bleeding. Patient was taking coumadin 4
mg daily prior to admission. Coumadin dose held on admission.
Her cymbalta dose will be decreased to 30 mg a day on discharge,
and she will continue on coumadin 3 mg a day on discharge. She
will have INR checked in a few days by [**Year (4 digits) 269**].
# HTN: Her blood pressures were markedly elevated when she
arrived, and this was likely secondary to her volume overload.
Her bps on last day of hospitalization were well controlled on
her home toprol dose.
# CAD: Patient with known CAD s/p multiple PCIs with stenting.
Most recent cardiac catheterization [**2186-12-19**] with no evidence of
flow limiting lesions and patent RCA stents. No evidence of
active ACS on EKG. Plan to continue home regimen. Continued home
beta blocker, statin. Baby aspirin was restarted (it was not
clear why she was not taking)
# Anemia: Chronic; HCT above baseine 33.
# DM2, poorly controlled: A1C 7.5% 9/10. Continued SSI.
# Fibromyalgia: Stable; continued home nortriptyline and
cymbalta.
# Physical deconditioning: patient without any focal findings
of weakness on exam, but per physical therapy she is markedly
deconditioned. She was repeatedly encouraged to be discharged
to a rehab/[**Hospital1 **], but she refused. The hospitalist, PT, nursing
staff and PCP all discussed this with her. Patient told PT that
she is incapable of walking much at home, and that she uses a
swivel chair to get around in her house. She did not want to
actively participate with PT even when she was in the hospital.
# Self neglect - Patient has missed various medical
appointments, and was admitted after missing doses of lasix and
having INR of 9. Patient does seem to be competent regarding
her medical conditions, but wants "to be left alone". She goes
to bed and wakes up when she wants to, and admits to taking her
meds at inconsistent times of the day. She was seen by the
social worker in house and will have [**Name (NI) 269**]/PT at home.
# Diabetes Mellitus: A1c of 8. Started on glucophage 500 mg
daily, and she met with the nutritionist as well.
# Sleep d/o: Patient with very interrupted sleep. She says it
is from polyuria, but may be from OSA. She had inpatient sleep
study, and results are [**Name (NI) **] at time of d/c.
Medications on Admission:
Lipitor 40 mg po daily
Lasix 120 mg po daily
Protonix 40 mg daily
Nortiptyline 30 mg daily
KCl 60 meq daily
Coumadin 4 mg daily
Metoprolol 100 mg [**Hospital1 **]
Proair inh prn
Spiriva inhaler daily
Cymbalta ER 60 mg daily
Discharge Medications:
1. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. warfarin 3 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
4. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): PLEASE TAKE DAILY IN THE MORNING; IF YOUR WEIGHT GOES
UP BY 3 LBS, PLEASE TAKE 3 TABLETS IN THE EVENING AS WELL. .
8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every [**6-19**]
hours: Dr [**Last Name (STitle) 3649**] prescribed these to you on [**10-12**]; please use the
pills that she prescribed and see her if you need more. .
10. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. Glucophage 500 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Acute on chronic diastolic CHF
COPD
mechanical mitral valve replacement - on coumadin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with shortness of breath and a decrease in
your oxygen level. This was due to your congestive heart
failure - a condition that leads you to build up fluid in your
legs and lungs that impair your breathing. With the use of
lasix, we removed the excess fluid and your breathing improved.
It is very important that you take your medications every day.
In addition, you had a sleep study during this admission. You
will be contact[**Name (NI) **] about the results. Your INR (coumadin level)
was very high when you were admitted. THe [**Name (NI) 269**] will recheck it
in a few days. Given that you have a mechanical heart valve,
having a stable coumadin level is critical.
Medications changes:
We reduced your cymbalta to 30 mg once a day.
We started you on a medicine called glucophage for your
diabetes.
.....
Followup Instructions:
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: WEDNESDAY [**2187-11-28**] at 2:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6475**], MD, MPH [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
[**Location (un) 269**] and physical therapist will see you at home after discharge.
|
[
"278.01",
"799.02",
"V43.3",
"416.8",
"V15.81",
"584.9",
"V46.2",
"414.01",
"496",
"285.21",
"729.1",
"V85.43",
"V45.82",
"585.3",
"428.0",
"V58.61",
"403.90",
"327.23",
"250.00",
"428.33",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11961, 12019
|
6446, 10183
|
314, 320
|
12149, 12149
|
3532, 6423
|
13184, 13626
|
2601, 2711
|
10457, 11938
|
12040, 12128
|
10209, 10434
|
12325, 13161
|
2726, 3513
|
255, 276
|
348, 1970
|
12164, 12301
|
1992, 2280
|
2296, 2585
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,228
| 140,535
|
29373
|
Discharge summary
|
report
|
Admission Date: [**2114-11-5**] Discharge Date: [**2114-11-19**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
fall, convulsions
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
EEG
lumbar puncture attempted
History of Present Illness:
82 year-old right-handed woman with a history of prior stroke
and dementia who presented with alteration in consciousness. The
history is per the primary team, the medical record, and the
pt's family. She had been in her usual state of health until
three days PTA. At that time, she was at home and experienced a
fall that was witnessed by one of her daughters. [**Name (NI) **] daughter
is not sure if
the fall was mechanical or unprovoked. She later said, however,
that after she fell, she was "shaking on the ground."
Specifically, she was not responsive and was seen to be
rhythmically shaking the arms and legs for roughly 5 minutes.
After this she was somewhat somnolent, but did not seem weak.
The next day, she complained of a headache. More significantly,
however, the pt's daughters noted that she became progressively
more somnolent and withdrawn. She seemed to stare ahead at
people and not respond appropriately. Her speech was
unintelligible.
She was not eating, drinking, or taking her medications. Her
daughters also noticed that the right side of her face seemed to
"droop." As this persisted, her daughters took her to an OSH
for evaluation this morning.
At the OSH, she was described as "alert and nonverbal." She was
found to have a temperature of 99.6F and initial BP was
161/60mmHg. Labs were notable for an INR 2.5, and were otherwise
normal except for BUN of 29. She underwent CT of the head which
revealed small right subdural hematoma (8 to 9mm). She received
2
units of FFP, 5mg of sc vitamin K, and was loaded with 1g of
phenytoin. She was transferred to [**Hospital1 18**] for neurosurgical
evaluation. She was intubated on arrival to [**Hospital1 18**], and was given
2 units of proplex. Neurosurgery consultation was requested.
The pt was unable to offer a review of systems, however her
daughters noted that she had no recent complaints other than
headache for the past two days.
Past Medical History:
stroke, per daughters over 20 years ago. At that time, she
presented with inability to speak; daughter cannot remember if
there was weakness as well. She was treated with warfarin at
that time, then restarted on the coumadin for unknown reasons
several years ago.
dementia: per daughters, at baseline she is able to recognize
her loved ones, feed herself, ambulate. She requires help with
washing and IADLs.
s/p pacemaker placement
hypertension
gout
Social History:
She lives at home with one of her daughters. She has no history
of tobacco, alcohol, or illicit drug use. She is originally from
[**Country 3587**].
Family History:
Notable for mother with stroke.
Physical Exam:
On admission:
Vitals: T: 100.2F P: 63 R: 16 BP: 115/58
General: Lying in bed with eyes closed, intubated.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: No JVD or carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs with transmitted upper airway sounds
bilaterally
Cardiac: difficult to auscultate over breath sounds, but
apparently RRR, and no murmur heard
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally, 1+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
mental status: Opens eyes transiently to noxious stimuli. Does
not follow commands.
cranial nerves: PERRL 3.5 to 2.5mm. Funduscopic exam was
technically limited as pt resisted eye opening, but revealed no
papilledema, exudates, or hemorrhages. EOMI difficult to assess
secondary to forceful eye closure. Corneal reflex and nasal
tickle present bilaterally. No overt facial asymmetry (but
difficult to tell given ETT in place). Gag reflex intact.
motor: Normal bulk throughout. Tone mildly increased in lower
extremities. Withdraws to noxious stimuli in all four
extremities. No adventitious movements noted. No myoclonus
noted.
sensory: Grimaces to noxious stimuli in all four extremities and
sternal rub.
DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 3 4
R 3 3 3 3 3
Plantar response was extensor bilaterally.
Pertinent Results:
Admission labs:
[**2114-11-5**] 08:59PM BLOOD WBC-5.7 RBC-3.10* Hgb-9.9* Hct-27.6*
MCV-89 MCH-31.8 MCHC-35.7* RDW-14.4 Plt Ct-170
[**2114-11-5**] 08:59PM BLOOD Neuts-70.9* Lymphs-21.8 Monos-6.1 Eos-0.7
Baso-0.4
[**2114-11-5**] 08:59PM BLOOD PT-20.1* PTT-31.5 INR(PT)-1.9*
[**2114-11-5**] 08:59PM BLOOD Glucose-144* UreaN-29* Creat-1.5* Na-143
K-3.3 Cl-100 HCO3-32 AnGap-14
[**2114-11-6**] 01:00AM BLOOD ALT-18 AST-27 LD(LDH)-209 CK(CPK)-166*
AlkPhos-112 Amylase-86 TotBili-1.3
[**2114-11-6**] 01:00AM BLOOD Lipase-14
[**2114-11-6**] 01:00AM BLOOD Albumin-3.7 Calcium-9.4 Phos-2.8 Mg-2.2
[**11-5**]: CT HEAD WITHOUT IV CONTRAST: 1. Right subdural hematoma
in the temporal parietal region. No midline shift or significant
mass effect. 2. Encephalomalacic change in the left MCA
distribution, consistent with an area of prior infarction. 3.
Cavernous internal carotid artery calcification bilaterally.
There is asymmetric enlargement of the left ICA at this
location, suggesting aneurysmal dilatation.
[**11-8**]: CT head without contrast: A cavum septum pellucidum et
vergae is present and is a normal variant. Again noted is
right-sided subdural hematoma extending along the right
convexity in the temporoparietal region which is unchanged in
size or character. There is unchanged effacement of the
surrounding sulci with associated mass effect. No intracranial
hemorrhage is identified. A large area of low attenuation within
the left posterior frontal and temporal lobes is visualized
reflecting encephalomalacic changes from prior infarction. There
is no shift in normally midline structures. Extensive
calcification of the carotid arteries in their cavernous course
is present. No abnormalities are noted within the osseous
structures or soft tissues.
IMPRESSION: This study is unchanged from previous. There is a
right subdural hematoma in the temporoparietal region with mild
effacement of the adjacent sulci and mild regional mass effect
without shift of normally midline structures. Encephalomalacic
change in the left middle cerebral artery distribution is
consistent with prior infarction.
[**11-5**]: PORTABLE AP CHEST RADIOGRAPH: The ET tube tip is
positioned within the mid to lower trachea, approximately 2 cm
above the carina. There is an NG tube seen, with the tip in the
stomach. The patient has a pacemaker overlying the left
hemithorax, with leads positioned within the right atrium and
ventricle. There is a lead overlying the right hemithorax, with
the tip positioned within the ventricle. There is cardiomegaly.
The lungs are clear. No pleural effusions or pneumothorax is
seen. The pulmonary vasculature is within normal limits. The
soft tissue and osseous structures are unremarkable.
IMPRESSION: ET tube and NG tube in satisfactory position.
Cardiomegaly.
EEG [**11-6**]: This is an abnormal portable EEG due to the presence
of
frequent epileptiform sharp and slow wave discharges seen over
the left
parietal temporal aregion and due to right temporal sharp and
slow wave
discharges seen independently and less frequently. In addition,
the
background is slow and disorganized. The first two abnormalities
suggest cortical dysfunction in the left parietal temporal
region as
well as right temporal cortical dysfunction. The third
abnormality
suggests deep, midline subcortical dysfunction and is consistent
with a
mild encephalopathy. Regarding epilepsy, the frequent
epileptiform
discharges increase the risk of seizures. During this 20 minute
recording, there was no clear seizure activity recorded.
ECHO: The left atrium is dilated. The right atrium is markedly
dilated. A
left-to-right shunt across the interatrial septum is seen at
rest. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] Right ventricular chamber
size and free wall motion are normal. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] The ascending aorta is
mildly dilated. The aortic valve leaflets are moderately
thickened. There is mild aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is moderate/severe mitral valve prolapse.
Moderate (2+) mitral regurgitation is seen. The mitral
regurgitation jet is eccentric. The tricuspid valve leaflets are
mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is no pericardial effusion.
[**11-12**] Upper Extremity US: PICC line in the left basilic vein with
no flow seen in the basilic, but good flow in the brachial,
axillary and subclavian veins on the left, and normal flow in
the deep veins of the right upper extremity.
[**11-12**] Cspine CT with contrast: 0.9 x 0.7 cm left extradural mass
with displacement and mild indentation on the cord at C2-3
level. The differential includes hematoma, phlegmon, and tumor.
Recommend to repeat at least six hours without IV contrast to
evaluate the baseline appearance and assess for contrast
enhancement.
[**11-13**] Cspine CT without contrast: Small extradural mass at the
level of the C2-3 vertebrae. This likely represents a calcific
tumor such as a meningioma. The presence of an epidural
hematoma, although possible, is less likely due to the focal
nature of this high-density area.
[**11-14**] Chest/Abdomen/Pelvic CT: 1. Bilateral pleural effusions,
greater on the left than on the right. 2. Marked cardiomegaly
with biatrial enlargement, extensive atherosclerotic coronary
artery calcifications, and pacemaker seen. 3. Tortuous
abdominal aorta with extensive atherosclerotic calcification, no
evidence of aortic aneurysm. Focal area of dilatation of the
right common iliac artery. 4. Multiple low-attenuation lesions
within the liver, the largest of which is most likely a cyst.
Multiple smaller lesions are too small to be characterized. If
the patient has a known malignancy, or risk factors for
hepatocellular carcinoma, three-month followup with dedicated
liver imaging is recommended.
[**11-15**] Lower extremity US: No evidence of bilateral lower
extremity deep venous thrombosis.
[**11-16**] EEG: Markedly abnormal portable EEG due to the low
voltage slow background with generalized bursts of slowing and
background suppression and with multifocal areas of sharp wave
discharges. These sharp waves were frequent on the left side
early in the recording. The slow background and generalized
phenomena suggest a widespread encephalopathy. There were also
multifocal sharp waves seen frequently. These suggest multifocal
cortical areas of dysfunction with potential epileptogenesis.
Infection is one possible cause but multifocal vascular disease
is another. There were no prolonged discharges to suggest
ongoing seizures, at least during the course of this recording.
Brief Hospital Course:
82yo woman with a history of stroke and dementia who presented
with alteration in consciousness, exam notable for severe
encephalopathy, intact brainstem reflexes, and bilateral lower
extremity hyperreflexia with clonus. Her history is very
convincing for a fall with a seizure and resulting subdural
hematoma. It is most likely that she had a seizure, either focal
in her lower extremities or generalized, which caused the fall;
the fall caused the subdural. Her fever likely due to an
underlying infection which may have precipitated the seizure,
but she does have a source for a seizure given her prior stroke,
and she has evidence for bilateral epileptiform discharges on
her EEG. While the fever is unlikely secondary to a meningitis,
lumbar puncture was unsuccessful and so she was treated
empirically with ampicillin, vancomycin, and ceftriaxone for a
fourteen day course. Her altered consciousness was likely due to
CNS injury in a patient with a previous stroke and dementia.
She was initially intubated for concern in the ED of inability
to protect her airway. She was admitted to the ICU. She was
treated with dilantin for seizure prophylaxis. Focal rhythmic
jerking of her RLE was seen on [**11-8**]. EEG was performed and
showed bilateral frequent epileptiform sharp and slow wave
discharges over the left parietal temporal region and right
temporal region (less commonly), but no seizures. Coumadin was
held given the hemorrhage, and SBP maintained below 150. She had
a repeat head CT, which was stable. She was continued on
ampicillin, ceftriaxone, and vancomycin. HSV was thought to be
very low probability so the acyclovir started on admission was
discontinued.
She was extubated on [**11-8**] and called out to the floor.
Once transferred to the floor, she had the following medical
problems:
1) Neuro: After transfer, she did not have clinical seizures
but did have impaired alertness. An EEG was obtained, which was
abnormal. She was continued on her Dilantin. It was noticed
that she was not moving all of her extremities well. The right
sided weakness could be explained by the old left MCA stroke;
however, her left side was weak as well. A cervical spine CT
was obtained, which showed a calcified mass at C2/C3 thought
likely to be due to a hematoma. No intervention was performed.
Because there were some concerns that the fevers may be
secondary to the Dilantin, it was discontinued and she was
started on Keppra. A repeat EEG was
2) CV: Her blood pressure medications were titrated to
maintain normal BPs. On a CXR on [**11-14**] because of some symptoms
of respiratory distress, there were concerns that there was a
pericardial effusion; therefore, an echo was obtained which was
showed no pericardial effusion and good EF.
3) ID: Because of concerns of meningitis, an LP was attempted
initially but unsuccessful. She was started on Vancomycin,
Ampicillin, and Ceftriaxone for infectious coverage. Patient
had low grade temperatures and CXR was hazy; therefore, Flagyl
was started for possible aspiration pneumonia. She continued to
have fevers with a mild leukocytosis and elevated ESR and CRP.
Because of her generalised edema, ultrasounds of her upper and
lower extremities were obtained to look for DVT and found to be
negative. Infectious disease was consulted and recommended
slowing discontinuing the antibiotics. Her Ampicillin,
Vancomycin, and Ceftriaxone were dicontinued on [**11-16**]. Flagyle
was discontinued on [**11-17**]. As part of their recommendations, a
torso CT was obtained, which was negative. On [**11-19**], she
started having fevers again and was recultured.
4) FEN/GI: Patient had multiple electrolyte disturbances
during her course incluing hypernatremia, hypokalemia,
hypophosphatmemia. They were corrected based on her daily blood
chemistries. Patient received nutrition through an NG tube.
She had an elevated BUN/Cr as well as edema in all her
extremities with high input compared to output. Internal
medicine was consulted and recommended decreasing her free water
intake as well as restarting her Lasix.
5) Pulm: There were some concerns of aspiration pneumonia that
was treated with a course of Flagyl. She remained on nasal
cannula.
6) Heme: Patient was anemic and labs were consistent with iron
deficiency anemia. Since she also needed volume, she was
transfused 2 units of PRBCs.
7) Psychosocial: Updates were given to the family and they
decided to make her DNR/DNI.
Early morning around [**11-19**] midnight, she had some [**Last Name (un) 6055**]-[**Doctor Last Name **]
respirations and subsequently passed away. Family has agreed to
an autopsy.
Medications on Admission:
warfarin 2.5mg po daily
lasix 80mg po daily
vasotec 10mg po daily
cochicine 10mg po daily
lorazepam prn
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Subdural hemorrhage, clinical seizure, demential, previous
stroke, s/p pacemaker placement, hypertension, gout
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"274.9",
"E888.9",
"507.0",
"401.9",
"780.39",
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"213.2",
"852.00",
"780.6",
"275.3",
"344.89",
"428.0",
"782.3",
"276.0",
"276.8",
"438.9",
"280.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"99.07",
"96.72",
"99.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
16308, 16317
|
11463, 16125
|
281, 350
|
16471, 16480
|
4452, 4452
|
16533, 16632
|
2953, 2986
|
16279, 16285
|
16338, 16450
|
16151, 16256
|
16504, 16510
|
3001, 3001
|
224, 243
|
378, 2296
|
3670, 4433
|
4469, 11440
|
3015, 3568
|
3583, 3653
|
2318, 2770
|
2786, 2937
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,529
| 178,984
|
51352
|
Discharge summary
|
report
|
Admission Date: [**2175-8-9**] Discharge Date: [**2175-8-14**]
Date of Birth: [**2110-12-10**] Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
L arm pain
Major Surgical or Invasive Procedure:
L humerus ORIF
History of Present Illness:
64F pedestrian struck. Was crossing the street and was hit by a
car traveling an unknown MPH. Pt experienced loss of
consciousness, doesn't remember being hit or falling to the
ground. Evaluated by trauma team, c/o isolated left shoulder
pain.
Past Medical History:
coronary artery disease, s/p coronary artery bypass [**2173-9-8**]
PMH:
Hypertension
hyperlipidemia
Peripheral Arterial Disease
Carotid Artery Disease
Bilateral subclavian stenosis s/p L stent [**5-23**]
Chronic back pain/Head ache on narcotics
Herpes Simplex
coronary artery disease, s/p coronary artery bypass [**2173-9-8**]
PMH:
Hypertension
hyperlipidemia
Peripheral Arterial Disease
Carotid Artery Disease
Bilateral subclavian stenosis s/p L stent [**5-23**]
Chronic back pain/Head ache on narcotics
Herpes Simplex
Social History:
Lives with:alone
Occupation:financial planner
Tobacco:quit age 32
ETOH:6 glasses/week
Family History:
Father died of MI age 50, mother with MI age 65
Physical Exam:
AOx3
NAD
Breathing comfortably, speaking in full sentences
RUE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearms are soft
LUE: incision on shoulder c/d/i; dressed
No other skin changes.
Axillary, R/M/U SITLT
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
LLE: ttp at lateral malleolus with mild swelling. Wrapped in
ACE-bandage.
Pertinent Results:
[**2175-8-9**] 10:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2175-8-9**] 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR
[**2175-8-9**] 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR
[**2175-8-9**] 10:00PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-1 TRANS EPI-<1
[**2175-8-9**] 10:00PM URINE HYALINE-15*
[**2175-8-9**] 10:00PM URINE MUCOUS-OCC
[**2175-8-9**] 01:45PM PT-11.1 PTT-27.3 INR(PT)-1.0
Brief Hospital Course:
The patient was admitted to the Orthopaedic Trauma Service for
repair of a L Humerus fracture. The patient was taken to the OR
and underwent an uncomplicated ORIF L Humerus. The patient
tolerated the procedure without complications and was
transferred to the PACU in stable condition. Please see
operative report for details. Post operatively pain was
controlled with a PCA with a transition to PO pain meds once
tolerating POs. The patient became hypotensive on POD1 and was
transferred to the TSICU for further care. Due to acute blood
loss anemia, she was transfused 2UPRBC. The patient tolerated
diet advancement without difficulty and made steady progress
with PT.
Weight bearing status: NWB LUE. Sling for comfort.
The patient received peri-operative antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. 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:
2. Acyclovir 400 mg PO Q12H
PRN cold sores. Pt may refuse if not needed
3. Amlodipine 10 mg PO DAILY
BP<100
4. Aspirin 325 mg PO DAILY
5. Atorvastatin 10 mg PO DAILY
6. BuPROPion (Sustained Release) 150 mg PO BID
7. Clopidogrel 75 mg PO DAILY
9. Furosemide 20 mg PO DAILY
BP<100
10. Isosorbide Mononitrate 30 mg PO DAILY
BP<100, HR<60
11. Lisinopril 40 mg PO DAILY
BP<100
12. Metoprolol Tartrate 12.5 mg PO BID
Hold BP<100, HR<60
15. Sertraline 100 mg PO DAILY
16. Tizanidine 2 mg PO TID
hold BP<100
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Acyclovir 400 mg PO Q12H
PRN cold sores. Pt may refuse if not needed
3. Amlodipine 10 mg PO DAILY
BP<100
4. Aspirin 325 mg PO DAILY
5. Atorvastatin 10 mg PO DAILY
6. BuPROPion (Sustained Release) 150 mg PO BID
7. Clopidogrel 75 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Furosemide 20 mg PO DAILY
BP<100
10. Isosorbide Mononitrate 30 mg PO DAILY
BP<100, HR<60
11. Lisinopril 40 mg PO DAILY
BP<100
12. Metoprolol Tartrate 12.5 mg PO BID
Hold BP<100, HR<60
13. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
After PCA has been d/c
RX *oxycodone 5 mg [**2-13**] Tablet(s) by mouth q4hrs Disp #*90 Tablet
Refills:*0
14. Senna 1 TAB PO BID:PRN constipation
15. Sertraline 100 mg PO DAILY
16. Tizanidine 2 mg PO TID
hold BP<100
17. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
status post L humerus fracture ORIF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
******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 L arm
******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.
******FOLLOW-UP**********
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 [**11-26**] 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.
Physical Therapy:
NWB LUE
Treatments Frequency:
dry to dry; staples to be removed at 10-14 days
Followup Instructions:
******FOLLOW-UP**********
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 [**11-26**] 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.
Please call Cognitive Neurology for further testing given your
recent loss of consciousness: [**Telephone/Fax (1) 6335**].
Completed by:[**2175-8-14**]
|
[
"433.30",
"272.4",
"920",
"V45.82",
"443.9",
"V45.81",
"719.47",
"V15.82",
"E814.7",
"V10.82",
"285.1",
"311",
"433.10",
"V45.79",
"401.9",
"812.03",
"458.9",
"812.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.02",
"79.31"
] |
icd9pcs
|
[
[
[]
]
] |
4923, 4994
|
2341, 3532
|
319, 336
|
5074, 5074
|
1749, 2318
|
6862, 7438
|
1278, 1328
|
4083, 4900
|
5015, 5053
|
3558, 4060
|
5225, 5479
|
1343, 1730
|
6760, 6768
|
6790, 6839
|
269, 281
|
5491, 6742
|
364, 613
|
5089, 5201
|
635, 1158
|
1174, 1262
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,115
| 160,763
|
35896
|
Discharge summary
|
report
|
Admission Date: [**2111-7-1**] Discharge Date: [**2111-7-6**]
Date of Birth: [**2058-8-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
asymptomatic
Major Surgical or Invasive Procedure:
[**2111-7-1**]:
1. Coronary artery bypass grafting x3, left internal mammary
artery to left anterior descending artery, bypass from the
ascending aorta to the obtuse marginal artery branch of the
circumflex artery using reversed autogenous saphenous vein
graft, bypass from the ascending aorta to the diagonal artery
branch of the left anterior descending artery using reversed
autogenous saphenous vein graft.
2. Endoscopic vein harvest of the greater saphenous from the
right leg.
History of Present Illness:
52 year old male with diabetes and ESRD on dialysis is
undergoing evaluation for kidney transplant and was referred for
cardiac clearance. He underwent stress MIBI and was noted to
have a small reversible defect in the distal
septum and apex. He has been seen by Dr. [**Last Name (STitle) 81555**] [**Name (STitle) **] who has
recommended cardiac catheterization. He was found to have
coronary artery disease upon cardiac catheterization and is now
being referred to cardiac surgery for revascularization
Past Medical History:
s/p Coronary Artery Bypass grafting x3
Past Medical History:
Coronary artery disease
diabetes-diet controlled
ESRD on dialysis
hyperlipidemia
GI bleed s/p gastric ulcer 14 months ago AV fistula left arm
Past Surgical History:
Gastric Bypass Surgery (with subsequent 120 lbs weight loss)
Social History:
Race:Caucasian
Last Dental Exam:6 months ago, tooth extraction
Lives with: Wife
Contact:[**Last Name (NamePattern4) 553**] (wife) Phone #[**Telephone/Fax (1) 81556**]
Occupation:On disability
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**1-27**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Family History:Premature coronary artery disease- non
contributory
Physical Exam:
Admission
Pulse:69 Resp:14 O2 sat:100/RA
B/P Right:98/56 Left:no BP d/t AV fistula
Height:5'7" Weight:185 lbs
Patient's "dry weight" is 85 kg.
General:
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [] grade ______
Abdomen: Soft [X] non-distended [X] non-tender [X] + BS [X]
Extremities: Warm [X], well-perfused [X] Edema no edema
Varicosities: None [X]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: palp Left: palp
DP Right: palp Left: palp
PT [**Name (NI) 167**]: palp Left: palp
Radial Right: palp Left: palp
Carotid Bruit No bruits heard
Pertinent Results:
Admission
[**2111-7-1**] 01:22PM FIBRINOGE-326
[**2111-7-1**] 01:22PM PT-14.2* PTT-29.8 INR(PT)-1.3*
[**2111-7-1**] 01:22PM PLT COUNT-273
[**2111-7-1**] 01:22PM WBC-14.8*# RBC-2.82* HGB-9.3* HCT-28.8*
MCV-102* MCH-32.8* MCHC-32.1 RDW-14.6
[**2111-7-1**] 03:40PM UREA N-38* CREAT-5.8*# SODIUM-142
POTASSIUM-4.9 CHLORIDE-107 TOTAL CO2-24 ANION GAP-16
Discharge
[**2111-7-6**] 04:51AM BLOOD WBC-5.4 RBC-2.89* Hgb-9.6* Hct-27.9*
MCV-97 MCH-33.1* MCHC-34.2 RDW-15.0 Plt Ct-229
[**2111-7-6**] 04:51AM BLOOD Plt Ct-229
[**2111-7-6**] 04:51AM BLOOD Glucose-67* UreaN-47* Creat-6.6*# Na-138
K-4.1 Cl-95* HCO3-28 AnGap-19
[**2111-7-6**] 04:51AM BLOOD Mg-2.4
[**2111-7-5**] 04:28AM BLOOD Calcium-8.1* Phos-4.3 Mg-2.3
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2111-7-3**] 4:49 PM
CSRU [**2111-7-3**] 4:49 PM CHEST PORT. LINE PLACEMENT Clip #
[**Clip Number (Radiology) 81557**]
Final Report: The previously placed Swan-Ganz catheter was
obviously changed against a conventional central venous access
line. The course of the line is unremarkable, the tip of the
line projects over the right atrium, the line could be pulled
back by approximately 7 cm to ensure safe position within the
mid SVC.
No evidence of complications, notably no pneumothorax.
Unchanged status post CABG with normal alignment of sternal
wires. Minimal blunting of the left costophrenic sinus, a small
pleural effusion cannot be excluded. No evidence of pulmonary
edema or pneumonia.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Brief Hospital Course:
Mr [**Known lastname **] was a same day admission for coronary artery bypass
grafting with Dr [**First Name (STitle) **] on [**2111-7-1**]. Please see operative report
for details in summary he had: 1. Coronary artery bypass
grafting x3, left internal mammary artery to left anterior
descending artery, bypass from the ascending aorta to the obtuse
marginal artery branch of the circumflex artery using reversed
autogenous saphenous vein graft, bypass from the
ascending aorta to the diagonal artery branch of the left
anterior descending artery using reversed autogenous saphenous
vein graft.
2. Endoscopic vein harvest of the greater saphenous from the
right leg. His bypass time was 63 minutes with a crossclamp of
53 minutes. he tolerated the operation well and was transferred
to the cardiac surgery ICU in stable condition. He remained
hemodynamically stable, woke neurologically intact and was
extubated several hours after his arrival in ICU. POst
operatively he was seen by the Nephrology service to initiated
hemodyalysis. He continued to require pressor support and
remained in the ICU until POD4 when he finally was weaned from
pressors. All tubes lines and drains were removed per cardiac
surgery protocol and w/o complication. Once on the stepdown
floor he worked with nursing and physical therapy to increase
his strength and endurance. The remainder of his hospital course
was uneventful.
On POD5 he was discharged home with visiting nurses, he is to
follow up with Dr [**First Name (STitle) **] in 1 month
Medications on Admission:
Medications at home:
CALCIUM ACETATE 667 mg- 3 Capsules with meals
CINACALCET [SENSIPAR] 30 mg Daily
OXYCODONE 5 mg PRN
SIMVASTATIN 10 mg Daily
ZOLPIDEM 10 mg PRN HS
ASCORBIC ACID 1,000 mg Daily
B COMPLEX-VITAMIN C-FOLIC ACID 0.8 mg Daily
VITAMIN B-12 250 mcg Daily
GLUCOSAMINE 500 mg Daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN fever, pain
2. Amiodarone 400 mg PO BID
400mg [**Hospital1 **] x1 week then, 400mg daily x1 week then, 200mg daily
RX *amiodarone 200 mg 2 tablet(s) by mouth twice a day Disp #*65
Tablet Refills:*1
3. Aspirin EC 81 mg PO DAILY
RX *Adult Low Dose Aspirin 81 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*1
4. Calcium Acetate 667 mg PO TID W/MEALS
5. Cinacalcet 30 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
RX *Colace 100 mg 1 capsule(s) by mouth twice a day Disp #*60
Tablet Refills:*1
7. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *Dilaudid 2 mg [**12-22**] tablet(s) by mouth four times a day Disp
#*50 Tablet Refills:*0
8. Nephrocaps 1 CAP PO DAILY
9. Simvastatin 10 mg PO DAILY
RX *simvastatin 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
s/p Coronary artery bypass grafting x3
PMH:
diabetes-diet controlled
ESRD on dialysis
hyperlipidemia
GI bleed s/p gastric ulcer 14 months ago
Past Surgical History:
Gastric Bypass Surgery (with subsequent 120 lbs weight loss)
AV fistula left arm
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema: none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2111-7-14**] 10:45
Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2111-8-4**] 1:30
Cardiologist: Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] [**2111-7-29**] at 3:00 [**Location (un) 620**]
Please call to schedule appointments with your
Primary Care Dr.[**First Name (STitle) **],[**First Name3 (LF) 8758**] [**Telephone/Fax (1) 67950**] ..in [**3-26**] 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:[**2111-7-6**]
|
[
"583.81",
"585.6",
"V49.83",
"V45.11",
"V45.86",
"250.40",
"414.01",
"V17.3",
"998.11",
"285.21",
"272.4",
"427.31",
"V12.71",
"458.29",
"E878.2",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"39.95",
"36.12",
"39.31"
] |
icd9pcs
|
[
[
[]
]
] |
7130, 7179
|
4415, 5941
|
321, 806
|
7469, 7690
|
2836, 4392
|
8493, 9327
|
2045, 2099
|
6283, 7107
|
7200, 7342
|
5967, 5967
|
7714, 8470
|
5988, 6260
|
7365, 7448
|
2114, 2817
|
268, 283
|
834, 1340
|
1423, 1565
|
1667, 2014
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,880
| 135,453
|
178
|
Discharge summary
|
report
|
Admission Date: [**2162-3-3**] Discharge Date: [**2162-3-25**]
Date of Birth: [**2080-1-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1828**]
Chief Complaint:
Mr. [**Known lastname 1829**] was seen at [**Hospital1 18**] after a mechanical fall from
a height of 10 feet. CT scan noted unstable fracture of C6-7 &
posterior elements.
Major Surgical or Invasive Procedure:
1. Anterior cervical osteotomy, C6-C7, with decompression and
excision of ossification of the posterior longitudinal ligament.
2. Anterior cervical deformity correction.
3. Interbody reconstruction.
4. Anterior cervical fusion, C5-C6-C7.
5. Plate instrumentation, C5-C6-C7.
6. Cervical laminectomy C6-C7, T1.
7. Posterior cervical arthrodesis C4-T1.
8. Cervical instrumentation C4-T1.
9. Arthrodesis augmentation with autograft, allograft and
demineralized bone matrix.
History of Present Illness:
Mr. [**Known lastname 1829**] is a 82 year old male who had a slip and fall
of approximately 10 feet from a balcony. He was ambulatory at
the scene. He presented to the ED here at [**Hospital1 18**]. CT scan
revealed unstable C spine fracture. He was intubated secondary
to agitation.
Patient admitted to trauma surgery service
Past Medical History:
Coronary artery disease s/p CABG
CHF
HTN
AICD
Atrial fibrillation
Stroke
Social History:
Patient recently discharged from [**Hospital1 **] for severe
depression. Family reports patient was very sad and attempted to
kill himself by wrapping a telephone cord around his neck. Lives
with his elderly wife, worked as a chemist in [**Country 532**].
Family History:
Non contributory
Physical Exam:
Phycial exam prior to surgery was not obtained since patient was
intubated and sedated.
Post surgical physical exam: (TSICU per surgery team)
Breathing without assistance
NAD
Vitals: T 97.5, HR 61, BP 145/67, RR22, SaO2 98
A-fib, rate controlled
Abd soft non-tender
Anterior/Posterior cervical incisions [**Name (NI) 1830**]
Pt is edemitous in all four extremities, no facial edema
Able to grossly move all four extremities, neurointact to light
touch
Distal pulses weakly intact
Medicine Consult:
VS: Tm/c 98.9 142/70 61 20 96%RA
I/O BM yesterday 220/770
Gen: awake, calm, cooperative and pleasant, lying in bed
Neck: c-collar removed
CV: irregular, normal S1, S2. No m/r/g.
lungs: cta anteriolry
Abd: Obese, Soft, NTND, decreased bs
Ext: trace b/l le edema, 1+ UE edema
neuro/cognition: thought [**3-17**], "8", not to place,
Pertinent Results:
====================
ADMISSION LABS
====================
WBC-8.4 RBC-4.43* Hgb-11.9* Hct-38.6* MCV-87 MCH-26.9*
MCHC-30.9* RDW-17.3* Plt Ct-191
PT-20.4* PTT-28.1 INR(PT)-1.9*
CK(CPK)-183* Amylase-70
Calcium-8.5 Phos-2.0* Mg-1.9
Glucose-121* Lactate-2.3* Na-140 K-4.3 Cl-101 calHCO3-26
==================
RADIOLOGY
==================
CT scan C spine [**2162-3-3**]:
IMPRESSION:
1. Fracture of the C6 as described involving the right pedicle
(extending to the inferior facet) and left lamina. Anterior
widening at the C6-7 disc space and mild widening of left C6-7
facet also noted. Prevertebral hematoma at C6 with likely
rupture of the anterior longitudinal ligament.
2. Lucency in the right posterior C1 ring may represent a
chronic injury.
Likely old avulsion fracture at T2 pedicle on the left.
3. Ossification of both anterior and posterior longitudinal
ligaments with
compromise of the central spinal canal. Degenerative disease is
further
described above.
CT ABDOMEN/PELVIS ([**2162-3-3**])
IMPRESSION:
1. No acute injuries in the chest, abdomen, or pelvis.
2. Three discrete pleural fluid collections in the right
hemithorax, likely pseudotumors.
3. Small hypodense lesion in the pancreatic body is of unclear
etiology, may represent pseudicyst or cystic tumor. Further
evaluation with MRI may be performed on a non- emergent basis.
4. Bilateral renal cysts.
5. Foley catheter balloon inflated within the prostatic urethra.
Recommend emergent repositioning.
CT SINUS/MAXILLOFACIAL ([**2162-3-3**])
1. Bilateral nasal bone fractures.
2. Left frontal scalp hematoma with preseptal soft tissue
swelling. Question foreign body anterior to the left globe.
Recommend clinical correlation. Small amount of extraconal
hematoma in the superior aspect of the left orbit.
3. Linear lucency in the right posterior ring of C1. Correlate
with CT C- spine performed concurrently.
HEAD CT ([**2162-3-3**])
1. No acute intracranial hemprrhage.
2. Left frontal scalp hematoma.
3. Nasal bone fractures. Recommend correlation with report from
facial bone CT scan.
4. Lucency in the right posterior ring of C1. Please refer to
dedeicated CT C-spine for further detail.
5. Left cerebellar encephalomalacia, likely due to old
infarction.
CHEST [**2162-3-10**]
The Dobbhoff tube passes below the diaphragm with its tip most
likely terminating in the stomach. The bilateral pacemakers are
demonstrated with one lead terminating in right atrium and three
leads terminating in right ventricle. The patient is in mild
pulmonary edema with no change in the loculated pleural fluid
within the major fissure.
CT HEAD [**2162-3-11**]
1. A tiny amount of intraventricular hemorrhage layers along the
occipital horns of the ventricles bilaterally. Recommend followp
imaging.
2. Left frontal scalp hematoma has decreased in size.
3. Unchanged left cerebellar encephalomalacia.
4. Nasal bone fractures are better evaluated on dedicated
maxillofacial CT.
RIGHT SHOULDER X-RAY ([**2162-3-11**])
Mild glenohumeral and acromioclavicular joint osteoarthritis.
Nonspecific ossification projecting over the upper margin of the
scapular body and adjacent to the lesser tuberosity. Diagnostic
considerations include the sequela of chronic calcific bursitis,
intraarticular bodies, and/or calcific tendinitis of the
subscapularis tendon.
Increased opacity projecting over the right hemithorax and minor
fissure, better delineated on recent chest radiographs and chest
CT
RIGHT UPPER EXTREMITY ULTRASOUND ([**2162-3-13**])
1. Deep venous thrombosis in the right axillary vein, extending
proximally into the right subclavian vein, and distally to
involve the brachial veins, portion of the basilic vein, and the
right cephalic vein.
2. Likely 2.0 cm left axillary lymph node, with unusual
son[**Name (NI) 493**] features somewhat suspicious for malignancy.
Followup ultrasound is recommended in 4 weeks, and FNA/biopsy
may be considered at that time if no interval improvement.
[**2162-3-14**]
CT ABDOMEN WITH IV CONTRAST: There are small-to-moderate
bilateral pleural effusions, on the right with a loculated
appearance. There is associated compressive atelectasis. The
visualized portion of the heart suggests mild cardiomegaly.
There is no pericardial effusion. There is a 9-mm
hypoattenuating, well-defined lesion in the left lobe of the
liver (2:12) too small to accurately characterize but
statistically most likely representing a cyst. There are
bilateral, partially exophytic renal cysts. The spleen is normal
in size. There is a 5-mm hypoattenuating focus in the pancreatic
body, most likely representing focal fat. The gallbladder and
adrenal glands are unremarkable. An NG tube terminates in the
stomach. There is no ascites. The large and small bowel loops
appear unremarkable without wall thickening or pneumatosis. Oral
contrast material has passed into the ascending colon without
evidence of obstruction. There is no ascites and no free air.
There is a small pocket of air in the left rectus muscle,
tracking over a distance of approximately 10 cm.
CT PELVIS WITH IV CONTRAST: The pelvic small and large bowel
loops, collapsed bladder containing Foley catheter and seminal
vesicles appear unremarkable. The prostate is enlarged,
measuring 5.9 cm in transverse diameter. The rectum contains a
moderate amount of dried stool. There is no free air or free
fluid.
BONE WINDOWS: No suspicious lytic or sclerotic lesions. There is
DISH of the entire visualized thoracolumbar spine. There also
are degenerative changes about the hip joints with large
acetabular osteophytes.
IMPRESSION:
1. Stable bilateral pleural effusions, loculated on the right.
2. New focus of air tracking within the left rectus muscle with
associated tiny amount of extraperitoneal air (2:53). No
associated stranding or fluid collection. Please correlate
clinically if this could be iatrogenic, such as due to s.q.
injections.
3. 5-mm hypoattenuating focus in the pancreatic body. This could
represent focal fat, although a cystic tumor cannot be excluded.
If this is of concern, then MRI is again recommended for further
evaluation.
4. Hypoattenuating focus in the left lobe of the liver, too
small to accurately characterize.
5. Bilateral partially exophytic renal cysts.
6. Moderate amount of dried stool within the rectum.
A wet read was placed and the pertinent findings were discussed
by Dr. [**First Name (STitle) 1831**] [**Name (STitle) 1832**] with Dr. [**First Name (STitle) 1833**] at 11:30 p.m. on [**2162-3-14**].
[**2162-3-16**]
VIDEO OROPHARYNGEAL SWALLOW FINDINGS: Real-time video
fluoroscopic evaluation was performed after oral administration
of thin and puree consistency of barium, in conjunction with the
speech pathologist.
ORAL PHASE: Normal bolus formation, bolus control, AP tongue
movement, oral transit time, and no oral cavity residue.
PHARYNGEAL PHASE: There is normal swallow initiation and velar
elevation. There is mild-to-moderate impairment of laryngeal
elevation with absent epiglottic deflection. There is
moderate-to-severe increase in pharyngeal transit time. There is
residue in the valleculae and piriform sinuses with moderate
impairment of bolus propulsion. There was aspiration of both
thin and puree barium.
IMPRESSION: Aspiration of thin liquids and puree. For additional
information, please see the speech and swallow therapist's
report from the same day.
[**2162-3-18**] CT Head w/out:
FINDINGS: There is a small amount of blood layering in the
occipital horns of both lateral ventricles, unchanged though not
as dense given evolution. No new hemorrhage is identified. The
ventricles, cisterns, and sulci are enlarged secondary to
involutional change. Periventricular white matter hyperdensities
are sequelae of chronic small vessel ischemia. Encephalomalacia
in the left cerebellar hemisphere secondary to old infarction is
unchanged. The osseous structures are unremarkable. The
visualized paranasal sinuses and mastoid air cells are clear.
Skin staples are noted along the superior- posterior neck
secondary to recent spinal surgery.
IMPRESSION: No interval change with a very small
intraventricular hemorrhage.
No discharge labs as patient CMO.
Brief Hospital Course:
Mr. [**Known lastname 1829**] was seen at [**Hospital1 18**] after his fall from a height
of approximatly 10 feet. CT scans of his chest, abdomen and
pelvis were negative for pathology. CT scan of his C-spine
showed fracture of anterior and posterior elements at C6-7. He
was also shown to have a right nasal bone fracture.
C-spine fracture: Mr. [**Known lastname 1829**] [**Last Name (Titles) 1834**] two surgical
procedures to stabilized his c-spine. [**2162-3-4**]: anterior
cervical decompression/fusion at C6-7. [**2162-3-5**]: Cervical
laminectomy C6-C7 & T1 with Posterior cervical arthrodesis
C4-T1. He tolerated the procedures well. He was extubated
without complication.
After his surgical procedures, Mr. [**Known lastname 1829**] was transfered
to the medicine service at [**Hospital1 18**] for his medical care. While on
the medicine service, patient was found to be persistently
aspirating and failed his speech and swallow evaluation. Patient
and family were not interested in an NG tube or PEG for
nutrition. Patient also developed a venous clot of the right
upper extremity and the decision was made to not proceed with
medical treatment. Goals of care were changed to comfort
measures only. A foley was placed after patient had difficulty
with urinary retention and straight cathing. A palliative care
consult was obtained for symptom management and patient was
discharged to hospice with morphine, olanzapine, and a foley in
place for symptomatic relief.
Medications on Admission:
Coumadin
seroquel
docusate
metoprolol
folate
lovastatin
captopril
ASA
ipratroium inhaler
Ferrous sulfate
furosemide
citalopram
isosorbide
meprazole
Discharge Medications:
1. Bisacodyl 10 mg Suppository Sig: [**12-30**] Suppositorys Rectal
DAILY (Daily) as needed for constipation.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for wheezing.
3. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) solution Inhalation Q6H (every 6 hours) as needed for
wheezing.
4. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q4H
(every 4 hours) as needed for pain: may shorten interval as
needed to control pain.
5. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO QHS (once a day (at bedtime)) as needed for
agitation.
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily): may be
discontinued if patient not tolerating pills or refusing to
take.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
1. Cervical spondylosis with calcification of posterior
longitudinal ligament.
2. Fracture dislocation C6-C7.
3. Ossification of the posterior longitudinal ligament.
4. Aspiration Pneumonia
1. Cervical spondylosis with calcification of posterior
longitudinal ligament.
2. Fracture dislocation C6-C7.
3. Ossification of the posterior longitudinal ligament.
4. Aspiration Pneumonia
1. Cervical spondylosis with calcification of posterior
longitudinal ligament.
2. Fracture dislocation C6-C7.
3. Ossification of the posterior longitudinal ligament.
4. Aspiration Pneumonia
Discharge Condition:
Stable to outside facility
Discharge Instructions:
Patient has been made CMO at the request of him and his family.
He has a foley placed for urinary retention. Please use morphine
as needed for pain and olanzapine as needed for agitiation.
Patient has known history of aspiration documented on speech and
swallow. It is the patient and the family's wish for him to
continue to eat and drink as desired.
Followup Instructions:
Follow up with your primary care physician as needed.
|
[
"453.8",
"802.0",
"V12.54",
"401.1",
"788.20",
"805.06",
"428.0",
"E882",
"428.23",
"427.31",
"293.0",
"V45.81",
"507.0",
"V45.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.53",
"81.02",
"96.71",
"81.03",
"96.04",
"81.63"
] |
icd9pcs
|
[
[
[]
]
] |
13316, 13388
|
10785, 12269
|
487, 959
|
14013, 14042
|
2591, 10762
|
14442, 14499
|
1706, 1724
|
12467, 13293
|
13409, 13992
|
12295, 12444
|
14066, 14419
|
1857, 2572
|
274, 449
|
987, 1321
|
1343, 1417
|
1433, 1690
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,478
| 104,766
|
28786
|
Discharge summary
|
report
|
Admission Date: [**2170-11-9**] Discharge Date: [**2170-11-13**]
Service: MEDICINE
Allergies:
Codeine / Sulfa (Sulfonamide Antibiotics) / Penicillins
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
Bloody bowel movement
Major Surgical or Invasive Procedure:
Sigmoidoscopy ([**2170-11-12**])
History of Present Illness:
[**Age over 90 **]F with a pmh significant for osteoarthritis, HTN, and prior C.
Diff infection x2, transferred via [**Location (un) **] from [**Hospital1 6687**] for
acute onset, painless LGIB. Overnight at 2am, Ms. [**Known lastname 69553**] [**Last Name (Titles) 5058**]
and had a large painless BM that was formed and brown, with
surrounding bright red blood. While at the OSH she had labs
significant for HCT of 39, and a chem 7 within normal limits.
She was normotensive and her HR was within normal limits. While
there she began to feel "unwell," had a large dark BM and
correspondin BPs in the 80s/50s. She was placed in T-[**Last Name (un) **], given
2L IVF with return of BP to 110s systolic and resolution of
symptoms. She was given 1 dose of Cipro, Flagyl, and stool
cultures were sent. Planned CT abd, but pt became transiently
hypotensive. She was transferred to our ED for higher level of
care.
.
Denies associated abdominal pain, fever, recent antibiotic use
or travel. No sick contacts. [**Name (NI) **] CP, SOB, diarrhea, constipation,
no anticoagulation use. Denies dizziness, lightheadedness, or
pre-syncope. HD stable with normal MS in transport.
.
In the ED, initial VS were: 99.8, 74, 118/63, 16, 98% on RA.
Guaiac + with dark red blood and stool. A T&S was sent, 2 PIV
placed. NG lavage negative. GI c/s: recommend NG lavage to r/o
UGIB. Received 1L NS in the ED. A CXR showed no acute
cardiopulmonary process.
.
On arrival to the MICU, she was resting in bed comfortable,
normotensive, with 18 and 20g IVs. She was without complaint.
.
Review of systems:
(+) Per HPI
(-) All else negative.
Past Medical History:
Hypertension
Osteoarthritis
Prior history of C. Diff x2
Social History:
Originally from [**Hospital1 6687**]. Husband past away 31 years ago. She
has 4 children (5 total, 1 past away from complications of DM),
8 grandchildren, and 1 great-grandchild.
- Tobacco: Former
- Alcohol: No EtoH
- Illicits: No elicits
Family History:
Non-contributory
Physical Exam:
On Admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no cervical LAD
CV: Normal rate and regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Crackles at the bilateral bases, no wheezes, rales,
ronchi, otherwise clear
Abdomen: soft, TTP in the RLQ, LUQ, LLQ. Non-distended, bowel
sounds present, no organomegaly, no rebound or guarding
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
On Discharge:
VS - 96.4, 128/66, 72, 16, 95%RA
GENERAL - well-appearing woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD,
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/ND, mild diffuse tenderness (similar to
prior), no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-26**] throughout, sensation grossly intact throughout
Pertinent Results:
Admission-
[**2170-11-9**] 01:44PM BLOOD WBC-9.6 RBC-3.89* Hgb-11.5* Hct-33.1*
MCV-85 MCH-29.5 MCHC-34.6 RDW-13.3 Plt Ct-252
[**2170-11-9**] 01:44PM BLOOD Neuts-89.8* Lymphs-6.6* Monos-2.8 Eos-0.4
Baso-0.4
[**2170-11-9**] 01:44PM BLOOD PT-13.1 PTT-25.7 INR(PT)-1.1
[**2170-11-9**] 01:44PM BLOOD Glucose-115* UreaN-18 Creat-0.6 Na-136
K-3.5 Cl-100 HCO3-24 AnGap-16
[**2170-11-9**] 01:44PM BLOOD ALT-10 AST-16 AlkPhos-60 TotBili-0.5
[**2170-11-10**] 04:53AM BLOOD Calcium-8.3* Phos-2.3* Mg-1.9
Discharge-
[**2170-11-13**] 06:05AM BLOOD WBC-6.8 RBC-4.05* Hgb-11.9* Hct-34.3*
MCV-85 MCH-29.5 MCHC-34.8 RDW-14.3 Plt Ct-223
[**2170-11-13**] 06:05AM BLOOD Glucose-99 UreaN-11 Creat-0.7 Na-143
K-3.7 Cl-103 HCO3-32 AnGap-12
[**2170-11-13**] 06:05AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.0
Microbiology-
[**2170-11-10**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL-Negative
[**2170-11-9**] MRSA SCREEN MRSA SCREEN-FINAL-Negative
Studies-
CT Abdomen ([**2170-11-9**])-
1. Minimal stranding adjacent to sigmoid colon is more likely
chronic changes from prior diverticulitis and less likely to be
mild uncomplicated
diverticulitis.
2. Mildly dilated bile ducts with smooth tapering at the
ampulla. Likely
gallstones. There is likely sphincter dysfunction or papillary
stenosis, but if labs show a cholestatic picture further
evaluation with MRCP would be recommended.
3. Cystic lesion in the head of the pancreas measuring up to 2.5
cm is likely side branch intraductal papillary mucinous
neoplasm. Evaluation with MRCP on a non-emergent basis is
recommended unless stability can be shown from prior imaging.
4. Mild pulmonary fibrosis.
CXR ([**2170-11-9**])-
AP upright and lateral views of the chest are obtained. Lungs
are essentially clear bilaterally without definite signs of
pneumonia or CHF. No pleural effusion or pneumothorax is seen.
Cardiomediastinal silhouette
appears grossly unremarkable. Degenerative changes are noted in
the T-spine with small endplate spurs noted. No free air below
the right hemidiaphragm is seen.
Sigmoidoscopy ([**2170-11-12**])-
-Stool in the colon
-Diverticulosis of the sigmoid colon
-Mild focal erythema in the rectum and sigmoid colon (biopsy)
-Otherwise normal sigmoidoscopy to splenic flexure
Recommendations:
-Await biopsy results
-No clear etiology of her symptoms were found. Bleeding may have
been related to diverticula or mildly abnormal mucosa may be
related to resolving ischemic colitis.
Brief Hospital Course:
[**Age over 90 **] year old female with a pmh of HTN and osteoarthritis who
presented to an OSH with bright red blood mixed with brown stool
and large dark stool at OSH ED consistent with LGIB.
.
# LGIB:
New onset without pro-dromal symptoms. Not accompanied by
subjective abdominal pain, diarrhea, cramping, or f/c, but
patient was tender on exam. Patient was evaluated by GI who
recommended starting moviprep for possible colonoscopy and CT
scan to evaluate for ischemic colitis. She was started on
cipro/flagyl due to concern for diverticulitis; however,
antibiotics were discontinued when the CT scan suggested that
the inflammatory changes were more chronic. She under went a
flexible sigmoidoscopy, which did not show additional bleeding,
but also did not reveal a clear bleeding source. The etiology
of her bleeding remains unclear, likely [**1-24**] diverticuli or
episode of resolving ischemic colitis.
Patient's HCT dropped from 31 on admission to 25. She received
2 units of pRBCs and her HCT increased appropriately and
remained stable (31.9-34.3) upon discharge.
# HTN:
Home antihypertensives were held in MICU given current bleed,
and possible ischemia in the setting of GIB. As patients BP had
remained stable and the patient was not experiencing additional
bleeding, her home meds were restarted.
==========================
TRANSITIONAL ISSUES:
==========================
# Cystic lesion of pancreas - likley IMPN, can get outpatient
work-up
# Mild pulmonary fibrosis - patient is not reporting any
respiratory complaints, can also get outpatient work-up.
Medications on Admission:
Hydrochlorothiazide
Vasotec
Potassium chloride
Discharge Medications:
1. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
2. enalapril maleate 10 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. potassium chloride Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Lower gastrointestinal bleed
Secondary:
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 69553**],
It was a pleasure taking part in your care. You were
transferred to [**Hospital1 18**] because you were experiencing a GI bleeding
and there were concerns regarding your blood pressure. You were
observed in our medical intensive care unit and your blood
pressures remained stable. You no longer were experiencing
overt bleeding and you were transferred to the general medical
floor.
You later underwent a sigmoidoscopy which did not show any
additional bleeding, but it also did not reveal its original
source. The pain/bleeding may have been due to a lack of blood
flow to the colon, but this process seems to have resolved.
We recommend you continue taking all of your medications as
previously directed. No changes were made.
Followup Instructions:
Please follow up with your PCP, [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 22442**],
within the next week.
We also recommend you contact Dr.[**Name2 (NI) 23373**] office ([**Telephone/Fax (1) 2306**],
regarding possible follow up.
|
[
"401.9",
"562.12",
"715.90",
"577.2",
"515",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25"
] |
icd9pcs
|
[
[
[]
]
] |
7979, 7985
|
6097, 7446
|
286, 321
|
8092, 8092
|
3635, 6074
|
9035, 9324
|
2321, 2340
|
7777, 7956
|
8006, 8071
|
7705, 7754
|
8243, 9012
|
2355, 2355
|
2970, 3616
|
7467, 7679
|
1930, 1967
|
224, 248
|
349, 1911
|
2369, 2956
|
8107, 8219
|
1989, 2047
|
2063, 2305
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,420
| 135,587
|
21472
|
Discharge summary
|
report
|
Admission Date: [**2103-4-13**] Discharge Date: [**2103-4-14**]
Date of Birth: [**2063-4-12**] Sex: F
Service: MEDICINE
Allergies:
Latex / Cefaclor
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
tongue swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
40 yoF w/ a h/o lupus and lupus anticoagulant (h/o PEs on
coumadin) developed tongue swelling the night prior, She states
that at 4:30 p.m. on [**4-12**] she noted some tongue swelling mainly
on the R side of her tongue, she had taken robitussin and
claritin for cough / nasal congestion 4 hours earlier. By 10
p.m. she noted that she was unable to formulate words, but able
to make sounds. She noticed no wheezing or high pitched
breathing sounds, no difficulty breathing, throat swelling,
lightheadedness, rashes, hives or pruritis. No other allergic
symptoms or other symptoms. No HA, no CP, abd pain, diarrhea,
constipation, urinary symptoms, fevers or chills, no dysphagia
or odynophagia. She denies any other symnptoms. She has noted
immense improvement in her symptoms.
.
The patient reported to [**Hospital 8125**] Hospital where she was unable to
speak due to the swelling- she rec'd benadryl, zantac, and
solumedrol. Sent to [**Hospital1 18**] for ENT consult- per ENT believe
hematoma vs. AVM, CT of neck without airway compromise, no
clinical airway compromise.
.
In the ED, initial VS: T 99.0 HR 88 BP 126/84 RR 16 O2 sat: 98%
RA. Prior to transport to the ICU VS were: T 97.8 HR 64, BP
110/64, HR 18, O2 sat: 98%.
Past Medical History:
Lupus (rash, PVOD)
PVOD (pulmonary [**Last Name (un) **] occlusive disease)
Bilateral pulmonary emboli 6 years prior- dx w/ Lupus
anticoagulant in [**10-4**] and at that point started on coumadin
History of pneumonia [**9-3**]
Chronic anemia of iron deficiencey
Restrictive lung disease
s/p cholecystecomty in '[**82**]
Social History:
The patient smoked 2 packs/day for 20 years but quit 10 years
ago. No ETOH recently, no drug use. She lives w/ boyfriend.
Family History:
Diabetes Mellitus in maternal aunts, sister allergic to bee
stings, mother and sister healthy. Father w/ HTN.
Physical Exam:
Vitals - 96.2 101/57 67 18 98% on RA
GENERAL: well appearing, pleasant NAD, AOX3
HEENT: MMM, malar rash noted.
Mouth: subungual erythema c/w subungual hematoma, submental
fullness without assymetry and no tenderndess, Mallampatti III.
Tongue appears normal size
CARDIAC: RRR, no m/r/g
LUNG: CTAB no wheezes
ABDOMEN: soft, NT, ND, BS+, no masses or organomegal
EXT: WWP, no c/c/e
NEURO: AOx3, grossly normal
DERM: multiple erythematous patches with some mild central
clearing.
On discharge: tongue with dusky discoloration throughout tongue,
without swelling, assymetry, or tenderness; tongue with ROM. No
difficuty breathing or speaking.
Pertinent Results:
[**2103-4-13**] 07:40AM BLOOD WBC-4.9 RBC-4.38 Hgb-11.3* Hct-34.5*
MCV-79* MCH-25.9* MCHC-32.8 RDW-15.5 Plt Ct-181
[**2103-4-13**] 07:40AM BLOOD Neuts-92.1* Lymphs-5.7* Monos-1.6*
Eos-0.6 Baso-0.1
[**2103-4-13**] 07:40AM BLOOD Plt Ct-181
[**2103-4-13**] 07:40AM BLOOD PT-25.4* PTT-43.8* INR(PT)-2.4*
[**2103-4-13**] 07:40AM BLOOD Glucose-154* UreaN-9 Creat-0.7 Na-141
K-4.1 Cl-107 HCO3-25 AnGap-13
[**2103-4-13**] 07:40AM BLOOD C3-166 C4-32
[**2103-4-13**] 07:40AM BLOOD C1Q-PND
[**2103-4-13**] 09:34AM BLOOD C1 ESTERASE INHIBITOR, FUNCTIONAL
ASSAY-PND
.
MICRO:
[**2103-4-13**] Nasal swab. MRSA SCREEN (Final [**2103-4-15**]): No MRSA
isolated.
.
IMAGING:
CT neck with contrast [**2103-4-13**]: IMPRESSION: 1. No evidence of
neck or floor of mouth infection. No drainable collection. 2.
Superior mediastinal lymph nodes, increased in size from [**11-9**], [**2102**], chest CT. NOTE ADDED AT ATTENDING REVIEW: I agree with
the above, except that there are prominent level 2 nodes
bilaterally. on the left, the largest node measures 11 mm in
short axis, which is above size criteria. Both the left and
right sided
nodes are elongated and likely reactivw.
.
Brief Hospital Course:
# Tongue swelling: Upon presentation the patient had no evidence
of airway compromise. CT neck was obtained which was
unrevealing for focal collection. ENT and Allergy were
consulted. She was admitted to the ICU for airway monitoring
and treated with IV prednisone and zyrtec for likely angioedema
related to the cefaclor she had been taking. Anticoagulation
was temporarily held given initial concern for subungual
hematoma vs. possible AVM. The swelling decreased dramatically
over hours in the setting of this treatment (even while the
patient was therapeutic on coumadin, making angioedema more
likely) and the patient was transferred to the medical floor.
C3 and C4 were within normal limits and C1 esterase inhibitor
and C1Q were pending at discharge. The patient had trace tongue
swelling the following morning and some dusky discoloration
thought to be related to resolved microvascular bleeding in the
setting of therapeutic INR. A 7 day prednisone taper was
initiated, zantac continued and the patient was instructed that
she most likely has an allergy to cefaclor (ceclor) and that she
should avoid the entire class of cephalosporins in the future.
This was listed as an allergy in our system and the patient was
instructed to notify all future providers of this reaction to
this class of antibiotics. She was prescribed epi-pens and
instructed on their use. The patient was instructed to follow
up with Allergy as an outpatient by calling the number they had
given her, as well as with her PCP the following business day to
have her INR checked and her anticoagulation adjusted
accordingly.
.
# H/o PEs related to lupus anticoagulation: The patient's
coumadin was held due to initial concern for AVM/bleeding into
her tongue. The coumadin was restarted when her swelling
improved and angioedema was thought to be a much more likely
cause of her tongue symptoms.
.
# Pulmonary hypertension/venoocclusive disease: we continued her
home nighttime supplemental O2 and sildenafil.
.
# Lupus: plaquenil was continued.
.
# Superior mediastinal lymph nodes: increased in size compared
to previous CT scan in [**11-3**]. The patient was instructed to
follow this up with Dr. [**Last Name (STitle) 2168**] an outpatient.
Medications on Admission:
Coumadin (7.5mg MWF, 5mg on other days)
Plaquenil 200mg po bid
Sildenafil 20mg po tid
Albuterol prn
home O2- 2L at night
Discharge Medications:
1. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Sildenafil 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler
Inhalation
4. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO Mon, Wed, Fri.
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Tu, Thurs, Sa,
Sun.
6. Prednisone 20 mg Tablet Sig: Please see below Tablet PO DAILY
(Daily) for 7 days: Please take 3 tabs on [**4-15**]; 2 tabs on
[**4-18**]; 1 tab on [**4-21**].
.
Disp:*16 Tablet(s)* Refills:*0*
7. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) injection
Intramuscular as needed as needed for difficulty breathing,
tongue swelling.
Disp:*2 pens* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Angioedema
Secondary:
Lupus
Hypercoagulability secondary to lupus anticoagulant
Discharge Condition:
Alert and oriented, able to ambulate without assistance.
Discharge Instructions:
You were admitted to the hospital with tongue swelling. You
underwent a CT scan of your neck which did not reveal any
noticeable pockets of infection, and were seen by Allergy and
Ear Nose and Throat doctors, who felt that your swelling was
most likely a form of allergic reaction ("angioedema"), possibly
to cefaclor, that may sometimes worsen to the point of
compromising breathing. You were admitted to the intensive care
unit to ensure the safety of your breathing, and you were
treated with steroids and antihistamine medications and improved
to the day of discharge. Given your initial symptoms, a neck CT
was done and showed some enlarged lymph nodes which had grown
slightly since imaging from last [**Month (only) 359**]. As below, please
discuss how to follow this and evaluate this as an outpatient
with Dr [**Last Name (STitle) **] within the next 1-2 weeks.
You also have lupus, and lupus anticoagulant with history of
blood clots; your warfarin was continued while you were
hospitalized.
We made the following changes to your medications:
1. discontinued cefaclor
2. added prednisone, to be taken 60 mg from [**2016-4-13**], 40 mg
[**2019-4-17**], 20 mg on [**4-21**].
3. added zyrtec 10 mg daily until you follow up with Allergy
Please take your other medications as prescribed. You should not
take cefaclor in the future as you may have this reaction again.
You should discuss this allergy with providers in the future as
you may have an allergy to all medications in this class of
antibiotics ("the cephalosporins"). You are being given 2
epi-pens that you should have available for injection in the
event that you have an episode of severe allergy or anphylaxis
(wheezing, difficult breathing, throat or tongue swelling) in
the future.
Followup Instructions:
* Please follow up with Allergy early next week by calling the
number you were given by them.
* Please have your INR checked on Monday and sent to your PCP.
* Please call Dr. [**Last Name (STitle) 25237**] early next week to arrange for follow
up.
* Please set up an appointment with Dr. [**Last Name (STitle) 2168**] as soon as
possible (ideally within the next 1-2 weeks). Please discuss
with him the finding lymph nodes in your chest that are somewhat
larger than seen in your [**10/2102**] chest scan. We will email him
as well.
Please keep the following appointment or call if you need to
change it:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8157**], M.D. Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2103-5-15**] 1:30
Completed by:[**2103-4-16**]
|
[
"995.1",
"V15.82",
"V46.2",
"E928.9",
"V58.61",
"E849.0",
"710.0",
"785.6",
"518.89",
"289.81",
"280.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7250, 7256
|
4020, 6254
|
292, 299
|
7381, 7440
|
2840, 3997
|
9247, 10043
|
2054, 2165
|
6425, 7227
|
7277, 7360
|
6280, 6402
|
7464, 8492
|
2180, 2657
|
2671, 2821
|
8521, 9224
|
237, 254
|
327, 1556
|
1578, 1899
|
1915, 2038
|
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