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14,070
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48791
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Discharge summary
|
report
|
Admission Date: [**2197-10-17**] Discharge Date: [**2197-10-20**]
Date of Birth: [**2140-5-23**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This patient is a 57 year old
gentleman with chronic renal insufficiency secondary to
systemic lupus erythematosus with worsening hypertension,
peripheral edema and proteinuria for the past five months.
The patient was scheduled for an elective renal biopsy. He
underwent a biopsy procedure performed by Dr. [**Last Name (STitle) **] on
[**10-17**]. During the procedure, he had had marginally
elevated blood pressures at 170/100. He had three passes
with a 16 gauge needle with good core biopsies obtained and
he had no immediate complications. This procedure was
performed under ultrasound guidance.
Approximately two hours after the procedure, the patient
developed severe 10 out of 10 back pain at the site of the
biopsy. Blood pressures which had been 110 during the case
were found to be in the 110/60 range. He was unable to void
and a Foley catheter could not be passed initially, but
ultimately this was successfully done. STAT CT scan was
obtained which revealed a large retroperitoneal bleed and the
patient was transferred to the MICU Service.
PAST MEDICAL HISTORY: His past medical history is outlined
as previously:
1. SLE diagnosed in [**2171**].
1. Chronic renal insufficiency.
1. Hypertension.
1. Coronary artery disease status post CABG in [**2187**].
MEDICATIONS:
1. Prednisone 20 mg p.o. q. day.
2. Imuran 50 mg p.o. q. day.
3. Lasix 40 mg p.o. twice a day.
4. Coreg 25 mg p.o. twice a day.
5. Pravachol 300 mg p.o. q. day.
6. Fosamax 70 mg once a week.
7. Aspirin 81 mg p.o. q day which was held for three weeks
prior to procedure.
8. Azathioprine 50 mg p.o. q. day.
ALLERGIES: Sulfa and amoxacillin.
SOCIAL HISTORY: He is married and on disability.
PHYSICAL EXAMINATION: His physical examination on admission
to the MICU is remarkable for temperature of 94.6 F.; heart
rate 57; blood pressure 111/69; respiratory rate 20; 100
percent on room air. He was a well developed, well nourished
gentleman in no acute distress, breathing comfortably,
answering all questions appropriately. HEENT: His
extraocular motions were intact without nystagmus. He had
pale conjunctivae but moist mucous membranes. His neck was
supple without lymphadenopathy. His chest examination was
entirely clear to auscultation and percussion. Cardiac:
Regular rhythm; normal S1 and S2 without appreciable murmurs,
rubs or gallops. Abdomen was soft, nontender, nondistended
with normoactive bowel sounds. His extremities were cool and
his distal pulses were not palpable. Neurologically, he is
oriented to time, person and place. Cranial nerves II
through XII were grossly intact.
LABORATORY DATA: A CBC that was obtained at the start of the
case revealed white blood cell count of 11.7, hematocrit 35.9
and platelets of 208 with an INR of 1.0 and PTT of 20.9. BUN
and creatinine 46 / 1.6.
A STAT hematocrit at 5 p.m. three hours post procedure
revealed that his hematocrit had dropped 6 points to 29 and a
repeat one hour and 15 minutes later revealed his hematocrit
had dropped further to 22.2.
HOSPITAL COURSE BY SYSTEMS:
1. Retroperitoneal bleed secondary to complication of a renal
biopsy: The patient was transferred to the Medical
Intensive Care Unit where he was monitored closely. He
received six units of packed red blood cells with
significant bump in his hematocrit to 43.3 and no evidence
of further bleeding or hemodynamic instability.
Transplant Surgery was made aware immediately of his
presence in the Intensive Care Unit.
1. Coronary artery disease: Despite the hypotension in the
setting of extensive blood loss, the patient did not have
any chest pain or ischemic changes. Beta blockers and
aspirin were held but he was able to be maintained on his
Coreg.
1. Chronic renal insufficiency: The patient did receive N-
acetocytlcystine times three after his dye load was given
for a STAT CT scan to evaluate for the retroperitoneal
bleed. His creatinine held stable. The Renal
consultation team was intimately involved in his care.
The results of his renal biopsy suggested a diffuse
proliferative glomerular nephritis and his Imuran was
discontinued. He was started on CellCept and his
prednisone was increased. Ultimately, he was able to be
transferred to the floor where he was watched for one day
further and his hematocrit remained stable.
He was discharged to home on following medications.
DISCHARGE MEDICATIONS:
1. Prednisone 40 mg p.o. q. day.
2. CellCept [**Pager number **] mg p.o. twice a day.
3. Carvedilol 12.5 mg, two tablets twice a day.
4. Amlodipine 10 mg a day.
5. Lasix 40 mg twice a day.
6. Epogen.
7. Protonix 40 p.o. q. day.
8. Oxycodone 5 p.r.n.
9. Tylenol p.r.n.
10. Pravastatin 20 q. day.
11. Folic acid one q. day.
CONDITION ON DISCHARGE: His condition on discharge is
stable.
DISPOSITION: To home.
DISCHARGE DIAGNOSES:
1. Retroperitoneal bleed secondary to renal biopsy.
1. Diffuse proliferative glomerular nephritis.
FOLLOW UP: To followup with his renal attending, Dr. [**Last Name (STitle) **],
in two weeks. Additionally in the interval week he will have
a repeat CBC obtained and the results will be faxed to Dr.
[**Last Name (STitle) **] at [**Telephone/Fax (1) 434**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5704**], [**MD Number(1) 5705**]
Dictated By:[**Last Name (NamePattern4) 102534**]
MEDQUIST36
D: [**2198-5-18**] 18:05:02
T: [**2198-5-18**] 19:19:51
Job#: [**Job Number 102535**]
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4,556
| 137,689
|
6362
|
Discharge summary
|
report
|
Admission Date: [**2174-3-3**] Discharge Date: [**2174-3-8**]
Date of Birth: [**2100-2-3**] Sex: M
Service: Neuro.[**Last Name (un) **].
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
gentleman status post an MVA, was the restrained driver that
hit a tree and was thrown on top of the passenger, hitting
his head on the windshield. He was responsive at the scene
and then became less responsive. He was sent to [**Hospital6 **], supposedly unarousable, only arousable
to sternal rub with GCS of [**3-18**] there. A head CT was done, C
spine, and torso CT were done, and the patient was then
transferred to [**Hospital1 69**].
PHYSICAL EXAMINATION: On exam, his temperature was 99.9,
blood pressure 172/81, heart rate 62-103. Saturation 100% on
two liters. In general, the patient was lying in bed,
intubated. Neurologically, eyes were closed, but opened
easily to voice. Shows two fingers and squeezed on the left
hand. Wiggled toes to command. Pupils 2.2 mm down to 1.5
bilaterally. EOM's full. Positive corneals. Blinks to
threat, right side greater than left. Localizes briskly to
stimulation on the left side, withdraws less briskly to
stimulation of the right arm and leg. Deep tendon reflexes
2+ at the biceps, triceps, brachial radialis, patella, and
Achilles.
LABORATORY/DIAGNOSTICS: On admission, white count 6.4,
hematocrit 46.8, platelets 164. Sodium 142, K 3.4, 104/24,
21/1.2, and 130. His gas was 7.52, 30, 92.
The patient had a CT of the C spine which just showed
degenerative disc disease.
Head CT showed a left-sided frontal subdural hematoma at the
convexity with 7 mm of midline shift.
CT of the torso was preliminarily negative.
HOSPITAL COURSE: The patient was seen by Dr. [**Last Name (STitle) 739**]
who felt the patient would require emergent evacuation of the
left subdural hematoma. He was, therefore, taken to the OR
and underwent a left frontal craniotomy for excision of the
subdural hematoma without intraoperative complication.
Postoperatively, the patient was monitored in the ICU for
close neurologic observation. The vital signs were stable.
He was afebrile. His pupils were 1 mm and reactive
bilaterally, moving all extremities, and responds to pain -
left greater than right. His right lower extremity toes were
upgoing and he withdrew his lower extremities to pain. The
left lower extremity was downgoing. His incision was clean,
dry, and intact. He had a JP drain in which drained 60 cc of
bloody fluid.
On postoperative day number one, the patient was extubated.
Continued to follow commands and speech was clear once
extubated. A repeat head CT showed good evacuation of the
subdural hematoma. The patient remained neurologically
stable and was transferred to the regular floor on [**2174-3-6**].
He has remained neurologically stable, awake, alert, oriented
times three, moving all extremities with good strength. He
was cleared by physical therapy for discharge home. He will
follow-up with Dr. [**Last Name (STitle) 739**] in one month with a repeat
head CT. He will follow-up with his primary care doctor this
week for a blood pressure check and glucose check. His
glucose checks, here at the hospital, have been anywhere from
100-195, receiving two units of subcutaneous insulin on two
occasions. His blood pressure medications, metoprolol 25 mg
PO b.i.d., amlodipine 5 mg PO q day, and Dilantin for one day
- 100 mg PO t.i.d.
CONDITION ON DISCHARGE: His condition was stable at the time
of discharge.
[**Name6 (MD) 742**] [**Name8 (MD) **], M.D.
[**MD Number(1) 743**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2174-3-8**] 11:12
T: [**2174-3-8**] 11:19
JOB#: [**Job Number 24619**]
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|
685, 1705
|
187, 662
|
3470, 3765
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,039
| 111,084
|
19201
|
Discharge summary
|
report
|
Admission Date: [**2109-3-6**] Discharge Date: [**2109-3-20**]
Date of Birth: [**2046-12-21**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 62 year old male with
multiple medical problems including tracheobronchial malacia
status post tracheoplasty in [**2108-5-29**] and then status
post tracheostomy on [**2108-12-18**] complicated by
aspiration and pulmonary problems most likely due to his non-
surgical neurologic issues. His last pneumonia was two weeks
ago. He has no complaints of chest pain, shortness of breath,
but has been complaining of persistent abdominal pain with
nausea requiring Compazine and occasional extreme pain
requiring morphine sulfate, no fevers, chills, nausea or
vomiting, diarrhea, constipation or other stool changes.
PAST MEDICAL HISTORY: Significant for COPD, asthma,
aspiration pneumonia, coronary artery disease status post
distant MI, diabetes mellitus, peripheral neuropathy,
tracheobronchial malacia, hypertension, increased
cholesterol, gastroesophageal reflux disease.
MEDICATIONS: He takes Compazine, morphine sulfate, insulin,
aspirin, Lipitor, Atrovent, simethicone, guaifenesin.
PHYSICAL EXAMINATION: On admission, temperature was 98.4
degrees, heart rate 94, blood pressure 102/56, respiratory
rate 18, 100 percent on 2 liters nasal cannula oxygen. The
trach is noted to be in place with a Passy-Muir valve. Neck
is supple. Heart rate was in regular rate and rhythm.
Bilaterally, there were rales with a few scattered wheezes.
Abdomen was nondistended with a G-tube in place with some
signs of tympany. Abdomen revealed well healed incision
sites.
HOSPITAL COURSE: Thus, at this time, the patient was
admitted for further evaluation and treatment at [**Hospital1 346**]. He was to be preoperatively
prepared for a [**Hospital1 **] fundoplication and colostomy take-down.
The patient was appropriately preoperatively prepared with a
GoLYTYELY prep. He was given intravenous antibiotics. Beta
blockers were given and an EKG was performed which showed no
significant changes as well as a chest x-ray which also
showed no significant changes. The patient was typed and
screened and consent was signed for the procedure. On [**2109-3-7**], the patient proceeded to the Operating Room without
incident and underwent the following procedure. An
exploratory laparotomy was performed with lysis of adhesions.
An open [**Year (4 digits) **] fundoplication was performed. A colocolostomy
was performed times two and a colostomy take-down as well.
The patient received general anesthesia and also received an
epidural at this time. The patient received 2 units of packed
red blood cells in the Operating Room and a 14-French
jejunostomy tube was also placed during this time for feeding
purposes in the background of his recurrent aspiration. The
patient was brought to the Post-Anesthesia Care Unit shortly
thereafter and was noted to be hypotensive at this time with
blood pressures into the 80s/40s. This was noted likely to be
secondary to epidural that was bolused in the Operating Room.
He received Neo-Synephrine in the Post-Anesthesia Care Unit
and was given albuterol nebulizer treatments and when the
blood pressure rose appropriately, the Neo-Synephrine drip
was stopped and esmolol was given to control tachycardia. A
chest x-ray was done which showed no evidence of pneumothorax
at this time. Also, of note, the patient's temperature was to
103 degrees F. The patient remained on the ventilator during
this time as he was retaining some carbon dioxide still.
Also, at this time, a central venous line had been placed and
this was checked for position on chest x-ray and adjusted
appropriately. The patient was brought to the Trauma
Intensive Care Unit at this time and received 3 liters of IV
fluids bolused and was started on a Dilaudid patient
controlled analgesia device. Also, at this time, the epidural
was stopped. On postoperative day #2, the patient was again
noted to be febrile. However, he was able to be weaned to a
tracheostomy mask and he was also started on a clear diet at
this time without difficulty. He was also started on TPN at
this time. Also of note, the patient was continually followed
by Acute Pain Service during is inpatient stay who made
frequent recommendations in regards to his care and on
postoperative day #4, the patient was able to be sent to the
floor from the Intensive Care Unit. He did complain at this
time of brief chest tightness that was nonradiating without
diaphoresis or shortness of breath. An EKG was done that was
normal. Nitroglycerin was given sublingually one time with
some improvement. Enzymes were ordered to be cycled. They
were all found to be negative and to show no significant rise
that would be indicative of myocardial damage. The patient
continued to progress on the floor. The patient was also
followed by Thoracic Service during his time as an inpatient
as the patient was familiar to Dr. [**Last Name (STitle) 952**]. The patient was
then seen by Physical Therapy on postoperative day #4 to
improve his activity. The patient at times was recalcitrant
to instructions to getting out of bed. Attitude was described
as lack luster. However, this began to improve during his
hospital stay as he slowly increased his activity with the
encouragement of the Surgical Team and the physical
therapists. The patient was also placed on antibiotics
levofloxacin, cephazolin and vancomycin on [**3-12**],
postoperative day #5, for a culture that came back growing
Pseudomonas. On [**3-15**], postoperative day #8, a VAC
dressing was started on his midline abdominal wound. This
required only a very small strip of VAC sponge. The patient
tolerated the procedure well. Also of note during his stay on
postoperative day #12, the patient was seen again by the
Acute Pain Service that suggested an increase of methadone to
10 mg p.o. t.i.d., start Topamax 25 mg p.o. q.h.s., for
neuropathic pain, to continue Tylenol, to start ibuprofen 400
mg q.6h. and to continue Dilaudid 4 mg p.o. q.4h. as needed
for pain. These recommendations were followed. The case was
discussed again at length with the Acute Pain Service and the
VAC dressing was replaced again on the day of discharged,
[**2109-3-20**], by Dr. [**First Name (STitle) **] and the appropriate paperwork
was completed for discharge to a rehabilitation facility.
DISCHARGE INSTRUCTIONS: The patient is to be discharged to a
rehabilitation facility and to receive aggressive physical
therapy and to receive VAC dressing changes every three days.
The patient is to continue to receive tube feeds as he has
been while in the hospital. These instructions are to
accompany the rest of his paperwork.
FINAL DIAGNOSIS: Chronic obstructive pulmonary disease,
asthma, hypertension, hypercholesterolemia, diabetes
mellitus, peripheral neuropathy, gastroesophageal reflux
disease, recurrent pneumonia, tracheobronchial malacia,
tracheoplasty, tracheostomy, colostomy, Clostridium
difficile, methicillin-resistant staph aureus.
RECOMMENDED FOLLOW-UP: The patient is to follow up with Dr.
[**Last Name (STitle) 952**] in [**12-30**] weeks at [**Telephone/Fax (1) 52342**]. The patient is to follow
up with Dr. [**First Name (STitle) 2819**] in [**10-11**] days at [**Telephone/Fax (1) 2998**].
DISCHARGE MEDICATIONS: Ipratropium bromide 18 mcg aerosol
two puffs inhaled q.i.d., guaifenesin [**5-7**] ml p.o. q.6h. as
needed, ipratropium bromide 0.02% solution, one inhalation
q.6h. as needed, insulin Regular human as directed, heparin
sodium porcine 5000 units b.i.d., metoprolol 100 mg b.i.d.,
famotidine 20 mg b.i.d., acetaminophen 1000 mg t.i.d.,
atorvastatin calcium 20 mg daily, miconazole nitrate powder
to be applied to the J-tube site t.i.d., hydromorphone 4 mg
p.o. q.4h. as needed for pain, topiramate 25 mg p.o. q.h.s.,
methadone 10 mg p.o. t.i.d., vancomycin 1 g q.12h for 6 days,
metronidazole 500 mg q.8h. for six days, ceftazidime 2 g
q.8h. for 6 days.
DISPOSITION: The patient will be discharged to
rehabilitation facility.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 18475**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2109-3-20**] 11:30:35
T: [**2109-3-20**] 12:50:43
Job#: [**Job Number **]
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29,233
| 130,835
|
31294
|
Discharge summary
|
report
|
Admission Date: [**2145-6-23**] Discharge Date: [**2145-7-10**]
Date of Birth: [**2072-9-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Pancreatic head mass
Obstructive Jaundice
Major Surgical or Invasive Procedure:
Whipple Procedure
Laparoscopic Staging with intraoperative ultrasound
History of Present Illness:
This very healthy 72-year-old gentleman presented to [**Hospital3 **]
Hospital recently with a number of weeks of progressive
relatively painless jaundice.
He initially presented to [**Hospital3 **] hospital on [**6-21**] with
obstructive jaundice X 10 days. He has had intermittent episodes
of painless jaundice for the last 20 yrs, always resolving after
a few days; he never sought evaluation for these, as they
resolved after a few days. In [**Month (only) 547**], he had an episode in
[**State 108**], at which time he had severe diffuse abdominal pain. The
abdominal pain resolved after ~ 1 hour and his jaundice went
away a few days after that. He has not had abdominal pain since
that time. His jaundice recurred at the beginning of [**Month (only) **]. He
had a CT of his abdomen [**6-16**], which showed intra and
extrahepatic biliary dilitation, pancreatic duct dilation. It
also noted a cystic uncinate process mass and low attenuation in
the pancreatic head.
He underwent a MRCP which showed high grade biliary obstruction
with a fluid multilobulated lesion in the pancreatic head. He
underwent a repeat ERCP on [**6-22**], with extension of prior
sphincterotomy, however, again the biliary duct could not be
cannulatedHe was worked up with an ERCP which included a
pancreatogram which showed a pancreatic ductal stricture.
However, technical problems, due to a periduodenal diverticulum
prevented a cholangiogram from being achieved. During this
procedure, bleeding was incurred at the site and the patient was
transferred to our institution for further management. Follow-up
ERCP showed evidence of huge clot in this diverticulum and at
the ampullary region and there was no possible way to perform
another interrogation of the bile duct. The patient then had a
significant GI bleed from this and was found to be extravasating
from this area. An interventional radiology technique took place
and was able to embolize the bleeding pancreaticoduodenal arcade
vessels. Once this was under control, we then sought to figure
out why he was suffering from a well developed progressive deep
jaundice from biliary obstruction. His bilirubin was in the 20
range.
I performed a number of measures in the days preceding this
operation including a CT scan with an angiogram, MRI scan and an
endoscopic ultrasound test. These were all equivocal in
demonstrating a suspected tumor mass. However, they did show
stricturing of the bile duct and in some cases, hyperenhancing
tissue within the bile duct. There was still some concern that
this was a benign process like stone disease but, for the most
part, the evidence weighed towards
a malignant process in that both the ducts were strictured. We
also did a CA19-9 level which was over 2100 and his deep
standing high bilirubin of 20 weighed against stone disease,
particularly in the fact that he had no stones in his
gallbladder or bile duct on ultrasound.
Past Medical History:
HTN, atherosclerosis, Gout, Recurrent jaundice, Hypothyroidism
Social History:
Lives in [**Location 4979**] with his wife. [**Name (NI) **] in [**State 108**]. 7
grandchildren. Retired.
Wife has severe osteoporosis and chronic pain issues.
No alcohol use. No tobacco or IVDU.
Family History:
Noncontributory
Physical Exam:
Afebrile, AVSS. A+O x 3
CV: RRR
Chest: lungs clear bilat.
Abd: +BS, NT, ND
Pertinent Results:
[**2145-6-23**] 10:15AM BLOOD WBC-5.2 RBC-3.91* Hgb-13.0* Hct-36.5*
MCV-93 MCH-33.2* MCHC-35.6* RDW-16.6* Plt Ct-286
[**2145-6-25**] 04:00AM BLOOD WBC-4.8 RBC-2.20*# Hgb-7.1*# Hct-21.3*#
MCV-97 MCH-32.4* MCHC-33.5 RDW-17.2* Plt Ct-267
[**2145-6-26**] 05:43AM BLOOD WBC-6.2 RBC-3.35* Hgb-10.5* Hct-28.7*
MCV-86 MCH-31.3 MCHC-36.5* RDW-16.9* Plt Ct-216
[**2145-7-4**] 11:15AM BLOOD WBC-10.3 RBC-2.95* Hgb-9.5* Hct-28.6*
MCV-97 MCH-32.1* MCHC-33.1 RDW-15.8* Plt Ct-441*
[**2145-7-4**] 01:15AM BLOOD Glucose-153* UreaN-26* Creat-1.3* Na-140
K-3.7 Cl-104 HCO3-25 AnGap-15
[**2145-6-24**] 06:55AM BLOOD ALT-290* AST-145* AlkPhos-531*
TotBili-21.7*
[**2145-7-4**] 01:15AM BLOOD ALT-84* AST-60* AlkPhos-212* Amylase-20
TotBili-18.3*
[**2145-6-23**] 10:15AM BLOOD Lipase-150*
[**2145-7-4**] 01:15AM BLOOD Lipase-25
[**2145-7-4**] 01:15AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.9*
.
[**Numeric Identifier 73810**] TRANCATHETER EMBOLIZATION [**2145-6-25**] 8:41 AM
[**Hospital 93**] MEDICAL CONDITION:
72 year old man with acute bleeding at site of pre-cut
sphincterotomy (ampulla). Now has melena, BP was 60 now 90 after
3 units. Getting FFP for INR of 1.6, platelets normal. Needs
angiography.
IMPRESSION: Successful embolization of pancreaticoduodenal
branches supplying the abnormal focus in the periampullary / mid
descending duodenum, as above.
.
CTA ABD W&W/O C & RECONS [**2145-6-26**] 12:46 PM
IMPRESSION:
1. Marked intrahepatic and central bililary ductal dilatation
without pancreatic ductal dilatatation and without a definite
pancreatic mass. Subtle differential enhancement in the region
of the abrupt caliber change of the CBD may be further evaluated
with endoscopic ultrasound or repeat ERCP.
2. Outpouching adjacent to medial duodenum likely representing
diverticulum, however given reported history, cannot exclude
small contained duodenal perforation.
3. Proximal ascending aortic aneurysmal dilation, up to 5.1 cm
in diameter.
4. Splenic infarcts.
.
MRCP (MR ABD W&W/OC) [**2145-6-28**] 9:15 PM
IMPRESSION:
1. Marked intra and extrahepatic biliary ductal dilatation.
While no filling defects are demonstrated in the visible portion
of the duct, the distal duct, including the portion at the
ampulla, are obscured by susceptibility artifact and therefore
cannot be evaluated.
2. Minimal dilation of the pancreatic duct at the head and neck,
with a cluster of cysts in the pancreatic head.
3. Hepatic cysts.
4. Bilateral renal cysts.
5. Gallstones.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2145-6-28**] 10:04 AM
IMPRESSION:
1. Marked intrahepatic biliary ductal dilatation, without focal
lesions seen.
2. Dilated gallbladder without stones.
3. A 13 mm simple cyst.
.
ECHO Study Date of [**2145-6-28**]
Conclusions:
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best
excluded by transesophageal echocardiography). There is mild
symmetric left
ventricular hypertrophy with normal cavity size and systolic
function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion
abnormality cannot be fully excluded. Right ventricular chamber
size and free
wall motion are normal. The aortic root is moderately dilated at
the sinus
level. The ascending aorta is moderately dilated. The aortic
arch is mildly
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 structurally normal. There is no mitral valve
prolapse.
Mild to moderate ([**1-5**]+) mitral regurgitation is seen. There is
mild pulmonary
artery systolic hypertension.
IMPRESSION: Mild symmetric left ventricuclar hypertrophy with
normal cavity
size and preserved global biventricular systolic function.
Dilated thoracic
aorta. Mild aortic regurgitation. Mild-moderate mitral
regurgitation.
These findings are c/w hypertensive heart.
CLINICAL IMPLICATIONS:
Based on [**2145**] 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:
He was transferred to [**Hospital1 18**] for a repeat ERCP, which he
underwent [**6-23**]. This revealed fresh clot in the duodenum with
oozing at the major papilla. Epinephrine was applied to the site
with successful hemostasis. He is now being transferrred to the
general medical service for further management. He notes 3
episodes of maroon stool today (small amount). No abdominal
pain, nausea, vomiting. (+) diffuse pururitis. No fevers, chills
1) Obstructive jaundice: s/p 3 failed ERCPs
- concern for possible pancreatic neoplasm given uncinate
cyst/heterogeneous pancreatic head
CEA was 1.3 and CA [**57**]-9 was 2123
.
2) Rectal bleeding: suspect this is secondary to bleeding from
sphincterotomy site, as visualized on [**6-23**] endoscopy (s/p epi).
He received 7 U of prbc, 2 u ffp.
Went into a-fib with RVR, started on dilt gtt, now off and was
converted to NSR with diltiazem
.
3) HTN: continue lisinopril; hold atenolol for now
.
4) Gout: continue allopurinol
.
5) Hypothyroidism: continue levothyroxine
.
6) F/E/N: clear liquids for now, NPO after MN
.
7) Ppx: pneumoboots
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
================================================================
Surgery was then consulted and a CTA was ordered on [**6-26**] showing
- marked intrahepatic biliary ductal dilatation; 1.5 cm cystic
structure in left hepatic lobe, adjacent to the middle hepatic
vein branch; marked dilatation of the central bile duct and
cystic ducts with abrupt narrowing just proximal to the level of
the ampulla; no pancreatic ductal dilatation; no obstructing
mass in pancreas; small, cystic mass in the uncinate process;
pancreas is normal, without peripancreatic inflammatory changes.
[**6-28**] RUQ US - Marked intrahepatic biliary ductal dilatation,
without focal lesions seen. Dilated gallbladder s stones. A 13
mm simple cyst.
[**6-28**] EUS - Dilated bile duct with hyperechoic intrinsic lesion -
stone versus cholangiocarcinoma.
On [**6-29**] he went to the OR for a Whipple procedure.
Post-operatively he followed the Whipple pathway.
Post-op Hypotension. He had a BP of 82/50 in the PACU on POD 0.
He received a post-op fluid bolus and responded well.
Post-op Hyperglycemia: He initially had some elevated blood
sugars. This was treated with an Insulin sliding scale.
GI/Abd: He was NPO with IVF and a NGT. Per the pathway, his NGT
was removed on POD 3 and his diet was slowly advanced over the
next few days.
His incision was C,D,I with no redness or signs of infection. A
JP amylase was tested on POD 6 and this was 3800. The drain was
removed on the evening of POD 7 because it was a low output
leak. Shortly thereafter he began developing intense abdominal
pain and exhibited peritoneal signs in the RLQ. A CT was
obtained the next morning and showed a large perianastomotic
fluid collection,
and additional marked stranding and fluid within the
right lower quadrant.
He continued to have pain to the RLQ. Another CT was obtained on
[**7-8**] and showed stable appearing collection and clinically his
pain improved and VS continued to be stable. We decided to watch
and wait and allow his body to absorb this fluid. He continued
to improve without incident and was tolerating a regular diet.
The staples on his incision were removed prior to discharge.
Pain: He was started on an epidural for pain control. He was
then switched to a PCA and eventually PO narcotics for pain
control.
Post-op Shortness of Breath: He complainded of SOB on POD 4. An
EKG and CXR were negative. He was slightly fluid overloaded with
crackels at the bases. He received IV Lasix with good effect and
relief of his SOB. He received an additional 10mg IV Lasix on
POD 5 with good diuresis. He continued to have +2 LE edema. He
received 20 mg IV Lasix on POD 7.
Pathology: Adenocarcinoma, pT3 - no lymph node involvment,
Margins uninvolved by invasive carcinoma.
Medications on Admission:
Atenolol 50mg daily
Lisinopril 20mg daily
Levothyroxine 112mcg daily
Zocor
HCTZ
Allopurinol
ASA 325 mg daily
Discharge Medications:
1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO q4H PRN as needed
for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Pancreatic Head Mass
CBD obstruction
Atrial Fibrilation
GI Bleed s/p ERCP (sphinctorotomy site)
Post-op Shortness of Breath
Pancreatic Leak
Abdominal Pain
Discharge Condition:
Good
Tolerating Diet
Pain well controlled.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
Please resume all regular home medications and take any new meds
as ordered.
.
Continue to amubulate several times per day.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**]
Date/Time:[**2145-7-23**] 9:45
Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks.
Completed by:[**2145-7-10**]
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23,049
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18822
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Discharge summary
|
report
|
Admission Date: [**2149-11-20**] Discharge Date: [**2149-11-24**]
Service: MED
HISTORY OF PRESENT ILLNESS: An 82-year-old male with a past
medial history significant for CAD status post 4-vessel CABG
in [**2147-8-25**], question of sick-sinus syndrome, history
of PAF, not anticoagulated, question of renal insufficiency,
who presented to the ED with 5 to 6 melenic stools. The
patient was in his usual state of health until 6 days ago
when he developed diarrhea.
He underwent colonoscopy on [**11-10**] days prior to admission
as part of a work up for diarrhea. Findings included a single
sessile 2.5 cm polyp, 2 small 2 to 3 mm sessile benign
appearing polyps and several small mild diverticula. He had
been off aspirin therapy for colonoscopy and just restarted
aspirin 3 days prior to admission. Polypectomy was performed
and the polyps were completely removed. Path showed no
invasive carcinoma and the procedure was performed without
complication. Diarrhea resolved several days prior to
admission which the patient attributes to starting taking
acidophilus.
On the morning of admission the patient was in his usual
state of health and had an outpatient abdominal CT scan at
[**Hospital3 **] Hospital to evaluate "kidney cysts" per his
reports. He reports that after drinking PO contrast he had an
episode of bright red blood noted on the toilet tissue
followed by 6 melenic bowel movements. He denies recent
heartburn, abdominal pain, rectal pain, nausea, vomiting,
chest pain, shortness of breath. No recent NSAID use. He
reports brief episode of lightheadedness upon standing while
in the emergency room.
In the ED he had a temperature of 96.5, heart rate of 83,
blood pressure 128/58, respiratory rate of 18 with an oxygen
saturation of 100% on room air. Orthostatics in the ER showed
lying heart rate of 56, BP of 119/60, and standing heart rate
of 76 and blood pressure of 56/36 with lightheadedness on
standing, however notably he later was able to stand and walk
to te bathroom without any lightheadedness. He received
Protonix 40 mg IV x1, 1 liter of normal saline x1. NG lavage
was performed yielding less than 10 cc of bright red blood.
The patient refused RBC scan. While in the ED he reported 5
to 6 episodes of black stools with an episode of bright red
blood per rectum in the ER of 200 cc. Given the question of
GI bleed and severe orthostasis, he was admitted to the MICU.
GI was consulted and recommended bleeding scan if bleeding
continues.
PAST MEDICAL HISTORY:
1. History of gastritis, colitis diagnosed by EGD and
colonoscopy 20 years ago in [**Country 532**] but no recent
heartburn.
2. History of syncope. Negative EKG and Holter in [**2147**].
Negative Holter in [**2149**]. Thought to be vagal in origin.
3. History of paroxysmal atrial fibrillation postop '[**47**],
again [**2148-9-25**]. Originally treated with
amiodarone, discharged from [**Hospital1 18**] in [**2148-9-25**] on
Coumadin. Echo [**2149-9-25**] showed no PAF or flutter
but did reveal underlying sinus bradycardia with
intermittent PR prolongation, left atrial abnormality, no
significant AV block or prolonged pauses, moderate atrial
ectopy, low grade ventricular ectopy.
4. Question of sick sinus syndrome. Autonomic testing [**6-9**], [**2149**] with evidence of parasympathetic nervous system
dysfunction on Valsalva and heart rate variability
testing. Possible junctional tachybradycardia, tachy-
brady sick sinus. Normal tilt table testing, so not
indicative of orthostatic hypotension.
5. CAD status post silent MI. CABG x4 in [**2147-8-25**]. No
complications. Percutaneous PTCA. Echo [**2147**], EF of 50 to
55%. Mild mitral regurgitation.
6. Cervical spondylosis. MR cervical spine [**2149-5-25**].
7. Liver hemangioma, ultrasound and CT [**2148-2-25**].
8. Chronic renal insufficiency. Baseline creatinine 1.2 to
1.5. Small left kidney. History of nephrolithiasis since
[**2130**], last symptomatic stone [**2132**].
9. Hyperlipidemia.
10. Glaucoma. Left cataract surgery.
11. MRI showing lacunar infarcts.
12. Essential tremor.
13. Prostate adenoma resection.
14. Removal of toes on left foot from frost bite.
HOME MEDICATIONS:
1. Neurontin 300 mg PO t.i.d.
2. Aspirin 81 mg PO once daily.
3. Lipitor 10 mg PO once daily.
4. Atenolol 100 mg PO once daily.
5. Metamucil QID.
6. Xalatan eye drops.
7. Cosopt eye drops.
ALLERGIES: Novocain and sulfa causes rash.
SOCIAL HISTORY: The patient denies tobacco. He drinks
socially. Immigrant from [**Country 532**]. Married and lives with wife
in [**Name (NI) 745**]. Formally a physics researcher.
FAMILY HISTORY: Mother died of coronary artery disease,
father of [**Name2 (NI) 51531**], sister has asthma.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature of 97.5,
heart rate 67, blood pressure 124/71, respiratory rate 15,
97% on room air. GENERAL: Awake, alert, and in no apparent
distress lying comfortably in bed. Does not appear pale.
HEENT: Normocephalic, atraumatic. Oropharynx clear. Mucous
membranes moist. Right eye surgical. Neck supple. No masses.
No thyromegaly. JVP about 5 cm. CV: Regular and normal S1 and
S2; [**3-2**] holosystolic murmur at apex. PULMONARY: Clear to
auscultation bilaterally. BACK: No CVA tenderness. ABDOMEN:
Hyperactive bowel sounds. Nontender. Nondistended. Liver span
5 cm in the mid clavicular line. EXTREMITIES: Warm and well
perfused. No clubbing, cyanosis or edema. Radial pulse 1+, DP
1+. SKIN: Normal turgor. No masses. NEUROLOGIC: Alert and
oriented x3, nonfocal.
LABORATORY DATA: Notable for hematocrit of initially 48 and
then on recheck 36 dropping to 33 in the emergency room. INR
1.4. Chemistry is notable for creatinine of 1.0. Iron indices
show iron level of 141, ferritin of 41, TIBC of 244.
ASSESSMENT: An 82-year-old male with a past medial history
significant for CAD status post 4-vessel CABG, question of
sick-sinus syndrome, history of atrial fibrillation, not
anticoagulated, syncope, cervical spondylosis, liver
hemangioma, and chronic renal insufficiency who presents with
lower GI bleed and orthostasis.
PROBLEM: GI bleed. The patient was initially admitted to the
ICU. Two large bore IVs were placed. The patient was placed
on nothing by mouth. Started on Protonix 40 mg IV b.i.d. His
aspirin and Lopressor were held. Serial hematocrits were
obtained. Vitamin K was given to reverse his slightly
elevated INR. The patient was evaluated by gastroenterology
and he had a colonoscopy. The patient had BiCAP of the
polypectomy site. His hematocrit was stable after his
colonoscopy. Aspirin was held for 14 days post his
colonoscopy. He was called back to the floor. His hematocrit
remained stable 2 days after his procedure.
CONDITION ON DISCHARGE: Stable. Hematocrit 34.
DISCHARGE MEDICATIONS: The patient was discharged on:
1. Lipitor 10 mg PO once daily.
2. His eye drops.
3. His Neurontin 300 mg PO t.i.d.
4. Protonix 40 mg PO once daily.
5. Aspirin was to be held for 14 days post discharge.
PLAN: The patient will follow up with his primary care
physician [**Name Initial (PRE) 176**] 1 week.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 6648**]
Dictated By:[**Last Name (NamePattern1) 19183**]
MEDQUIST36
D: [**2150-2-19**] 09:49:32
T: [**2150-2-19**] 10:41:30
Job#: [**Job Number 51532**]
|
[
"414.00",
"272.4",
"V45.81",
"562.10",
"276.52",
"V49.72",
"285.1",
"780.2",
"458.9",
"427.31",
"585.9",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.43"
] |
icd9pcs
|
[
[
[]
]
] |
4684, 4778
|
6836, 7384
|
4242, 4484
|
4801, 6763
|
120, 2483
|
2505, 4224
|
4501, 4667
|
6788, 6812
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,371
| 174,658
|
32345
|
Discharge summary
|
report
|
Admission Date: [**2152-9-21**] Discharge Date: [**2152-10-5**]
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Penicillins
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
ischemic left leg
Major Surgical or Invasive Procedure:
angiogram with Tpa of PT artery [**2152-9-22**]
History of Present Illness:
Onset ofleft toe pain seven days prior to admission with known
pvd s/p bilaterl lower extremity bpg's ( left fem-PT with issvg)
with increasing leg and thigh pain 24hrs prior to admission.
Evaluated at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ER , no dopperable pulses left leg. IV
bolus heparin given and patient transfered to [**Hospital1 8482**] for further
evaluation.
Past Medical History:
history of dyslipdemia
histroy of CAD,3Vessel disease by cardiac cath with Aortic valve
stenosis
history of hyponatremia
histroy of ESRD [**1-22**] DM on hemodialysis (Tu,[**Last Name (un) **],Sat)
hisory of anemia of chronic disease
history of chronic systolic CHF,compensated
history of gout,asymptomatic
history of degenerative arthritis
histroy of lumbar disc disease s/p laminectomy
histroy of depression
histroy of DVT ? Lower extremity
history of polymyalgia rheumatica
histroy of nephrolithiasis
history of BPh
history of recurrent UTi
histroy of carotid disease [**Doctor First Name 3098**] <40%,[**Country **] nl
histroy of lucnar infract
histroy of left menisectomy
histroy of left inguinal herinaorrphy
Social History:
nursing home resident
former tobacco and ETOH abuser
Family History:
unknown
Physical Exam:
Gen: no acute distress, dementied
Lungs: CTA
Heart: RRR
ABD:bengin
EXT: Left cold from foot to knee with blue toes. poor capillary
refill. necrotic toe tips. Rt. Ext warm
pulse exam: palpable femorals bilateral.left DP monophasic graft
palpable at knee.rt. DP and Pt dopperable graft palpable.
Neuro: Ox1, nonfocal
Brief Hospital Course:
[**2152-9-22**] IV heparin. remained NPO for angio. Renal consulted for
hemodialysis needs.
angiogram with TPA of left Pt.IV heparin.
[**2152-9-23**] Found unresponsive on Am rounds.T max 100(ax) B/p 97/45
fasting glucose 66. IV dextros 50% administered 40% fase mask
applied with improvement in oxygenation. EKG no acute changes.
abg's obtained. Transfered to ICU.CVVHF began.CT head negative.
requiring Neo gtt.intubated for airway protection.
[**Date range (1) 75561**] remained in ICU.Neuro consulted for ? seizure
activity.Recommendations EEG r/o seizure disorde,MRI?MRA r/o
stroke, LP if febrile to r/o encephlitis( less likely given
clinical picture),continue ativan gtt. toxic-metabolic
encephlopathy secondary to lack of hemodialysis and azotrenam.
Inital and repeat EEG's did notdemonstrate any seizure activity
but did demonstrate severe encophalopathy.Ultrasounds of
carotids demonstrated bilateral < 40% internal carotid
stenosis.MRI of head and neck demonstrated no intracrainal mass
or hemorrhage. patent rt. carotid without disease but < 40% ICA
diseae on left.Dilantin gtt began.[**2152-9-27**] tunnel catheter
placed. Neo weaned. Remained on insulin gtt.Mental staus slowly
improving.[**9-29**] epo began at HD.Tube feed began.[**9-30**] labetolol
gtt for SBP HTN.[**10-1**] Family meeting made DNR.[**10-2**] labetolol
ggt weaned. Extubated .[**10-3**] Patient made CMO and transfered to
regular nursing floor for continued care.
[**2152-10-4**] Lost bed at nursing home awaiting new bed. CMO
continued. Rehab screen restarted
[**2152-10-5**] discharged for hospice care.
Medications on Admission:
imdur 30mgm daily
colace 100mgm [**Hospital1 **]
ducolax supp prn
minocycline 100mgm [**Hospital1 **]
gabapentin 100mgm [**Hospital1 **]
levothryoxine 50mcg daily
nepro caps daily
vitamin c
folic acid
lopressor 12.5mgm [**Hospital1 **]
pholso
asa 325mgm daily
lantus 6 units @ HS humalog sliding scale
simvistatin 80mg HS
clexa 10mgm HS
seroquel 12.5mgm q6h prn
regland prn
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
2. Morphine 2 mg/mL Syringe Sig: [**12-22**] ml Injection Q2H (every 2
hours) as needed.
3. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: [**1-24**] ml Injection
Q8H (every 8 hours) as needed.
4. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Health of [**Hospital3 **] - [**Location (un) 32944**]
Discharge Diagnosis:
Ischemic left lower extremity pain
history of PVD s/p left fem-Pt bpg ISSVG
history of dementia
history of Dm2
histroyof hyperlipdemia
historyof coronary artery diseae 3 vessel by cardiac cath
history of aortic valve stenosis
history of hyponatremia
histroyof ESRD on hemodialysis
historyof chroinc anemia
histroyof chronic systolic congestive heart faillure,
compensated
history of gout
history of degenerative arthritis
history of DVT lower extermity
history of depression
history of polymyalgia rheumatica
historoy of nephrolithiasis
history of BPH,recurrent UTI's
history of lacunar infract with known carotid artery stenosis
history of disc disease,s/p lumbar laminectomy and discectomy
history of left menesectomy
history of right HD cath
history of inguinal hernia s/p repair left
histroy of perpheral vascualr disease s/p rt. sfa-dp bpg with
reversed GSV, complicated by wound infection s/p STSG, s/p left
fem-pt bpg ISSVG
Discharge Condition:
hemodynamically stable
Discharge Instructions:
followup as needed
Patient is DNR/DNI. Comfort measures only
Followup Instructions:
none
Completed by:[**2152-10-5**]
|
[
"403.91",
"E878.2",
"599.70",
"428.0",
"725",
"444.22",
"707.05",
"440.24",
"303.93",
"250.40",
"V15.82",
"E849.8",
"428.22",
"585.6",
"583.81",
"707.21",
"250.70",
"496",
"424.1",
"311",
"995.91",
"285.21",
"038.9",
"274.9",
"V45.81",
"780.39",
"414.00",
"996.74"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"00.41",
"96.07",
"89.19",
"39.50",
"99.10",
"88.48",
"39.95",
"38.95",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
4412, 4510
|
1925, 3517
|
259, 309
|
5485, 5510
|
5619, 5654
|
1562, 1571
|
3941, 4389
|
4531, 5464
|
3543, 3918
|
5534, 5596
|
1586, 1902
|
202, 221
|
337, 736
|
758, 1475
|
1491, 1546
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,077
| 110,935
|
43195
|
Discharge summary
|
report
|
Admission Date: [**2138-11-6**] Discharge Date: [**2138-11-15**]
Date of Birth: [**2077-8-15**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4533**]
Chief Complaint:
Bladder Cancer
Major Surgical or Invasive Procedure:
Vesiculectomy with ileal neobladder construction
History of Present Illness:
This is a 61-year-old man who presented with
gross hematuria and had a diagnosis of moderate grade TCC in
[**2135**]. He underwent 3 courses of BCG and in [**2137**], developed T2
muscle invasive TCC. He was aware of all options for
treatment, and wished for radical cystectomy with creation of
neobladder.
Past Medical History:
Arthritis, GERD, bladder cancer s/p BCG x2 and cystoscopy.
Social History:
No alcohol abuse, no nicotine abuse.
Was in Printing business, used dyes.
Family History:
3 uncles, 2 [**Name2 (NI) 12232**] with bladder CA
Physical Exam:
HEENT: no significant abnormalities noted
CV: RRR no MRG appreciated
RESP: CTA B/L, no RRW
ABD: soft, tender appropriately to palpation, BS +, mildly
distended, wounds CDI
EXT: no CCE, peripheral pulses palpable b/l
Pertinent Results:
[**2138-11-13**] 06:30AM BLOOD WBC-7.1 RBC-3.55* Hgb-11.2* Hct-32.1*
MCV-90 MCH-31.5 MCHC-34.8 RDW-15.0 Plt Ct-264
[**2138-11-6**] 06:22PM BLOOD WBC-8.6 RBC-4.00*# Hgb-12.5*# Hct-36.5*#
MCV-91 MCH-31.2 MCHC-34.1 RDW-14.6 Plt Ct-167
[**2138-11-13**] 06:30AM BLOOD Plt Ct-264
[**2138-11-6**] 06:22PM BLOOD PT-15.1* PTT-31.7 INR(PT)-1.4*
[**2138-11-13**] 06:30AM BLOOD Glucose-123* UreaN-30* Creat-1.3* Na-137
K-4.1 Cl-105 HCO3-25 AnGap-11
[**2138-11-6**] 02:45PM BLOOD UreaN-15 Creat-1.4*
[**2138-11-7**] 04:28AM BLOOD CK-MB-15* MB Indx-1.1 cTropnT-<0.01
[**2138-11-6**] 08:12PM BLOOD Type-ART Temp-37.6 pO2-108* pCO2-45
pH-7.36 calTCO2-26 Base XS-0 Intubat-NOT INTUBA
Brief Hospital Course:
Pt was admitted for Vesiculectomy and ileal neobladder
construction. Pt did well post operatively, but had episodes of
PVC's for which he was taken to MICU for observation.
Cardiology evaluated pt in MICU and began lopressor 25 mg [**Hospital1 **]
for ventricular Bigeminy. On POD 2 pt was transferred to floor
where he passed flatus and was advanced slowly on his diet,
which he tolerated in continuity. Pt conitued to have flatus
for entire post operative course, and normal bowel function
returned on POD 8. Pt's pain was intiially controlled with a
PCA, whcih was changed over to oral pain medication on POD 3.
[**Hospital 1094**] hospital course was significant for leakage of serous fluid
for the first 5 post operative days. JP creatinine was elevated
and CTU was c/w with extravasation of urine form neo bladder.
There was no ureteral leak on CTU. Pt was taught on how to
flush foley catheter, and was confortable with home care. JP
output dropped to less tha 10cc for 24hrs, and was d/c'd prior
to discharge. On POD 9 pt was cleared for discharge and sent
home with scheduled for follow up in 7 - 10 days for removal of
catheter. Pt was given Bactrim for 7 days and instructed to
begin CIprofloxacin on day prior to appointment with Dr. [**First Name (STitle) **]
for catheter removal.
Medications on Admission:
Advair 250/50, Flonase 1 [**Hospital1 **], Singulair 10 qd, Zyrtec 15 qd,
Zocor 40 hs, albuterol NEB PRN
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for 10 days.
Disp:*50 Tablet(s)* Refills:*0*
5. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
6. Cipro 250 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days: DO NOT START THIS MEDICATION UNTIL THE DAY BEFORE YOU
RETURN TO OFFICE FOR FOLEY CATHETER REMOVAL.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Bladder cancer
Discharge Condition:
stable
Discharge Instructions:
Return to ER if:
- persistent temp > 101.4
- severe abdominal or pelvic pain
- persistent nausea, vomiting or diarrrhea
- pus or bloody discharge from wound or urine
Followup Instructions:
f/u with Dr. [**First Name (STitle) **] in 1 -2 weeks, call office for appointment
|
[
"285.1",
"492.8",
"585.9",
"238.4",
"997.1",
"530.81",
"188.2",
"427.89",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"56.51",
"40.3",
"57.71"
] |
icd9pcs
|
[
[
[]
]
] |
4185, 4243
|
1901, 3206
|
330, 381
|
4302, 4311
|
1210, 1878
|
4526, 4612
|
906, 959
|
3361, 4162
|
4264, 4281
|
3232, 3338
|
4335, 4503
|
974, 1191
|
276, 292
|
409, 717
|
739, 799
|
815, 890
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,303
| 175,432
|
37581
|
Discharge summary
|
report
|
Admission Date: [**2108-1-21**] Discharge Date: [**2108-2-4**]
Date of Birth: [**2046-11-6**] Sex: F
Service: NEUROLOGY
Allergies:
Opioids-Morphine & Related
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
* intubation
History of Present Illness:
PER ADMITTING RESIDENT:
This is a 61 yo female with h/o hypertension, CAD, s/p
stents, who developed shortness of breath and lightheadedness
and
headache over the past 3 days. She was being treated for
pneumonia and UTI by her primary care doctor [**First Name (Titles) 151**] [**Last Name (Titles) **] and
predisone which both started on [**2108-1-18**]. She developed severe
headaches subsequently which the family were due to the [**Date Range **].
The PCP changed the medication to Levaquin on [**2108-1-20**], but the
headache persisted. She presented to OSH ([**Hospital 84338**]) with shortness of breath and lightheadedness.
When she initally presented to the OSH ED, she was awake and
alert. However, code stroke was called when she suddenly
developed left sided facial droop and weakness in the right arm
and leg. She had a brief episode of eye blinking and shaking of
both arms. Head CT showed an acute subarachnoid hemorrhage
along
the convexity of the left parietal lobe and a suggestion of
intraparencymal subtle hemorrhagic area in the left parietal
lobe. Prioir to transfer she was received lopressor 5 mg IV,
fosphenytoin 1 g, and 2 mg Ativan. Chest X-ray showed changed
flattening the diaphragm and some mild blunting of the
costophrenic angles. EKG showed sinus tachycardia with poor
R-wave progression in the anterior leads which is consistnet
with
her previous MI. Upon arrival to [**Hospital1 18**], she was noted to be
agitated. She developed agonal breathing and was then
intubated.
CT/CTA was performed.
On neuro ROS, as above.
On general review of systems,her husband denies [**Name2 (NI) **] shehad
fever,
chills, neuasea, vomting, or other cymptoms.
Past Medical History:
- htn
- hyperlip
- COPD
- PVD s/p bilateral iliac
- s/p left renal stents
- CAD s/p STEMI [**7-18**] with stenting x 3.
Social History:
- She lives with her husband who is the primary care
giver. She was ambulating independently
prior to admission.
.
HABITS
- Tobacco history: 40 pack yr, quit 3 yrs ago
-ETOH: None
-Illicit drugs: None
Family History:
No family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory
Physical Exam:
ON ADMISSION:
Physical Exam:
Vitals: T: 99.0 P:101 R: 22 BP: 138/86 SaO2: 100% on FiO2 40%
General: intubated and sedated
HEENT: NC/AT, 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.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: sedated, eyes closed, unable to follow commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2.5to 2mm and brisk. Funduscopic exam revealed no
papilledema, exudates, or hemorrhages.
III, IV, VI: unable to attest
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: unable
IX, X: + corneals bilaterallyl=
[**Doctor First Name 81**]: unable
XII: unable.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Moves all extremities to noxious stimuli
-Sensory: withdraws to painful stimuli
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response mute bilaterally.
-Coordination: unable
-Gait: unable
Pertinent Results:
Admission Labs:
.
WBC-32.0*# RBC-4.16* HGB-12.8 HCT-40.9 MCV-99* PLT-620
GLUCOSE-207* UREA N-18 CREAT-0.6 SODIUM-129* POTASSIUM-5.6*
CHLORIDE-99 TOTAL CO2-18* ANION GAP-18
CK-MB-NotDone cTropnT-<0.01
ALT(SGPT)-156* AST(SGOT)-202* CK(CPK)-76 ALK PHOS-49 TOT
BILI-0.2
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
.
URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG
amphetmn-NEG mthdone-NEG
URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD
.
[**2-3**] WBC 9.2, HCT 29.7, plts 958
ESR 75, lupus anticoagulant negative, hepatitis panel neg, HIV
Ab neg, ANCA neg, [**Doctor First Name **] neg, RF 12, beta-2 microglobulin 1.3, C3
166, C4 52
.
IMAGING
.
CTA ([**2108-1-21**]):
IMPRESSION: Unchanged small volume of focal subdural and
subarachnoid
hemorrhage with no underlying vascular malformation, cerebral
venous
thrombosis or aneurysm identified.
.
CXR ([**2108-1-21**]):
IMPRESSION:
1. ETT 5 cm from the carina.
2. No acute cardiopulmonary abnormality identified
CT head [**2108-1-26**]
FINDINGS: A non-contrast CT of the head was obtained. Again
noted is a small
amount of subdural hemorrhage layering along the
interhemispheric falx and
subarachnoid hemorrhage within the bilateral frontotemporal
sulci at the
cerebral convexities, mildly reduced in extent when compared to
the prior
study. There has been interval development of cortical and
subcortical
hypodensities within the bilateral posterior parietal lobes
extending
inferiorly into the occipital lobes, left greater than right.
There is no
evidence of intraparenchymal hemorrhage. No masses or shift of
midline
structures is identified. The ventricles are stable in size. The
basilar
cisterns are patent. The calvarium is intact. There is partial
opacification
of the left anterior ethmoidal air cells and mucosal thickening
within the
sphenoid sinuses.
IMPRESSION:
1. Interval development of cortical and subcortical
hypodensities within the
posterior parietal and occipital lobes. Differential diagnosis
includes PRES
versus bilateral infarctions, possibly secondary to venous sinus
thrombosis.
No definite CT evidence of venous sinus thrombosis is
identified. MRI and MRV
are recommended for further characterization.
2. Slight interval decrease in extent of subdural and
subarachnoid hemorrhage
within the bilateral frontotemporal regions at the cerebral
convexities.
MRI/V [**2108-1-27**]
1. Non-arterial distribution infarcts with large regions of
restricted
diffusion involving the left parietooccipital lobes, right
parietal lobe, and
additional scattered punctate foci within the right frontal
lobe. Stable
subarachnoid and subdural hemorrhage, as described above.
No evidence of arterial thrombosis, medium-to-large intracranial
vessel
vasospasm or vasculitis (though MRI/MRA may be insensitive), or
cerebral
venous thrombosis.
2. Mucosal thickening and fluid with near-complete opacification
of the left
maxillary sinus and partial opacification of the anterior left
ethmoid air
cells, not significantly changed in extent compared to CTA of
one day prior.
These findings were discussed at-length with Dr. [**Last Name (STitle) **] (Stroke
service), by
Dr. [**Last Name (STitle) **], on [**2108-1-27**] at 4:30 PM; by exclusion, this may
represent a severe
case of Call-[**Doctor Last Name 8271**] pathophysiology, proceding to infarction,
in a patient
with severe underlying vascular disease.
TTE [**2108-1-31**]
No atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF 70%). The aortic valve is not
well seen. No masses or vegetations are seen on the aortic
valve, but cannot be fully excluded due to suboptimal image
quality. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. No
masses or vegetations are seen on the mitral valve, but cannot
be fully excluded due to suboptimal image quality. Mild to
moderate ([**1-14**]+) mitral regurgitation is seen. No masses or
vegetations are seen on the tricuspid valve, but cannot be fully
excluded due to suboptimal image quality. There is apparently
severe pulmonary artery systolic hypertension (however, due to
the technically suboptimal nature of this study, a falsely
elevated pulmonary artery systolic pressure measurement caused
by contamination of the tricuspid regurgitation signal by the
mitral regurgitation cannot be excluded with certainty). There
is no pericardial effusion.
TEE [**2108-2-2**]
No mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect or patent foramen ovale is
seen by 2D, color Doppler or saline contrast with maneuvers.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are complex (>4mm) atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is no pericardial effusion.
IMPRESSION: PFO, ASD or intracardiac thrombus seen. Significant
thoracic aortic atherosclerosis.
CTA head/neck [**2108-2-2**]
Patent bilateral vertebral and carotid arteries. Mild narrowing
of the right
anterior carotid artery, new since prior CTA representing an
area of non-flow
limiting vasospasm
Discharge Labs:
136 | 99 | 6
-------------< 128
4.0 | 31 | 0.5
9.2
9.2 >------< 958
29.7
Brief Hospital Course:
Ms. [**Known lastname 4702**] is a 61 year-old woman with a past medical history
including hypertension, hyperlipidemia, CAD s/p STEMI, and PVD
s/p bilateral iliac stenting who initially presented to Caritas
with a three day history of headache, shortness of breath, and
lightheadedness. An emergent CT was performed when she developed
acute left facial droop, right hemiparesis, and apparent
convulsive movements; the imaging demonstrated a left parietal
subarachnoid hemorrhage and subdural hematoma in the falx
region. She was given ativan and fosphenytoin before transfer
to the [**Hospital1 18**] for further evaluation and care. She was admitted
to the stroke service from [**2108-1-21**] to [**2108-2-3**].
.
NEURO
Upon her arrival at the [**Hospital1 18**], a repeat CT was performed to
evaluate for any evolution of the lesions. The CT demonstrated
stability of the focal subdural and subarachnoid hemorrhage. CT
Angiography showed no underlying vascular malformation, cerebral
venous thrombosis or aneurysm identified. A repeat CT head
revealed bilateral parieto-occipital hypodensities, possibly
consistent with venous sinus thrombosis or PRES. However, no
evidence of thrombosis was seen on CTV. A TTE did not reveal a
cardioembolic source for her infarcts, however TEE was notable
for complex >4mm atheroma in the aortic arch. MRI with contrast
was performed which revealed no underlying malignancy, and
negative for venous sinus thrombosis. It was hypothesized her
presentation was most consistent with cerebral vasoconstriction
syndrome (Call [**Last Name (un) 8273**]). She was started on verapamil and
tolerating this [**Doctor Last Name 360**] well. A vasculitis panel was sent as
well, which was unrevealing and an LP showed 0 wbc, protein 30,
glucose 84. She was continued on her plavix and aspirin. In
response to her atheroma noted on TEE, it was decided to
increase the dose of her statin and continue her antiplatelet
agents rather than proceed with anticoagulation, primarily as it
was still thought unlikely that this was the cause of her
presentation.
.
Throughout the hospitalization, phenytoin was transitioned to
keppra for seizure prophylaxis. There were no further clinical
events noted and she has remained on 750 mg [**Hospital1 **]. It is
recommended that she continue the keppra for at least six
months.
.
RESP
Following her arrival at the [**Hospital1 18**], the patient developed agonal
breathing and was intubated for airway protection. She was
successfully extubated within 48 hours. She continued to have
intermittent difficulty with her respiratory status, likely due
to her COPD and pneumonia. Her nebulizers were increased in
frequency to q4h and she did require 2-3L O2 via NC. Her O2 was
weaned off and she is currently doing well on room air.
.
CVS
In the inital part of the hospitalization, the patient's blood
pressure dropped, requiring the support or pressors. The
hypotension was thought to be related to analgesics and the
sedatives required for intubation. She has been normotensive
for several days and her home beta blocker and ace-inhibitor
were restarted. An echocardiogram (TTE and TEE) were performed;
please see results section for details.
.
ID
To address the urinary tract infection diagnosed prior to
admission, ceftriaxone and pyridium were administered. Blood
cultures ([**2108-1-22**]) showed no growth. She completed a ten day
course of ceftriaxone (switched to cefpoxidime on day #8) given
her recent pneumonia as well as urinary tract infection.
Medications on Admission:
ranexa
hctz
metoprolol
plavix
singulair
lisinopril
ASA
crestor
mucinex
colace
senna
zantac
MVI
Buspar
carafate
ativan
APAP
albuterol
advair
spiriva
miralax
robitussin
maalox
Niroglycerin SL
Levaquin
prednisone
.
Allergies: opoid-morphine related medications
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours).
5. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for Fever/pain.
15. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
17. Verapamil 120 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
18. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for headache.
19. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Left parietal subarachnoid hemorrhage
Bilateral parieto-occipital infarcts
Likely cerebral vasoconstriction syndrome (Call [**Last Name (un) 8273**])
Discharge Condition:
A&Ox3, speech fluent. Naming, repetition, comprehension itact.
EOMI, VFF, face symmetric, tongue midline. Moves all
extremities antigravity and against resistance. Sensation
intact to light touch.
Discharge Instructions:
You were admitted for evaluation of headache, seizure, and
right-sided weakness. You were found to have a bleed in the
left side of your brain. A repeat CT scan showed infarcts on
both sides of your brain. This may have been due to a cerebral
vasoconstriction syndrome.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] (neurology). You may call
([**Telephone/Fax (1) 7394**] to schedule an appointment within 4-6 weeks.
We would recommend that you have a follow up MRI of your brain
in three months.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,722
| 175,402
|
35918
|
Discharge summary
|
report
|
Admission Date: [**2147-5-19**] Discharge Date: [**2147-7-3**]
Date of Birth: [**2093-1-28**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Coumadin / Latex / Adhesive Tape
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Esophageal Cancer
Major Surgical or Invasive Procedure:
[**2147-5-19**] Minimally invasive esophagectomy complicated by
anastamotic leak
[**2147-6-27**] EGD with balloon dilation of pylorus and botox injection
History of Present Illness:
This is a 54 yoM who was diagnosed in [**2147-1-12**] with Stage
IIa esophageal cancer. He underwent chemotherapy and radiation
with good response and was scheduled for elective laparoscopic
esohagectomy.
Past Medical History:
1) cardiomyopathy s/p pacemaker and defibrillator, mitral valve
repair
2) Chronic Atrial Fibrillation
3) nonfunctioning left kidney (BaseLine Cr 1.3)
4) GERD
Surgery:
5) ORIF right wrist
Social History:
The patient currently lives in [**Location (un) 3844**] in the city of [**Location (un) 81594**]. The patient has been on disability since [**2140**] due to
his cardiac problems.
Tobacco: 30 to 35 pack year history of smoking.
Alcohol: Prior significant alcohol intake.
Family History:
Noncontributory
Physical Exam:
Admission Physical
AAO x 3, NAD
RR Afib, rate controlled, mitral regurgitation
B/L rales at apices, Right base is crackles with decreased
breath sounds
soft, appropriately tender, mildly distended, wounds CDI
+ 1 edema B/L
Discharge Physical Exam
AOx3, NAD, comfortable
Irregular rhythm, normal rate, +MR
Lungs are clear
Left JP wound site with mild occasional drainage
J-tube site intact, abdomen protuberant but soft
Pertinent Results:
[**2147-5-20**] 02:34PM BLOOD Hgb-11.7* calcHCT-35
[**2147-5-19**] 12:08PM BLOOD Glucose-148* Lactate-1.4 Na-140 K-5.6*
Cl-103
[**2147-5-20**] 02:34PM BLOOD Glucose-122* Lactate-2.6* Na-138 K-4.4
Cl-108
[**2147-6-12**] 02:27AM BLOOD Digoxin-0.7*
[**2147-6-13**] 05:20AM BLOOD Digoxin-0.8*
[**2147-6-26**] 08:00PM BLOOD Digoxin-1.0
[**2147-6-11**] 01:35AM BLOOD TSH-3.0
[**2147-5-31**] 02:43AM BLOOD Triglyc-230*
[**2147-6-1**] 02:18AM BLOOD Triglyc-259*
[**2147-6-1**] 02:18AM BLOOD calTIBC-160* Ferritn-1138* TRF-123*
[**2147-5-19**] 05:24PM BLOOD Calcium-8.3* Phos-4.1 Mg-1.6
[**2147-5-20**] 01:14AM BLOOD Calcium-8.4 Phos-4.6* Mg-2.2
[**2147-5-21**] 12:09AM BLOOD Calcium-8.9 Phos-3.0# Mg-1.6
[**2147-5-22**] 01:30AM BLOOD Calcium-8.7 Phos-1.8* Mg-1.9
[**2147-6-28**] 05:38AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.9
[**2147-6-29**] 05:57AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.1
[**2147-6-30**] 06:00AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.0
[**2147-7-1**] 08:05AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.0
[**2147-5-20**] 01:14AM BLOOD CK(CPK)-691* Amylase-40
[**2147-5-24**] 08:39AM BLOOD ALT-18 AST-37 LD(LDH)-348* AlkPhos-76
TotBili-4.2*
[**2147-6-5**] 01:24AM BLOOD ALT-27 AST-51* LD(LDH)-175 AlkPhos-438*
TotBili-0.9
[**2147-5-19**] 05:24PM BLOOD Glucose-125* UreaN-16 Creat-1.1 Na-142
K-4.6 Cl-106 HCO3-27 AnGap-14
[**2147-5-20**] 01:14AM BLOOD Glucose-120* UreaN-17 Creat-1.2 Na-142
K-4.8 Cl-107 HCO3-26 AnGap-14
[**2147-5-21**] 12:09AM BLOOD Glucose-131* UreaN-26* Creat-1.7* Na-142
K-4.5 Cl-106 HCO3-26 AnGap-15
[**2147-5-22**] 01:30AM BLOOD Glucose-119* UreaN-22* Creat-1.1 Na-143
K-3.6 Cl-109* HCO3-25 AnGap-13
[**2147-5-23**] 03:10AM BLOOD Glucose-99 UreaN-19 Creat-1.1 Na-147*
K-3.9 Cl-111* HCO3-28 AnGap-12
[**2147-5-23**] 01:20PM BLOOD Glucose-98 UreaN-19 Creat-1.1 Na-150*
K-3.9 Cl-110* HCO3-29 AnGap-15
[**2147-6-28**] 05:38AM BLOOD Glucose-104 UreaN-29* Creat-0.9 Na-139
K-3.5 Cl-108 HCO3-23 AnGap-12
[**2147-6-29**] 05:57AM BLOOD Glucose-123* UreaN-30* Creat-0.8 Na-139
K-3.7 Cl-109* HCO3-23 AnGap-11
[**2147-6-30**] 06:00AM BLOOD Glucose-111* UreaN-29* Creat-0.8 Na-140
K-3.4 Cl-107 HCO3-23 AnGap-13
[**2147-7-1**] 08:05AM BLOOD Glucose-130* UreaN-26* Creat-0.8 Na-137
K-3.7 Cl-107 HCO3-22 AnGap-12
[**2147-5-19**] 05:24PM BLOOD PT-13.0 PTT-23.8 INR(PT)-1.1
[**2147-5-20**] 01:14AM BLOOD PT-13.7* PTT-30.0 INR(PT)-1.2*
[**2147-5-21**] 12:09AM BLOOD Plt Ct-145*
[**2147-5-22**] 01:30AM BLOOD Plt Ct-119*
[**2147-6-12**] 02:27AM BLOOD PT-14.0* PTT-34.1 INR(PT)-1.2*
[**2147-6-19**] 07:09AM BLOOD Plt Ct-269
[**2147-6-27**] 07:00AM BLOOD Plt Ct-420#
[**2147-6-28**] 05:38AM BLOOD Plt Ct-350
[**2147-5-19**] 05:24PM BLOOD WBC-11.8*# RBC-3.87* Hgb-13.2* Hct-37.9*
MCV-98 MCH-34.0* MCHC-34.7 RDW-14.4 Plt Ct-219
[**2147-5-20**] 01:14AM BLOOD WBC-9.6 RBC-3.74* Hgb-12.2* Hct-36.9*
MCV-99* MCH-32.6* MCHC-33.1 RDW-14.7 Plt Ct-201
[**2147-5-21**] 12:09AM BLOOD WBC-8.2 RBC-2.92* Hgb-10.0* Hct-29.4*
MCV-101* MCH-34.2* MCHC-33.9 RDW-14.5 Plt Ct-145*
[**2147-6-14**] 06:20AM BLOOD WBC-5.2 RBC-2.76* Hgb-8.8* Hct-26.4*
MCV-96 MCH-31.9 MCHC-33.3 RDW-14.8 Plt Ct-270
[**2147-6-19**] 07:09AM BLOOD WBC-5.2 RBC-2.92* Hgb-9.6* Hct-28.0*
MCV-96 MCH-32.8* MCHC-34.1 RDW-14.7 Plt Ct-269
[**2147-6-27**] 07:00AM BLOOD WBC-5.1 RBC-3.02* Hgb-9.2* Hct-27.8*
MCV-92 MCH-30.4 MCHC-33.0 RDW-14.5 Plt Ct-420#
[**2147-6-28**] 05:38AM BLOOD WBC-4.8 RBC-3.47* Hgb-10.7* Hct-31.4*
MCV-91 MCH-30.7 MCHC-33.9 RDW-15.0 Plt Ct-350
[**2147-5-20**] 07:04AM URINE Hours-RANDOM UreaN-149 Creat-279 Na-11
K-98 Calcium-1.3 Phos-96.8 Mg-3.0
[**2147-5-20**] 04:11PM URINE Hours-RANDOM Creat-346 Na-11
[**2147-5-20**] 07:22PM URINE Osmolal-487
[**2147-6-4**] 09:13PM URINE CastHy-28*
[**2147-5-24**] 08:39AM URINE RBC-[**3-16**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-<1
[**2147-6-1**] 12:45PM URINE RBC-5* WBC-2 Bacteri-FEW Yeast-NONE Epi-0
[**2147-6-4**] 09:13PM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-1
TransE-<1
[**2147-5-24**] 08:39AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-6.5 Leuks-NEG
[**2147-6-4**] 09:13PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
[**2147-5-29**] 04:02AM ASCITES WBC-[**Numeric Identifier **]* RBC-7000* Polys-66*
Lymphs-2* Monos-10* Macroph-22*
[**2147-6-12**] 01:10PM ASCITES WBC-825* RBC-[**2113**]* Polys-11* Lymphs-56*
Monos-26* Eos-2* Basos-1* Mesothe-4*
[**2147-5-29**] 4:02 am PERITONEAL FLUID
**FINAL REPORT [**2147-6-4**]**
GRAM STAIN (Final [**2147-5-29**]):
REPORTED BY PHONE TO DR. [**Last Name (STitle) **]. [**Doctor Last Name **] ON [**2147-5-29**] AT 0725.
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
FLUID CULTURE (Final [**2147-6-2**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
WORK UP PER DR. [**Last Name (STitle) **] [**4-/3288**] [**2147-5-30**].
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted. gram stain reviewed:.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS AND
CLUSTERS were observed ON [**2147-6-1**].
BETA STREPTOCOCCUS GROUP B. MODERATE GROWTH.
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. MODERATE
GROWTH.
VIRIDANS STREPTOCOCCI. HEAVY GROWTH.
PRESUMPTIVE STREPTOCOCCUS BOVIS. MODERATE GROWTH.
ENTEROCOCCUS SP.. MODERATE GROWTH.
ESCHERICHIA COLI. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| ENTEROCOCCUS SP.
| | ESCHERICHIA
COLI
| | |
AMPICILLIN------------ <=2 S <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- <=0.25 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S <=1 S
LEVOFLOXACIN---------- 0.25 S
MEROPENEM------------- <=0.25 S
OXACILLIN------------- 0.5 S
PENICILLIN G---------- 8 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=1 S
VANCOMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2147-6-4**]):
BACTEROIDES FRAGILIS GROUP. RARE GROWTH. BETA
LACTAMASE POSITIVE.
[**2147-6-12**] 10:50 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2147-6-14**]**
MRSA SCREEN (Final [**2147-6-14**]): No MRSA isolated.
[**Hospital1 69**]
[**Location (un) 86**], [**Telephone/Fax (1) 15701**]
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 81595**],[**Known firstname **] A [**2093-1-28**] 54 Male [**Numeric Identifier 81596**]
[**Numeric Identifier 81597**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/mtd
SPECIMEN SUBMITTED: Esophagectomy.
Procedure date Tissue received Report Date Diagnosed
by
[**2147-5-19**] [**2147-5-19**] [**2147-5-24**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dwc??????
Previous biopsies: [**Numeric Identifier 81598**] Slides referred for
consultation.
DIAGNOSIS:
Distal esophagus and proximal stomach, esophagogastrectomy:
- High grade glandular dysplasia present in a background of
Barrett's esophagus.
- No residual adenocarcinoma identified.
- No malignancy identified in seventeen paraesophageal
lymph nodes (0/17).
Note:
High grade glandular dysplasia is present in a background of
Barrett's esophagus (slide F). Some adjacent glands and ducts
show atypia consistent with treatment effect. Pathologic staging
of this specimen following neoadjuvant therapy is ypT0N0MX.
Proximal and distal surgical margins of resection are negative
for dysplasia.
Clinical: Adenocarcinoma, esophagus.
Gross:
The specimen is received fresh labeled with the patient's name,
"[**Known lastname 33474**], [**Known firstname 3613**] A", the medical record number and additionally
labeled "esophagectomy". It consists of an esophagogastrectomy
specimen that measures 20.5 x 8.5 x 2.2 cm in overall dimension.
The esophagus measures 13.5 cm in length and 1.3 cm in average
diameter. The gastric portion of the specimen measures 4.0 x 3.5
x 1.0 cm. Additionally, there is a triangle of stomach stapled
to the proximal esophageal margin measuring 7.0 x 5.5 x 0.8 cm.
Paraesophageal soft tissue is present measuring 11.5 x 4.0 x 1.0
cm. The omentum measures 13.0 x 6.0 x 1.2 cm. A palpable mass
is not present. The true distal stapled margin is inked [**Location (un) 2452**]
and the periesophageal soft tissue is inked black. The esophagus
and stomach are opened to reveal unremarkable tan mucosa. The
gastroesophageal junction is blocked out in two parts: a
proximal block and a distal block. The proximal and distal ends
of each block are inked blue and yellow, respectively. The
blocks are serially sectioned to reveal no residual tumor, there
the submucosa is diffusely fibrotic. The paraesophageal soft
tissue and omentum are dissected to reveal no grossly apparent
lymph nodes.
Final Report
INDICATION: 54-year-old man with rising T belly.
COMPARISON: No previous exam for comparison.
FINDINGS: The liver is diffusely echogenic consistent with fatty
infiltration. No focal liver lesion is identified. There is no
biliary
dilatation and the common duct measures 0.4 cm. The portal vein
is patent
with hepatopetal flow. A scant trace of ascites is seen in the
perihepatic
space. There are no gallstones and the gallbladder is not
distended. No
gallbladder wall thickening is seen. The pancrease is obscured
from view by
overlying bowel. The spleen is unremarkable and measures 10.7
cm. No ascites
is seen in the lower quadrants.
IMPRESSION:
1. No gallstones, no biliary dilatation, and no sign of
cholecystitis.
2. Echogenic liver consistent with fatty infiltration. Other
forms of liver
disease and more advanced liver disease including significant
hepatic
fibrosis/cirrhosis cannot be excluded on this study.
3. Scant trace of ascites in the perihepatic space. No ascites
seen in the
lower quadrants.
The study and the report were reviewed by the staff radiologist.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20982**], RDMS
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: [**Doctor First Name **] [**2147-5-25**] 7:02 PM
Final Report
STUDY: Percutaneous jejunostomy tube placement using ultrasound
and
fluoroscopic guidance.
INDICATION: Patient has previous laparoscopic feeding
jejunostomy tube placed
approximately four months previous. The tube has been removed,
yet needs to
be replaced given need for tube feeding since nutritional
requirements are not
met. Esophageal cancer.
RADIOLOGISTS: Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] performed the
procedure. Dr.
[**Last Name (STitle) **], the attending radiologist, was present and
participating throughout.
FINDINGS/PROCEDURE: Informed consent was obtained after the
risks, benefits,
and alternatives to the procedure were explained. A preprocedure
timeout was
performed using three patient identifiers. The patient was
placed supine on
the angiographic table and the abdomen was prepped and draped in
standard
sterile fashion. Fluoroscopy was used to identify the surgically
placed
staples indicating the site of jejunal loop tacking to the
anterior peritoneal
surface. Ultrasound and micropuncture set was utilized to gain
access to this
loop of jejunum. Conray contrast material confirmed entry into
the jejunal
loop. A guidewire followed by Kumpe catheter was used to secure
placement
into the jejunal loop. An Amplatz wire secured this site and
provides
stiffness for dilation of the tract. A 12 French Wills-[**Doctor Last Name 12433**]
jejunostomy
tube was secured in the jejunal loop and the guidewire was
removed. The
feeding tube was sutured to the skin. The patient tolerated the
procedure
well. There were no post-procedural complications.
ANESTHESIA: The patient was continually monitored by
radiological nursing
staff and 100 mcg fentanyl was administered for patient comfort.
Total
intraservice time was 40 minutes. 20 cc buffered lidocaine was
administered
for local anesthesia.
IMPRESSION: Successful ultrasound and fluoroscopic-guided
placement of
12 french jejunostomy tube. Tube is ready for use.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Doctor Last Name 4391**]
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6888**]
Approved: [**Doctor First Name **] [**2147-6-8**] 10:46 AM
Final Report
HISTORY: Rising creatinine, absent left kidney.
FINDINGS: The right kidney is normal in size, contour, and
echogenicity. The
right kidney measures 13.1 cm, with no hydronephrosis or
nephrolithiasis. The
left kidney is absent, as seen on prior PET/CT from [**12-19**]. The
urinary
bladder is within normal limits. Moderate ascites is noted.
IMPRESSION:
1. Normal appearance of the right kidney.
2. Nonvisualization of the left kidney, as noted on prior PET/CT
from [**12-19**].
3. Moderate ascites.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 81599**]
DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**]
Approved: TUE [**2147-6-6**] 12:07 PM
HISTORY: 54-year-old man status post esophagectomy with
persistent ileus,
please inject p.o. contrast through J-tube, question anastomotic
leak, ileus.
TECHNIQUE: 5-mm contiguous axial images from the thoracic inlet
through the
lesser trochanters without IV and with Gastrografin which was
injected via the
J-tube were obtained. Coronal and sagittal reconstructions were
included in
this study. Correlation is made to a prior abdominal ultrasound
dated [**2147-5-25**] as well as a prior PET scan dated [**2147-1-10**].
FINDINGS:
CT THORAX WITHOUT IV CONTRAST:
There are small bilateral pleural effusions with associated
compressive
atelectasis of the posterior lower lobes. Ground-glass opacities
are seen in
the right greater than left lungs. Central airways are patent.
The patient is status post esophagectomy with gastric
pull-through. Oral
contrast is admixed with gastric pull-through fluid. No frank
dehiscence of
the anastomotic sutures. No evidence of mediastinal
lymphadenopathy. Mild
atherosclerotic disease is seen in the thoracic aorta and
coronary arteries.
No evidence of pericardial effusion.
There is a single-lead left chest wall cardiac pacemaker with
its tip in the
right ventricle. Tip of the right PICC line is in the SVC.
Visualized
portion of the thyroid gland is unremarkable. A surgical drain
tracks along
the left aspect of the neck into the mediastinum to the level of
the distal
trachea.
CT ABDOMEN WITHOUT IV CONTRAST:
There is a moderate amount of ascites, predominantly located in
the
perihepatic region, bilateral pericolic gutters and tracking
along the small
bowel mesentery in the pelvis.
The lack of IV contrast limits the evaluation of the solid
parenchymal organs.
Liver, gallbladder, pancreas, spleen, adrenal glands, and right
kidney appear
normal. There is a rounded soft tissue density (29 [**Doctor Last Name **]) lesion in
the left
renal fossa which contains a peripheral calcification. This
lesion measures
1.8 cm x 1.5 cm and may represent a left kidney remnant.
Surgical staples are seen in the upper abdomen from the
patient's recent
esophagectomy and gastric pull-through. A J-tube is visualized.
Oral
contrast passes through the nondistended small bowel and colon
to the level of
the rectum. No evidence of bowel obstruction or ileus. No
evidence of
pneumatosis. No focal fluid collections or free air.
Moderate atherosclerotic disease is seen in the abdominal aorta
which is
normal in course and caliber. No evidence of retroperitoneal or
mesenteric
lymphadenopathy.
CT PELVIS WITHOUT IV CONTRAST:
The bladder is partially distended and contains air, likely from
prior
catheterization. Prostate gland contains calcifications. Seminal
vesicles are
unremarkable. No evidence of pelvic or inguinal lymphadenopathy.
OSSEOUS STRUCTURES: No suspicious osteolytic or osteoblastic
lesions. Mild
multilevel degenerative changes are seen in the thoracic and
lumbar spine.
IMPRESSION:
1. No evidence of ileus or bowel obstruction.
2. No frank dehiscence of the gastric pull-through anastomosis.
If there is
a clinical suspicion for anastomotic leak, a fluoroscopic study
is recommended
with water-soluble contrast. This study was performed with
Gastrografin
injection into the J-tube per the referring team's request.
3. Small bilateral pleural effusions.
4. Moderate amount of ascites.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) 306**] [**Last Name (NamePattern1) 6891**]
DR. [**First Name (STitle) 3934**] [**Name (STitle) 3935**]
Approved: MON [**2147-6-12**] 12:41 AM
HISTORY: 54-year-old male status post esophagectomy, with
distended abdomen,
found to have ascites.
No prior studies available for comparison.
FINDINGS: After discussion of the risks and benefits of the
procedure,
written informed consent was obtained. A preprocedure timeout
was performed
using multiple different patient identifiers.
Preliminary son[**Name (NI) 493**] images of the abdomen demonstrate a
moderate amount of
ascites, with the largest pocket within the right lower
quadrant, which was
chosen for percutaneous access. The right lower quadrant was
then prepped and
draped in a standard sterile fashion. 1% lidocaine was used for
local
anesthesia. A 5 French [**Last Name (un) 11097**] catheter was then advanced into the
abdomen, and
approximately 1.5 liters of tan-colored ascites was drained,
with samples sent
to the laboratory as requested.
The patient tolerated the procedure well, without immediate
post-procedural
complications. Dr. [**Last Name (STitle) **], the attending radiologist, was
present and
supervising throughout the procedure.
IMPRESSION: Uncomplicated ultrasound-guided diagnostic and
therapeutic
paracentesis, yielding 1.5 liters of tan-colored ascites.
Samples were sent
to the laboratory as requested.
ESOPHAGRAM DATED [**2147-6-21**]
HISTORY: A 54-year-old male with a history of laparoscopic
esophagectomy with
prolonged course of intolerance to p.o. and question anastomotic
leak in neck.
COMPARISON: CT dated [**2147-6-11**].
FINDINGS: Conray and thin barium were administered to the
patient orally.
Fluoroscopic images of the esophagogastric anastomosis were
obtained. The
barium passes through the upper esophagus into the intrathoracic
stomach
freely with no evidence of constrast extravasation, obstruction
or stricture.
A surgical drain is noted overlying the mediastinum in addition
to pacemaker
leads.
IMPRESSION:
No extravasation of contrast at the level of the intrathoracic
esophagogastric
anastamosis.
Date: Tuesday, [**2147-6-27**] Endoscopist(s): [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **],
MD
[**First Name (Titles) **] [**Last Name (Titles) 81600**], MD (fellow)
Patient: [**Known firstname 3613**] [**Known lastname 33474**]
Ref.Phys.: [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **], MD
Assisting Nurse(s)/
Other Personnel: [**First Name9 (NamePattern2) 3548**] [**Doctor Last Name **], Anesth
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 81601**], RN
[**Doctor Last Name 40535**] [**Last Name (un) **]
Birth Date: [**2093-1-28**] (54 years) Instrument: GIF 180
ID#: [**Numeric Identifier 81597**]
Medications: Monitored anesthesia care
Indications: 54 y/o gentleman with history of esophageal cancer,
s/p esophagectomy with gastroesophageal anastomosis, with
persistent drainage from the JP drain in the neck
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered MAC
anesthesia. The patient was placed in the left lateral decubitus
position and an endoscope was introduced through the mouth and
advanced under direct visualization until the third part of the
duodenum was reached. Careful visualization of the upper GI
tract was performed. The procedure was not difficult. The
patient tolerated the procedure well. There were no
complications.
Findings: Esophagus:
Other Esophago-gastric anastomosis visualized. Minimal air used
to insufflate the esophagus and stomach.
Stomach:
Contents: Bilious fluid was seen in the stomach body. The fluid
was removed with suction. The gastric folds in the region of the
antrum appeared erythematous and edematous. Mild resistance was
encountered in passing the scope past the pylorus in the
duodenum. Balloon dilation of the pylorus was performed. A 10mm
balloon was introduced for dilation and the diameter was
progressively increased to 15 mm successfully. Subsequently, 5
ml (100 Units) of Botox was injected in and around the pylorus.
Duodenum: Normal duodenum.
Impression: Esophago-gastric anastomosis visualized.
Minimal air used to insufflate the esophagus and stomach.
Bilious fluid was seen in the stomach body. The fluid was
removed with suction.
The gastric folds in the region of the antrum appeared
erythematous and edematous.
Mild resistance was encountered in passing the scope past the
pylorus in the duodenum.
Balloon dilation of the pylorus was performed. A 10mm balloon
was introduced for dilation and the diameter was progressively
increased to 15 mm successfully.
Subsequently, 5 ml (100 Units) of Botox was injected in and
around the pylorus.
Recommendations: NPO
Follow for response/complications
Follow-up with Dr. [**Last Name (STitle) **]
Additional notes: The procedure was performed by Dr. [**Last Name (STitle) **] and
the ERCP fellow. The patient's reconciled home medication list
is appended to this report.
Brief Hospital Course:
Patient was admitted postoperatively, in stable condiditon, to
the SICU. On POD 0, overnight, he went into atrial fibrillation
with rapid ventricular rate which was controlled with diltiazem
drip. His urine output was low and unresponsive to significant
fluid bolus. He was begun on vasopressin, low dose drip, which
imptoved his renal perfusion and his urine output increased. By
POD 2 he became more agitated and he was cared for on a CIWA
scale as he had a significant alcohol history. He required a
large amount of oxygen to keep his saturation up. Otherwise he
was doing well. On POD 3 he was diuresed with lasix which he
responded to well. This was continued on POD 4 as well, with
good response when he was restarted on lovenox and given
aggressive lasix diuresis. On POD 7 his chest tube was
discontinued and a clonidine patch and lopressor were added. TPN
was started on POD 8 and he had an ECHO which was unremarkable.
On POD 9 lopressor was increased and on POD 10 he was
persistantly tachycardic so a diltiazem drip was started. Given
large JP output and ? fevers he was started on
flagyl/zosyn/vanc/fluc. On [**6-1**] he was started on levaquin for
presumptive pneumonia. On [**6-2**] he underwent a J tube in IR and
his diltiazem drip was changed to J-tube medications.
On [**6-6**] he underwent a renal usg for increased creatinine which
was essentialy normal, though he remained distended. He was
discontinued off levo/flagyl on [**6-8**]. His creatinine improved
significantly by [**6-8**] with hydration. On [**6-10**] EP was consulted
and he was started on digoxin for refractory atrial
fibrillation. His atrial fibrillation responded well however
given his distension he underwent a CT torso which showed a
significant amount of ascited. This was tapped and he responded
well. On [**6-15**] he was started on tubefeeds slowly. For the next 2
weeks he had fluctuating levels of nausea and vomiting, which
were attributed to ? pyloric stenosis. His tubefeeds were held
and then restarted multiple times.
Given continued output from his JP drain each time he had a
small amount of retching, it was assumed that he had a leak in
his esophageal anastamosis, despite a drain study in radiology
that had indicated otherwise. He was noted to have continued
bouts of small amounts of emesis vs. regurgitation which
sometimes would have increased output in his L neck JP drain.
On [**6-25**] roughly 600cc was emptied from a JP drain and he
underwent EGD for presumptive pyloric stenosis. In this EGD his
pyloris was dilated and injected with botox and his symptoms
improved signficantly. Prior to discharge all of his medications
were switched to J tube with good effect. His JP was
progressively pulled back and ultimately d/c'ed on [**7-1**]. He was
tolerating his tubefeeds well with minimal regurgitation and no
drainage from his neck. Presumably his anastamotic leak was
self-contained. He will be discharged on a soft solid diet with
explicit warning about certain signs of collection / fevers. He
was also discharged on full tubefeeds.
Medications on Admission:
Toprol 50'', Lasix 40', K 20', Ativan 1prn, Protonix 40'',
Hydroxyzine 50'', Lovenox 120'
Discharge Medications:
1. Enoxaparin 100 mg/mL Syringe [**Month/Year (2) **]: Ninety (90) mg Subcutaneous
DAILY (Daily).
Disp:*qs x1month * Refills:*2*
2. Lorazepam 0.5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
3. Hydromorphone 2 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
4. Furosemide 20 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. All medications per J tube, strictly nothing by mouth
6. Digoxin 250 mcg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily):
per J tube.
Disp:*30 Tablet(s)* Refills:*2*
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
8. Codeine-Guaifenesin 10-100 mg/5 mL Syrup [**Last Name (STitle) **]: 5-10 MLs PO Q6H
(every 6 hours) as needed for cough.
Disp:*200 ML(s)* Refills:*0*
9. Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*60 Tablet(s)* Refills:*2*
10. Colace 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) cc PO twice a day.
Disp:*400 cc* Refills:*2*
11. Replete/Fiber Liquid [**Last Name (STitle) **]: Seventy Five (75) cc PO
hourly: Replete with fiber Full strength;
Goal rate:75 ml/hr
Flush w/ 50 ml water q6h.
Disp:*qsig x 2 weeks * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
community health and hospice
Discharge Diagnosis:
Esophageal carcinoma
Atrial fibrillation
Poor nutrition
Acute renal failure
Respiratory Insufficiency
Pyloric Stenosis
Anastomotic leak
Discharge Condition:
Stable, soft solids diet, tubefeeds at goal, afebrile,
occasional small amounts of expectoration 25-50cc daily
(positional)
Discharge Instructions:
You are being discharged home in stable condition. You may eat a
soft solid diet. It is very important to follow up your
medication regimen very strictly and continue your tubefeeds at
their current rate (goal). As we have discussed in your hospital
stay, it is ok to have small episodes of regurgitation but
should you have any significant bouts of emesis or significant
abdominal pain, please call Dr.[**Name (NI) 1482**] office or return to
the emergency room.
If you have any of the other following problems or concerns,
please call your doctor or return to the emergency room.
*Fever > 101.2
*Chest pain, shortness of breath
*Heart palpitations
*Abdominal pain, retching, vomiting
*Significant amounts of diarrhea
Followup Instructions:
Please call Dr.[**Name (NI) 1482**] office to follow up within 2 weeks
of discharge. ([**Telephone/Fax (1) 1483**]
Completed by:[**2147-7-3**]
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Discharge summary
|
report
|
Admission Date: [**2178-12-15**] Discharge Date: [**2178-12-22**]
Date of Birth: [**2110-3-24**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents / Amiodarone
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
HYPOTENSION IN SETTING OF RP BLEED
Major Surgical or Invasive Procedure:
Midline placement
History of Present Illness:
Mr. [**Known lastname **] is a 68 yo M w/ PMH CAD s/p CABG x4 in [**2163**], CHF
(EF-20%), VT s/p ablation and ICD in [**2-16**], HIT, who presented to
an OSH [**2178-12-12**] with hypotension and shock. Of note, he had been
at [**Hospital1 18**] [**10-16**] for infected ICD wire (likely originating from
foot infection), resulting in ICD wire removal. He was d/c'd to
rehab for planned 6 wk course of vanco (to be completed
[**2178-12-13**]). He presented to the OSH from rehab after the sudden
onset of L flank pain with SBP 50s. He was also hypoxic,
requiring NRB. On abd CT at the OSH, he was found to have an
enlarging L sided RP hematoma orginating from L kidney. Of note,
he had received one dose of fondaparinux on admission for his
h/o HIT. He initially required pressors, which were weaned off
[**12-14**]. He received 11U PRBCs, 3U FFP, 10mg Vit K x2, DDAVP
22.5mg. He was seen by urology at OSH, who recommended
conservative treatment for RP bleed.
.
He was also felt to have infection/sepsis contributing to his
hypotension, with lactate 8.0, and was started on vanco and
imipenem on admission. He was found to have GPC in clusters
growing from his PICC line, and this was removed. In addition,
coccyx wound cultures grew out acinetobacter, sensitive only to
aminoglycosides. The patient had WBC of 14.9 with L shift, no
fever noted. The patient also presented with plts of 174K which
trended down to 34K, so his mexiletine was discontinued as a
possible source of thrombocytopenia.
.
He was transferred to [**Hospital1 18**] on [**2178-12-15**]. Vancomycin was continued
for GPC PICC line infection, but other abx were discontinued. He
was also found to have a pneumonia, and was started on
ciprofloxacin. He has received 4U PRBC here, as well as 1U
platelets. His [**Date Range **] was resumed, after discussion with EP.
His [**Date Range **] dose was also increased to 40mg daily, due to a
gout flare.
.
ROS: Currently, denies CP, SOB, cough, F/C, back/flank pain, abd
pain, N/V, diarrhea, dysuria, dizziness.
Past Medical History:
Past Medical History:
1)CAD s/p CABG CABG [**2163**] (LIMA->LAD, SVG->D->OM2 jump graft,
SVG->LPDA)
- cath([**2177-1-31**]: patent LIMA->LAD, patent SVG->diagonal and OM2.
Occluded SVG-> L PDA.
- Underwent [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2->proximal and distal left circumflex/PVA
2)HTN
3)Hyperlipidemia
4)s/p VT ablation and ICD implantation [**2-16**]
5)COPD
6)Gout
7)chronic LLE ulcers
8)PVD/claudication
- s/p right external iliac artery stent [**8-/2176**]
- complicated by LUE hematoma, ? nerve injury;
- s/p right to left fem-fem bypass grafting in [**2178-5-11**]
9)spinal stenosis
- s/p back surgery
[**82**])bilateral renal masses
11)s/p L inguinal hernia repair
12)s/p cataract surgery
Social History:
Single, lives alone. Has visiting nurse service. Active smoker
of 10 cigarettes per day. Has smoked 1-2 packs per day for [**10-25**]
years. Denies ETOH. Retired construction worker.
Family History:
Non-contributory
Physical Exam:
VS: Temp: 97.6 BP: 130/82 HR: 102 RR: 18 O2sat: 100% on RA
Gen: chronically ill appearing, appears comfortable. NAD at
rest.
HEENT: anicteric, MMM, OP clear
Neck: no JVD
CV: RRR, II/VI SEM at LUSB
Lungs: Minimal bibasilar crackles, L>R.
Ab: +BS, slightly firm, mild tenderness on L side, no guarding
or rebound. Faint ecchymosis visible on L side.
Extrem: R wrist and elbow with discomfort on active and passive
ROM. Diffuse tophi. L foot with healing ulcer, no erythema or
discharge. 2+ pitting edema b/l. 1+ DP pulses.
Back: 5x6 cm sacral decubitus ulcer, no active pus or
surrounding cellulitis.
Pertinent Results:
Admission Labs:
[**2178-12-15**] 10:58PM PT-13.4* PTT-36.7* INR(PT)-1.2*
[**2178-12-15**] 10:58PM PLT SMR-LOW PLT COUNT-93*#
[**2178-12-15**] 10:58PM NEUTS-96.7* BANDS-0 LYMPHS-1.7* MONOS-1.5*
EOS-0.1 BASOS-0
[**2178-12-15**] 10:58PM WBC-9.0 RBC-2.67* HGB-8.5* HCT-23.6* MCV-88
MCH-31.9 MCHC-36.1* RDW-17.4*
[**2178-12-15**] 10:58PM ALBUMIN-3.2* CALCIUM-7.7* PHOSPHATE-7.2*#
MAGNESIUM-2.0
[**2178-12-15**] 10:58PM ALT(SGPT)-27 AST(SGOT)-31 LD(LDH)-377* ALK
PHOS-129* TOT BILI-1.1
[**2178-12-15**] 10:58PM estGFR-Using this
[**2178-12-15**] 10:58PM GLUCOSE-72 UREA N-62* CREAT-2.1* SODIUM-137
POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-15* ANION GAP-22*
.
Discharge Labs:
[**2178-12-22**] 06:25AM BLOOD WBC-6.5 RBC-3.21* Hgb-9.9* Hct-29.5*
MCV-92 MCH-30.8 MCHC-33.6 RDW-17.0* Plt Ct-100*
[**2178-12-22**] 06:25AM BLOOD Glucose-83 UreaN-76* Creat-1.6* Na-137
K-4.0 Cl-107 HCO3-20* AnGap-14
.
Micro:
[**2178-12-16**] 1:04 am CATHETER TIP-IV Source: right sc presept
cath.
**FINAL REPORT [**2178-12-18**]**
WOUND CULTURE (Final [**2178-12-18**]): No significant growth.
.
Imaging:
MRI Abdomen [**12-16**]:
FINDINGS: There is a large, approximately 30 cm in craniocaudad
dimension, perinephric hematoma that extends retroperitoneally
into the pelvis. This retroperitoneal collection displaces the
left kidney superiorly. There is a subcapsular component of this
large perinephric hematoma. No active extravasation is
visualized at the time of the examination. There was a delayed
nephrogram to the left kidney, however the arterial and venous
flow is preserved. Coronal reconstructions suggest that the left
kidney is intact. There is no history of trauma, this finding
may be secondary to rupture of a complicated cyst or bleeding
from lipid poor angiomyolipoma with coagulation deficiencies
causing excessive bleeding. On the prior examination of
[**2178-11-4**], no definitive angiomyolipoma was seen.
Post simple and hemorrhagic cysts are visualized within the
right kidney. Limited visualization of the adrenal glands, liver
and pancreas are unremarkable. There has been interval
development of multiple tiny subcapsular non-enhancing foci
within the spleen, which are not seen on the prior examination.
Question residual from infection in this patient with history of
MRSA bacteremia.
Multiplanar 2D and 3D reformations as well as subtraction images
were essential in demonstrating multiple perspectives for this
dynamic series.
IMPRESSION:
1. Large perinephric hematoma extending into the pelvis with
contiguity with the left kidney. In the absence of trauma, this
may be a complication of a ruptured cyst versus a bleeding lipid
poor angiomyolipoma. [**Date Range **] flow to the left kidney is
preserved and the left kidney appears intact on coronal
reformatted images.
2. New tiny foci seen in the subcapsular aspect of the spleen,
suggesting residual of prior infection in this patient with
history of MRSA bacteremia.
.
Renal US [**12-16**]:
IMPRESSION:
1. Edematous and distended left kidney without evidence of
Doppler flow, could be secondary to ischemia, i.e., venous
obstruction as a result of the hematoma. Further evaluation with
MRI is recommended.
2. Multiple right renal cysts with echogenic parenchyma
representing parenchymal disease.
3. Small ascites and right pleural effusion.
.
CXR PA/LAT [**12-22**]:
PA and lateral radiograph. Comparison [**11-10**] and [**2178-12-16**], as well as CT [**2176-9-4**].
Left lower lobe consolidation and effusion are unchanged. There
may be minimal atelectasis in the medial right lung base.
Mediastinal contours are stable. Calcification in the
interventricular septum and the myocardial left ventricular apex
are noted on the lateral view. Pulmonary vasculature is stable
and within normal limits.
There is an old healed right posterior seventh rib fracture.
IMPRESSION: No change in left lower lobe pleural effusion and
consolidation.
Brief Hospital Course:
Retroperitoneal Bleed: The patient was initially hypotense
requiring aggressive volume resusitation. The patient's Hct on
admission was 23. He was given a total of 11 units PRBCs as
well as 5 units of FFP. Renal US demonstrated an edematous and
distended left kidney. MRI abdomen showed a perinephric
hematoma with perserved [**Year (4 digits) 1106**] flow to the kidney, as well as
renal cysts. His cysts were thought the likely cause of the
bleed. Urology was consulted and recommended supportive care.
His Hct stabilized to 28-30. They recommended repeat imaging
with a MR urogram as an outpatient as long as remains clinically
stable. He will need follow up with urology as an outpatient,
and urgent evaluation if becomes clinically unstable.
.
MRSA Line Infection: Prior to admission, the patient had a
positive blood culture from his previous PICC line which grew
MRSA one day prior to completing course of vanco for MRSA
bacteremia, though other blood cultures were negative. Follow
up blood cultures here were negative. However, the patient was
continued on vanco. ID was consulted to determine proper course
of vanco. Although it was uncertain if he did in fact have a
line infection vs. a contaminant, they recommended to continue
vanco to complete a 14 day course starting [**12-13**]. A midline
catheter was placed on [**12-22**]. He should take vanco through
[**12-27**].
.
Pneumonia: The patient was thought to have a left lower lobe
pneumonia. The patient was given a 7 day course of cipro. He
remained afebrile with a normal WBC count, satting 100% on room
air. A repeat CXR did show persistent infiltrate. He was
clinically asymptomatic however. A repeat CXR in [**1-12**] weeks or
as symptoms dictate are needed to confirm resolution of his
pneumonia.
.
Thrombocytopenia: The patient was thrombocytopenic on admission.
His thrombocytopenia was thought secondary to multiple PRBCs
given. He did not receive any heparin products here. His
platelet count remained stable between 90-110. His platelet
count will need periodic monitoring. He is NOT TO RECEIVE
HEPARIN PRODUCTS.
.
Gout: The patient has known severe tophaceous gout. His
allopurinol and colchicine were held prior to admission. The
patient experienced an acute flare, mostly localized to his
right wrist. Because of his ARF, he was not given colchicine or
NSAIDS. Instead, he was given [**Date Range 2768**] 40mg with good result.
He continued 40mg x 4 days. His [**Date Range 2768**] was switched to
30mg on [**12-22**]. He should continue his [**Month/Year (2) **] taper as
follows, and restart his allopurinol as an outpatient at the
discretion of his PCP: [**Name10 (NameIs) 2768**] taper - [**2185-12-22**] 30mg,
[**2087-12-23**] 20mg, [**2090-12-25**] 10mg, [**2093-12-28**] 5mg then stop.
.
Acute Renal Failure: His ARF was thought likely due to ATN and
pre-renal azotemia from his hypotension. His creatinine
improved during admission to near his baseline. It was 1.6 on
discharge. His renal function will need to be followed for
resolution.
.
History of VTach: Continued on mexilitene without complications.
.
CHF: His metoprolol and lisinopril and statin were restarted
prior to discharge. His ASA and [**Month/Day/Year **] were held. They can be
restarted once the patient is more stable. He should also have
a repeat ECHO to assess his heart function.
.
Chronic Anemia: His Epoetin was continued at 4000 units SC q
MWF, as well as his ferrous sulphate.
.
Metabolic Acidosis: He initially had an acidosis secondary to an
elevated lactate. Once his lactate normalized, he continued to
have a non AG acidosis thought likely to his ARF. His acidosis
improved throughout his admission.
.
Sacral Wound: Patient will need pressure relief from his wound,
repositioning q2hrs prn. Wound care recommended cleansing with
commercial cleanser, patting dry, applying no-sting barrier wipe
to periwound tissue, applying aquacel sheet to ulcer, covering
with dry gauze and ABD, securing with mefix tape.
.
Foot Ulcer: Patient was seen by podiatry. Recommended aquacel
for 1st MPJ but not necessary for dorsal wound. Recommended
slightly moist environment for wounds. Can have partial weight
bearing, heel touch. Pt should f/u with Dr. [**First Name (STitle) 3209**] 1 week from
D/C [**Telephone/Fax (1) 543**]
.
Code: FULL for this admission
Medications on Admission:
Allopurinol 200mg PO qDay
Ambien 5mg PO qHS
Ascriptin 325mg PO qDay
Colchicine 0.6mg PO qDay
Flonase 50mcg/act nasal 2 sprays qDay
[**Telephone/Fax (1) 11573**] 40mg PO TID
Lisinopril 5mg PO qDay
[**Telephone/Fax (1) 105360**] 150mg PO BID
Oxycontin 40mg [**Hospital1 **]
Percocet 5-325 PO 1-2 Tabs q6hrs prn
Plavix 75mg PO qDay
Pravachol 40mg PO qDay
Senna
Sotalol 120mg PO BID
Discharge Medications:
1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
5. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
10. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
12. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Pravastatin 10 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
15. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
16. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
17. [**Hospital1 2768**] 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): for dates [**12-22**] - [**12-23**].
18. [**Month/Year (2) 2768**] 10 mg Tablet Sig: Two (2) Tablet PO once a day:
for dates [**12-24**] - [**12-25**].
19. [**Month/Year (2) 2768**] 10 mg Tablet Sig: One (1) Tablet PO once a day:
for dates [**12-26**] - [**12-28**].
20. [**Month/Year (2) 2768**] 5 mg Tablet Sig: One (1) Tablet PO once a day:
for dates [**12-29**]- [**12-31**] THEN STOP AFTER [**12-31**].
21. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
22. Vancomycin 1,000 mg Recon Soln Sig: Seven [**Age over 90 1230**]y
(750) Milligrams Intravenous q24 hours: Please take through
[**12-27**] to complete 14 day course.
23. Insulin sliding scale
Regular or Humalog insulin sliding scale at your discretion fo
hyperglycemia
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary Diagnosis:
Retroperitoneal bleed
MRSA line infection
Gout flare
.
Secondary Diagnoses:
Pneumonia
Thrombocytopenia
Anemia
Congestive Heart Failure
Acute Renal Failure
Hyperkalemia
SacralDecubitus Ulcer
Foot Ulcer
Heparin Induced Thrombocytopenia
Hypertension
Chronic Obstructive Pulmonary Disease
Discharge Condition:
stable, eatings solids easily
Discharge Instructions:
Pt has normal oxygen saturation on room air, with well
controlled blood pressure and heart rate. Patient will need to
continue Vancomycin until [**2178-12-27**] per recommendation of
infectious disease consult team.
Followup Instructions:
1)Mr. [**Known lastname **] has an appointment for an MRI of his kidneys on
[**1-8**] at 11:15 am on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building at
[**Hospital3 **], at [**Location (un) **]. He must be npo for 4 hours
prior, may take his meds. Per case management NO
PRE-AUTHORIZATION IS NEEDED given that patient's insurance is
medicare primary.
2)Pt has a follow up appointment with the Urologist Dr. [**First Name (STitle) **] on
Tuesday [**1-12**] at 11:15am, located at [**Hospital Ward Name 23**] Building [**Location (un) **] Please call [**Telephone/Fax (1) 6317**] if you need to cancel.
3) Follow up appointment with infectious disease [**1-26**] at
11:00am at [**Last Name (NamePattern1) 439**] [**Hospital 1422**] Clinic.
.
Patient has a podiatry appointment with Dr. [**First Name (STitle) 3209**] on Tuesday [**1-26**] at 10AM in the Dept of Podiatry at [**Hospital1 18**]
.
Please have patient follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3649**] in [**2-14**] weeks.
[**Telephone/Fax (1) 3070**]
|
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icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
15076, 15148
|
7990, 12351
|
324, 343
|
15496, 15528
|
4016, 4016
|
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3363, 3381
|
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15264, 15475
|
250, 286
|
371, 2400
|
4032, 4681
|
15188, 15243
|
2444, 3146
|
3162, 3347
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,846
| 145,525
|
6072
|
Discharge summary
|
report
|
Admission Date: [**2135-1-26**] Discharge Date: [**2135-1-27**]
Date of Birth: [**2074-2-1**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
End-stage renal disease
Major Surgical or Invasive Procedure:
AV graft left upper arm and right groin permacath
History of Present Illness:
this is a 60 year old female who presents to the [**Hospital1 18**] for
placement of an AV fistula and a Right groin permacath. She is a
pt with end-stage renal disease on hemo-dialysis.
Past Medical History:
ESRD on HD, GERD, DM, Hyperchol, Depression
Family History:
NC
Pertinent Results:
[**2135-1-27**] 05:54AM BLOOD WBC-9.8 RBC-3.34* Hgb-11.0* Hct-35.5*
MCV-106* MCH-32.8* MCHC-30.9* RDW-16.9* Plt Ct-485*
[**2135-1-26**] 11:15AM BLOOD WBC-8.7 RBC-3.42*# Hgb-10.9*# Hct-36.4#
MCV-106* MCH-31.9 MCHC-30.0* RDW-16.8* Plt Ct-528*
[**2135-1-27**] 05:54AM BLOOD Plt Ct-485*
[**2135-1-27**] 05:54AM BLOOD PT-25.6* PTT-34.4 INR(PT)-2.6*
[**2135-1-27**] 05:54AM BLOOD Glucose-152* UreaN-56* Creat-6.5* Na-143
K-5.3* Cl-101 HCO3-27 AnGap-20
[**2135-1-26**] 11:15AM BLOOD Glucose-172* UreaN-47* Creat-5.6*# Na-142
K-4.7 Cl-100 HCO3-29 AnGap-18
[**2135-1-27**] 05:54AM BLOOD Calcium-9.2 Phos-6.7*# Mg-3.6*
[**2135-1-26**] 01:17PM BLOOD K-4.7
.
.
CHEST (PORTABLE AP) [**2135-1-26**] 4:46 PM
IMPRESSION: No pneumothorax. No acute cardiopulmonary process.
.
.
CHEST FLUORO WITHOUT RADIOLOGIST IN O.R. [**2135-1-26**] 3:52 PM
A chest fluoroscopy without radiologist was performed in the OR
to assist with a port insertion. 31 seconds of fluoro time was
used. No images were saved.
.
.
Cardiology Report ECG Study Date of [**2135-1-26**] 11:19:58 AM
Sinus rhythm. Borderline left axis deviation. Possible left
anterior fascicular
block, although non-specific. Modest non-specific lateral T wave
changes. Since
the previous tracing of [**2131-10-17**] sinus tachycardia is absent,
axis is more
leftward and T wave changes have decreased.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
71 158 94 422/444.14 60 -30 79
.
.
Brief Hospital Course:
This pt was admitted to [**Hospital1 18**] on [**2135-1-26**] for her procedure as
described above. There were no intra or post operative
complications. She had no issues overnight; her systolic blood
pressure remained in the 90's range, which is baseline for this
patient. In the morning, she went for dialysis; no complications
or issues. The patient was tolerating a regular diet and
complaining of mild pain controlled with pain medications. She
was discharged in a stable condition and should continue all
medications prior to this admission - no new changes. She should
also continue her insulin sliding scale.
Medications on Admission:
Nexuim 40', Paxil 40', Renagel 800''', Lopressor 25'', Lasix
40'', RISS
Discharge Medications:
1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for Constipation.
2. Senna 8.6 mg Capsule Sig: One (1) Tablet PO QHS TUESDAY,
THURSDAY, SATURDAY ().
3. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for Constipation.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for Pain, Fever.
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q6H (every 6 hours) as needed for Pain.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
AV graft left upper arm and right groin permacath, with
end-stage renal disease.
Discharge Condition:
stable
Discharge Instructions:
Continue your dialysis. Please have your rehab facility check
your BP closely. Take pain medication as needed. Resume home
medications.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
Please see your nephrologist as needed, as well as your PCP.
[**Name10 (NameIs) **] dialysis as scheduled.
Please see Dr [**First Name (STitle) **] - call to make an appointment. ([**Telephone/Fax (1) 10248**]
Completed by:[**2135-1-27**]
|
[
"272.0",
"250.40",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"39.27",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
3983, 3998
|
2108, 2726
|
293, 344
|
4122, 4130
|
666, 2085
|
5232, 5472
|
643, 647
|
2848, 3960
|
4019, 4101
|
2752, 2825
|
4154, 5209
|
230, 255
|
372, 560
|
582, 627
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,301
| 126,378
|
27111
|
Discharge summary
|
report
|
Admission Date: [**2174-3-29**] Discharge Date: [**2174-5-6**]
Date of Birth: [**2115-7-6**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
[**2174-3-29**] Paracentesis
[**2174-4-1**] Paracentesis
[**2174-4-5**] EGD
[**2174-4-6**] Colonoscopy
[**2174-4-6**]: ABO Incompatible liver transplant with splenectomy: open
abdomen
[**2174-4-7**]: Takeback for abdominal washout, liver Bx and closure
[**Date range (1) 66581**]/12 and [**4-19**]: Plasmapheresis
-Dobhoff feeding tube
History of Present Illness:
Mr. [**Known lastname **] [**Known lastname **] is a 58 year old gentleman from [**Country 2045**], with a
history of cryptogenic cirrhosis (?NASH) c/b by ascites, hepatic
encephalopathy, muscle wasting and varices s/p banding in [**2169**],
who was admitted with confusion, found to have SBP. He most
recently had a MELD of 22 ([**2174-2-7**]), and is undergoing Liver
Transplant Evaluation (on transplant list). On day prior to
admission, his son found that he was confused while talking on
the telephone (son had described this as garbled speech).
Patient also had abominal distention/discomfort for several days
prior to admission, as well as nausea and vomiting on the day
prior to admission. He had not been taking lactulose for 4 days
prior to admission. He had no other medication changes; he was
not taking any Tylenol, NSAIDs or alcohol. Of note, he has
diuretic refractory ascites and recently underwent therapeutic
paracentesis with 10.5L removed on [**2174-3-18**].
.
He was brought by EMS to [**Hospital3 **], where FSBS was noted to be 5
(?erroneous). He had acute on chronic renal failure with
leukocytosis, elevated potassium and elevated LFTs; he recieved
3 nebs, 2 amps of D50 and one amp of sodium bicarbonate, and was
transferred with D10 running at 150 cc an hour. He had a
negative CT and CXR prior to transfer. On arrival to [**Hospital1 18**],
initial VS were 96.5 91 108/57 16 100% 2L. Initial labs revealed
a lactatemia to 5.6, [**Last Name (un) **] with Cr to 2.9, transaminitis with
ALT/AST 2400/500. Diagnostic paracentesis revealed evidence of
SBP with an absolute PMN count of 1830. His UA was likewise
suggestive of UTI with WBC and bacteria, though he had a recent
foley placed. He received 1LNS, vanco and zosyn up front, and
later CTX following the paracentesis result. On the medicine
floor, he has been afebrile and normotensive. The team held his
diuretics and nadolol, but treated with ceftriaxone and albumin
overnight.
.
On transfer to [**Hospital Ward Name 121**] 10, patient was comfortable. He denied any
abdominal pain. He is unsure of whether he has a fever. No chest
pain, shortness of breath, nausea, vomiting, BRBPR, melena,
cough, constipation.
Past Medical History:
-cryptogenic cirrhosis diagnosed [**2167**] during GIB, currently on
transplant list
-esophageal varices s/p banding [**2169**]
-hepatic encephalopathy
Social History:
He denies EtOH in the US, but admits drinking minimally in
[**Country 2045**]. Lives with his son and daughter-in-law locally. [**Name2 (NI) **] denies
smoking currently, but smoke [**5-8**] cigarettes for "a year or two"
when he was in his early 20s. Denies illicit drug use. He is
from [**Country 2045**] and came to the US in the mid [**2142**]. He is single and
has 3 children.
Family History:
Mother died of asthma at 65, father alive and well, no health
concerns (age 72). No h/o CAD or MI.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.7 (98.2) 122/57 (92-120/50-57) 95 (88-95) 24 96%RA
(94-96%RA, 99%4L)
FSBS: 74-135
GENERAL - Pleasant, very tired-appearing, interactive NAD
HEENT - PERRLA, EOMI, sclerae icteric, membranes are dry
NECK - Supple, no JVD, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB
ABDOMEN - Distended without any discomfort on palpation, though
no rebound or guarding tenderness. Normoactive BS. Nonreducible
RLQ hernia appreciated. Previous para site on the right with
minimal serosang drainage on bandage.
EXTREMITIES - WWP, trace peripheral edema, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, oriented to person, place, time, date, and
purpose. Speech is at time difficult to understand, though his
thought processes are easy to follow. CNs II-XII grossly intact,
muscle strength 5/5 throughout, sensation grossly intact
throughout. +asterixis.
.
Pertinent Results:
ADMISSION LABS:
[**2174-3-28**] WBC-10.3# RBC-2.74* Hgb-8.5* Hct-34.6* MCV-126*#
MCH-31.1 MCHC-24.6*# RDW-16.8* Plt Ct-88* Neuts-84.0*
Lymphs-8.9* Monos-6.9 Eos-0.1 Baso-0.1
PT-74.3* PTT-56.5* INR(PT)-7.5*
Glucose-250* UreaN-23* Creat-2.9*# Na-88* K-3.9 Cl-72* HCO3-11*
AnGap-9
ALT-485* AST-2391* AlkPhos-74 TotBili-5.8* Lipase-18
cTropnT-<0.01
Albumin-1.6* Calcium-5.8* Phos-4.4# Mg-1.5*
Lactate-5.6*
[**2174-3-29**] ASCITES WBC-2510* RBC-1490* Polys-73* Lymphs-3*
Monos-24*
ASCITES TotPro-2.3 Glucose-63
.
PERTINENT LABS:
[**2174-3-29**] 09:16AM Lactate-4.7*
[**2174-3-29**] 08:05PM Lactate-2.9*
[**2174-3-31**] 06:37AM Lactate-1.9
[**2174-3-30**] 05:40AM HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE
[**2174-3-30**] 05:40AM HCV Ab-NEGATIVE
[**2174-4-1**] 03:00PM ASCITES WBC-356* RBC-[**Numeric Identifier 6586**]* Polys-48*
Lymphs-13* Monos-8* Macroph-31*
[**2174-4-1**] 03:00PM ASCITES TotPro-2.6 Albumin-1.2
.
DISCHARGE LABS:
MICROBIOLOGY:
[**2174-3-28**] Blood cultures x2: no growth
[**2174-3-29**] Peritoneal fluid: 3+ PMNs but no organisms on gram
stain, no growth on culture
[**2174-3-29**] Urine culture: no growth
[**2174-3-29**] HBV VL: not detected
[**2174-3-29**] HCV VL: not detected
[**2174-4-1**] Peritoneal fluid: no PMNs/organisms on gram stain, no
growth on culture
[**2174-4-2**] HBV VL: Not detected
.
IMAGING:
[**2174-3-28**] CXR PA/lat: Bilateral pleural effusions, small to
moderate on the right and small on the left, with adjacent
airspace atelectasis. Pnuemonia must be excluded in the proper
clinical setting.
.
[**2174-3-29**] RUQ U/S w/Doppler: The liver is shrunken and nodular,
consistent with known cirrhosis. No focal liver lesions are
seen. There is no intrahepatic biliary duct dilatation. The
common duct could not be visualized. Concentric gallbladder wall
thickening likely relates to third spacing given the presence of
cirrhosis and moderate ascites. There is sludge as well as a
developing stone within the gallbladder. The spleen is markedly
enlarged, measuring 19.3 cm. There is a moderate quantity of
free fluid in the abdomen. The pancreas is not well assessed
secondary to overlying bowel gas.
Color and spectral Doppler imaging was performed of the hepatic
vasculature. The main portal vein is patent with hepatofugal
flow. The main hepatic artery has a normal arterial waveform
with a brisk systolic upstroke. The IVC is patent.
IMPRESSION:
1. Patent main portal vein with hepatofugal flow.
2. Cirrhotic liver with evidence of portal hypertension
including moderate
ascites and splenomegaly.
3. Sludge as well as a developing stone within the gallbladder.
.
[**2174-4-5**] EGD: 3 cords of grade I varices were seen in the lower
third of the esophagus. Scar tissue from previous banding was
noted. Stomach mucosa: diffuse friability, erythema and
congestion of the mucosa with contact bleeding were noted in the
whole stomach. These findings are compatible with severe portal
hypertensive gastropathy. Normal duodenum. 10French feeding tube
was placed.
.
[**2174-4-5**] Colonoscopy: A single semi-pedunculated 8 mm polyp of
benign appearance was found in the descending colon. A cold
forceps biopsy was performed for histology at the descending
colon. The polyp was not removed given pt's coagulopathy. Small
rectal varices were seen.
.
PATHOLOGY:
[**2174-4-5**] Colonic polyp: Inflammatory type
.
Labs at Discharge:
WBC-8.7 RBC-2.45* Hgb-7.3* Hct-24.4* MCV-100* MCH-29.6
MCHC-29.8* RDW-18.3* Plt Ct-541*
Glucose-93 UreaN-36* Creat-1.4* Na-132* K-5.0 Cl-106 HCO3-21*
AnGap-10
ALT-31 AST-18 AlkPhos-113 TotBili-0.8
Calcium-8.7 Phos-3.0 Mg-2.0
tacroFK-11.9
Brief Hospital Course:
Mr. [**Known lastname **] [**Known lastname **] is a 58yoM with cryptogenic cirrhosis presenting
with confusion and asterixis, who was found to have SBP and
acute on chronic kidney disease, accompanied by metabolic
acidosis.
.
.
ACTIVE ISSUES:
# Spontaneous bacterial peritonitis: Patient had abdominal
distention and discomfort along with fevers and confusion prior
to admission, with asterixis on presentation. Diagnostic tap
supported diagnosis of SBP with PMN count of 1450, despite the
slightly hemorrhagic tap. Cause of SBP is currently unknown,
though it likely contributed to his significant confusion prior
to admission. He was treated with ceftriaxone 2g q24hr x 5 days
and albumin. Repeat tap showed no continued SBP. He was then
started on ciprofloxacin 500 mg PO daily for prophylaxis.
.
# Encephalopathy: Patient with noted confusion and garbled
speech prior to admission. This is most likely multifactorial
from SBP, as well as acute liver on chronic liver failure and
non-compliance with lactulose at home. Along with current
confirmed SBP, patient has elevated transaminases in the
thousands, without a clear source, as RUQ U/S with Doppler
demonstrated no portal vein thrombosis and no other medication
changes or recent toxins. Mental status cleared with treatment
of infection and consistent lactulose use.
.
# Cryptogenic cirrhosis: Presented with decompensated cirrhosis
with rising transaminases into the thousands, elevated INR and
bilirubin, and low albumin. MELD on admission was 40. Infection
with organ hypoperfusion was most likely the cause of
decompensation. The patient was treated with vitamin K PO for
elevated INR. EGD demonstrated Grade II non-bleeding varices. He
was evaluated by transplant surgery for possible transplant and
transferred to the SICU and on [**2174-4-6**] he was taken to the OR for
ABO incompatible liver transplant with splenectomy. He was taken
to the OR with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. At the time of surgery, they
proceeded with a side-to-side caval cavostomy due to the size
mismatch between hepatic veins of the donor and recipient.
There was initially low flow through the portal vein, prior to
completing the portal venous anastomosis, an eversion
endovenectomy was attempted and this was marginally successful.
then once the liver was implanted, completion of a jump graft
SMV to PV conduit was done, and once hepatic arteries were
completed the liver pinked up. Portal flow was checked intra-op
by radiology showing satisfactory flow. Once all connections and
splenectomy were completed, the patient was markedly
coagulopathic and despite the addition of factor VII and blood
product replacement, the medical bleeding was continuing. At
that time it was decided to pack the patient with a laparotomy
sponge, temporary abdominal closure and planned return in 24
hours for closure.
On [**2174-4-7**] the patient was taken back to the OR,an abdominal
washout and liver biopsy were done. The abdomen was closed.
Of note, the patient received plasmapheresis prior to the
transplant with splenectomy and received daily plasmapheresis
through [**4-17**] and then again on [**4-19**] in response to Anti A and
Anti B titers above accepted range. On [**2174-4-20**] the titers were
noted to be Anti A 4 and Anti B negative. No further
plasmapheresis was required and the catheter was removed. Of
note, the patient received 7 doses of ATG through POD 6. (575
grams total) He received routine ABO incompatible Steroid course
and then followed prednisone taper per protocol. MMF has been
given at 1000 mg [**Hospital1 **] since transplant and Prograf was started on
POD 1 from original transplant, and levels have been monitored
with dosing changes as appropriate.
Patient was transferred from the ICU once stable.
He was started on tube feeds on POD 7, which seemed to be well
tolerated, however the existing drains appeared to become more
milky in appearance, and the triglyceride level was almost 700.
The patient was made NPO, Tube feeds were stopped and the
patient had a PICC line placed and was started on TPN for bowel
rest. Over the course of the next few days, the drainage became
more serous in appearance again, nutrition consult was obtained
to find the most low fat tube feed, and he was started on
Vivonex, and was given counseling regarding a low fat diet.
The lateral drain was removed on POD 18, and the splenectomy bed
drain was removed on POD 23.
He was tolerating the new tubes feeds, but still had poor oral
intake. The patietn was having increased diarrhea with negative
c diff, and the tube feeds were switched to nepro with
additional benefit of lower potassium in feeds. He is tolerating
these tube feeds and has now progressed to a regular diet, with
the JP drainage remaining serous in appearance.
He is ambulating with assist, and has been recommended to be
discharged to a rehab facility for further physical therapy.
.
# Acute kidney injury: most likely prerenal azotemia from
hyperperfusion in the context of SBP (with peripheral
vasodilation). Urine was very concentrated with ketones,
suggesting hypoperfusion. Capillary leak from hypoalbuminemia
also contributing. Kidney function improved with treatment of
infection and administration of albumin. Once the patient
received the liver transplant, his renal function was already
recoved, and has continued to be within normal limits
.
# Metabolic acidosis: Patient presented with metabolic acidosis
with elevated lactate, likely due to intravascular depletion and
hypoperfusion in the setting of SBP. Also elevated in context of
liver disease (liver clears 70% of lactate). Lactate trended
down to 1.9 with treatment of infection and administration of
lacutlose. Bicarbonate also corrected to normal.
.
# Hyponatremia: Most likely from third-spacing with decreased
intravascular sensed volume. Patient was supplemented with
albumin, with improvement of sodium. Since liver transplant
this has normalized
.
#. Cachexia: Very cachectic, secondary to cirrhosis. Dobhoff for
supplemental nutrition was placed at the time of EGD, but
patient self-discontinued this tube. Tube feeds with Vivonex at
95cc/hr were initiated post chyle leak. He developed some
diarrhea with this tube feed, and has now been switched to Nepro
with improved tolerance.
Patient is now ambulating with assistive device and physical
therapy
.
Medications on Admission:
1. Lasix 60 mg daily.
2. Lactulose titrated to three bowel movements daily (had not
taken for four days prior to admission).
3. Nadolol 20 mg daily.
4. Omeprazole 20 mg daily.
5. Spironolactone 50 mg daily (not taking).
6. Daily multivitamin.
Discharge Medications:
1. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. tenofovir disoproxil fumarate 300 mg 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 DAILY (Daily).
5. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO Q24H
(every 24 hours).
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
7. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours).
10. prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Follow transplant clinic taper.
11. insulin regular human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED).
12. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
Spontaneous bacterial peritonitis
Cryptogenic cirrhosis
s/p ABO incompatible liver transplant with splenectomy c/b chyle
leak
Malnutrition
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:
Please contact the Transplant Office [**Telephone/Fax (1) 673**] if you have
any of the following:
temperature of 101 or greater, chills, nausea, vomiting,
jaundice, inability to eat/drink or take any of your
medications, clogged feeding tube, increased abdominal pain,
increased fluid out the drains, incision or drain insertion
sites appear red or have drainage on dressing, abdominal
bloating, diarrhea or constipation.
.
Please check labs every Monday and Thursday; CBC, Chem 10, AST,
ALT, Tbili, Alk Phos, trough Prograf level, fax results to the
transplant clinic at [**Telephone/Fax (1) 697**].
Please do not add, delete or changes doses of any medications
without first consulting the transplant clinic due to
significant interactions with immunosuppressants that can occur.
.
Please drain and record the JP drain three times daily and as
needed. It is very important to monitor this drain for any
changes in appearance. It is currently serous in appearance,
monitor for cloudy/white drainage in bulb or if the drain output
becomes green in color, increases or develops a foul odor.
Patient had a chyle leak, but has tolerated a regular diet and
Nepro tube feeds, if the chyle returns please cll the transplant
clinic immediately.
.
Patient may shower, no tub baths or swimming
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2174-5-9**] 10:30, [**Last Name (NamePattern1) **], [**Hospital **] Medical Office
Building, [**Location (un) **], [**Location (un) 86**], MA
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2174-5-16**] 10:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14955**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2174-5-23**] 10:45
Completed by:[**2174-5-6**]
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47,962
| 196,410
|
7999
|
Discharge summary
|
report
|
Admission Date: [**2187-1-16**] Discharge Date: [**2187-1-19**]
Date of Birth: [**2157-1-1**] Sex: F
Service: PLASTIC
Allergies:
Vicodin
Attending:[**First Name3 (LF) 28638**]
Chief Complaint:
CC: implant site infection
Major Surgical or Invasive Procedure:
Removal of right breast implant and washout of right breast
wound.
History of Present Illness:
HPI: Ms. [**Known lastname 28639**] is a 30 year old women with a past medical
history significant for right-sided breast cancer s/p
chemoradiation and bilateraly mastectomies with reconstruction
complicated by infection admitted to an OSH yesterday with fever
and hypotension. She last saw her surgeon [**1-10**] who removed a
[**Last Name (un) **] from her right nipple, which has been complicated by
nonhealthing and drainage since reconstructive surgery in
[**Month (only) **]. She presented to [**Hospital **] hospital yesterday ([**1-15**])
with severe right breat pain, fever and chills, headache, and
dizziness. Initial ED vitals were T 102, HR 125, BP 100/61. She
got doses of Unasyn and gentamiycin as well as 2.5L IVF for a BP
of 76/40 before being admitted to OSH ICU. In the unit there,
she recieved vancomycin and gentamycin for right breast
cellulitis. She had an echo that did not show any evidence of
effusion or tamponade to cause her hypotension. She recieved
morphine and Toradol for her pain; per OSH d/c summary, Toradol
was more effective. Pt also states that Dilaudid (which she got
in the ED) helped. Labs at OSH were remarkable for WBC 23.7
(left shifetd with 13% bands), Hct 27. During her OSH stay, she
received 5L IVF and BP was 96/50 at the time of transfer. She
was reported to be making adequate urine despite her lower BPs.
Per patient, her pressures at her PMD's office are typically
110s/70s. She is being transfered to [**Hospital1 18**] for continued care as
her surgeon, Dr. [**Last Name (STitle) **], also operates here.
.
On arrival to [**Name (NI) 153**], pt compains of severe pain. She has
right-sided chest pain that is worse with deep inspirations. She
had palpitations earlier today which were treated as anxiety. +
nausea, but no vomiting or abdomninal pain. Otherwise, ROS
negative.
.
Onc Hx: R breast lump found in [**2184**], had double mastectomy in
[**2185**] followed by 18 months of chemo (including Taxol and
Herceptin) which was completed in [**2186-7-4**]. She aslo had 6
weeks of XRT, after which she required replacement of her
implants in 5/[**2186**]. She is B/L latissimus dorsi flaps, and her
most recent surgery was [**10/2186**] (nipple reconstruction by
[**Doctor Last Name **] at [**Hospital1 882**]). She has since had nonhealing of right
reconstruction with area of eschar (for which she has been using
wet to dry dressing but has been having purulent d/c).
Past Medical History:
hyperlipidemia
right breast cancer s/p bilateral mastectomies with latissimus
flap reconstruction
radiation
Social History:
(per OSH notes): Current smoker, 1ppd x 17 years. Social EtOH
use. No ilicit drug use. Works as a nanny. Lives with her
boyfriend and 2 children, ages 10 and 3.
Family History:
(per OSH notes): immediate family healthy, no known family Hx of
malignancy, although her mother was adopted.
Physical Exam:
VS: Temp: 98.9, BP: 91/45, HR: 80, RR: 14, O2 sat 95%
GEN: Alert, oriented and appropriate. Uncomfrotable [**3-7**] pain.
HEENT: pupils equil, scleras and conjunctiva clear B/L, slightly
dry MM
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, soft, nt
EXT: warm, no c/c/e
SKIN: right nipple errythema and tenderness, eschar noted around
surgical site
NEURO: no focal deficit
Pertinent Results:
LABS:
[**2187-1-16**] 07:15PM PT-15.0* PTT-31.4 INR(PT)-1.3*
[**2187-1-16**] 07:15PM PLT SMR-NORMAL PLT COUNT-174
[**2187-1-16**] 07:15PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2187-1-16**] 07:15PM NEUTS-78* BANDS-4 LYMPHS-12* MONOS-5 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2187-1-16**] 07:15PM WBC-21.7* RBC-3.09* HGB-9.8* HCT-31.0*
MCV-100* MCH-31.6 MCHC-31.5 RDW-12.4
[**2187-1-16**] 07:15PM ALBUMIN-3.1* CALCIUM-7.2* PHOSPHATE-2.0*
MAGNESIUM-1.6
[**2187-1-16**] 07:15PM estGFR-Using this
[**2187-1-16**] 07:15PM GLUCOSE-79 UREA N-7 CREAT-0.6 SODIUM-139
POTASSIUM-3.8 CHLORIDE-115* TOTAL CO2-18* ANION GAP-10
[**2187-1-16**] 08:53PM LACTATE-0.7
[**2187-1-17**] 04:33AM BLOOD WBC-17.1* RBC-2.83* Hgb-9.4* Hct-27.8*
MCV-98 MCH-33.0* MCHC-33.6 RDW-12.5 Plt Ct-159
[**2187-1-17**] 04:33AM BLOOD Plt Ct-159
[**2187-1-17**] 04:33AM BLOOD Glucose-78 UreaN-5* Creat-0.6 Na-138
K-3.9 Cl-112* HCO3-18* AnGap-12
[**2187-1-17**] 04:33AM BLOOD Calcium-7.3* Phos-2.5* Mg-2.4
[**2187-1-18**] 08:50AM BLOOD WBC-15.0* RBC-3.21* Hgb-10.2* Hct-30.8*
MCV-96 MCH-31.9 MCHC-33.3 RDW-12.1 Plt Ct-200
[**2187-1-18**] 08:50AM BLOOD Plt Ct-200
[**2187-1-18**] 08:50AM BLOOD Glucose-154* UreaN-6 Creat-0.6 Na-138
K-4.2 Cl-107 HCO3-24 AnGap-11
[**2187-1-18**] 08:50AM BLOOD Calcium-8.8 Phos-2.6* Mg-2.0
.
MICROBIOLOGY (still pending final results upon discharge)
[**2187-1-16**] 6:48 pm SWAB Source: right breast.
GRAM STAIN (Final [**2187-1-16**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2187-1-18**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
.
[**2187-1-17**] 6:10 pm SWAB RT BREAST IMPLANT SEROMA.
GRAM STAIN (Final [**2187-1-17**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
.
RADIOLOGY
Radiology Report UNILAT BREAST US RIGHT PORT Study Date of
[**2187-1-16**] 7:06 PM
IMPRESSION: No evidence of abscess or fluid collection within
the right
breast. Soft tissue edema is compatible with cellulitis.
Brief Hospital Course:
[**Hospital Unit Name 13533**]:
30yo F s/p double mastectomy, chemo/XRT, and recontructive
surgeries x 3 who was transfered from OSH with right breast
cellulitis and hypotension responsive to fluids.
.
# Breast Cellulitis: Seen by Plastic Surgery and Dr. [**Last Name (STitle) **].
After examining her and looking at the CT from the OSH, they
feel her right implant is infected. They plan to take her to the
OR on [**1-17**] for implant removal. Pt. left ICU for surgical
procedure. Continued on broad spectrum abx with vancomycin and
Unasyn. Was given 1g Tylenol ATC with 0.5-1mg Dilaudid q2 hours
PRN. Zofran PRN nausea.
.
# Hypotension: Meets SIRS criteia with hypotension and fever, so
sepsis [**3-7**] to foreign body infection as noted above. Ucx done
and pending at time of dsicharge.
Reported as fluid responsive from OSH and has responded to fluid
thus far here (102/53 after 2L NS). Continued to bolus PRN if
SBP drops into 80s. Will toelrate SBPs 90s/50s given pt
mentating appropriately and continues to have good UOP.
.
# dyslipidemia: held home statin for now
.
Emergency Contact: [**Name (NI) **],[**First Name3 (LF) **]
Relationship: MOTHER
Phone: [**Telephone/Fax (1) 28640**]
[**Name2 (NI) 7092**]: full
.
Patient went to OR with Dr. [**Last Name (STitle) **] on [**2187-1-17**] and had removal
of right breast implant and washout of right breast wound. She
tolerated the procedure well and her vital signs remained stable
and she was transferred to the floor post surgery. She was
given some dilaudid IV for pain relief post surgery and this
caused her to itch so she was given benadryl with good relief.
Patient's peri-areolar surgical incision remained clean, dry and
intact and her JP drain turned from serosanguinous to serous
fluid output. She remained afebrile with stable blood pressure
and generally asymptomatic of infection. She was maintained on
Unasyn and Vancomycin IV as an inpatient. Patient complained of
incessant headache on [**2187-1-18**] and found no relief with extra
strength tylenol. She reported that she got these headaches
from time to time and they were resistant to treatment with
tylenol, ibuprofen and Fioricet. When questioned further,
patient reported drinking highly caffeinated energy drinks daily
and she had not had any while in the hospital. Offered patient
oxycodone 5mg PO and she found some relief with this. Headache
did resolve after fiorocet, and PO intake.
On [**1-20**] ID recommended to discharge pt on Linezolid vs IV vanco
as well as augmentin. Mass Health request for linezolid approval
was requested. Pt did not wish to wait for approval and demanded
to be discharged on [**1-20**], understanding the expenses involved
in non coverage Linezolid use. Plastic surgery team spent 30
minutes explaining the options to the patient in a family
meeting. It was decided to give the patient her last VANCOMYCIN
and Unasyn dose prior to discharge and patient would be
contact[**Name (NI) **] on the morrow regarding approval or non-approval of
unasyn. If Linezolid is not approved patient understands the
need for a PICC and vancomycin treatment.
Pt has follow up with plastic surgery in 3 days.
Medications on Admission:
simvastatin 10 mg daily
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain: Max 8/day. Do not exceed
4gms/4000mg of tylenol per day.
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day:
Last dose PM on [**2187-1-27**].
Disp:*20 Tablet(s)* Refills:*0*
4. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day: Last dose: PM on [**2187-1-27**].
Disp:*20 Tablet(s)* Refills:*0*
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation for 7 days.
Disp:*14 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right breast cellulitis/infection
hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted on [**2187-1-16**] for Removal of right breast
implant and washout of right breast wound. Please follow these
discharge instructions.
.
Personal Care:
1. Leave your right breast dressing in place for 48 hours post
surgery
2. Clean around the drain site(s), where the tubing exits the
skin, with soap and water.
3. Strip drain tubing, empty bulb(s), and record output(s) [**3-8**]
times per day.
4. A written record of the daily output from each drain should
be brought to every follow-up appointment. your drains will be
removed as soon as possible when the daily output tapers off to
an acceptable amount.
5. You may shower daily. No baths until instructed to do so by
Dr. [**Last Name (STitle) **].
6. cover the nipple area with a clean, dry dressing daily to
wear beneath the surgibra.
.
Activity:
1. You may resume your regular diet.
2. DO NOT lift anything heavier than 5 pounds or engage in
strenuous activity until instructed by Dr. [**Last Name (STitle) **].
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered.
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so do
not take these meds with additional Tylenol.
4. Take prescription pain medications for pain not relieved by
tylenol.
5. Take your antibiotics as prescribed.
6. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
7. 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.
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
welling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
DRAIN DISCHARGE INSTRUCTIONS
You are being discharged with drains in place. Drain care is a
clean procedure. Wash your hands thoroughly with soap and warm
water before performing drain care. Perform drainage care twice
a day. Try to empty the drain at the same time each day. Pull
the stopper out of the drainage bottle and empty the drainage
fluid into the measuring cup. Record the amount of drainage
fluid on the record sheet. Reestablish drain suction.
Please note, you preffered to leave the hospital prior to
receiving approval for the antibiotic Linezolid. As discussed
approval does take about 24 hours. There is no guarantee that
this medication will be approved. If this is the case you will
need to have a special IV placed and an antibiotic call
vancomycin which you have been receiving in the hospital will be
administered through the IV.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] this coming Monday. please
call her office to schedule appointment time: [**Telephone/Fax (1) 1416**]. The
Plastic Surgery team resident on call (on Saturday [**1-20**]) will
contact you regarding the request for approval of your
antibiotic linezolid. If you do not hear from them by the
afternoon please call the # provided to you and ask to page the
plastic resident on call.
Completed by:[**2187-1-23**]
|
[
"E878.1",
"611.0",
"305.1",
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"V10.3",
"996.69",
"995.91",
"272.0",
"V87.41",
"288.60",
"V15.3",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"85.94"
] |
icd9pcs
|
[
[
[]
]
] |
10006, 10012
|
6058, 9238
|
294, 363
|
10102, 10102
|
3709, 5468
|
13909, 14370
|
3146, 3258
|
9313, 9983
|
10033, 10081
|
9264, 9290
|
10253, 13886
|
3273, 3690
|
228, 256
|
5761, 5776
|
391, 2820
|
5809, 6035
|
10117, 10229
|
2842, 2951
|
2967, 3130
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
488
| 178,969
|
46782
|
Discharge summary
|
report
|
Admission Date: [**2172-3-30**] Discharge Date: [**2172-4-2**]
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 79-year-old female
with a past medical history significant for coronary artery
disease, status post myocardial infarction in [**2172-4-4**],
osteoporosis, cataracts, asthma, osteoarthritis, who
presented to the Emergency Department from rehabilitation
after being found unresponsive. She was reportedly not using
her left arm, and had left neglect, at which time the
physician left the room for help, and when he returned, the
patient was on the floor suffering from left-sided
tonic-clonic seizure activity. The patient did not syncopize
per report. According to the patient, she recalls having
indigestion, vomited bile, she denied headache, dizziness,
palpitations, shortness of breath. She did not recall
falling, denied fainting in the past. She had no other
complaints.
PAST MEDICAL HISTORY: 1. Osteoarthritis. 2. Asthma. 3.
Coronary artery disease status post myocardial infarction in
[**2169-4-5**]. 4. Osteoporosis. 5. Cataracts.
ALLERGIES: Penicillin.
MEDICATIONS: 1. Albuterol metered dose inhaler. 2. Atrovent
metered dose inhaler. 3. Fluticasone 2 puffs b.i.d. 3.
Theophylline 300 mg b.i.d. 4. Aspirin 81 mg p.o. q.d. 5.
Colace p.r.n. 6. Levaquin 500 p.o. q.d. [**3-28**] to [**4-3**]. 7.
Indocin 25 mg p.o. q. 8 hours [**3-28**] to [**4-3**].
SOCIAL HISTORY: At nursing home rehabilitation, previously
lived alone in [**Location (un) 4628**].
PHYSICAL EXAMINATION: Vital signs showed a fingerstick of
131, blood pressure 123-153/45-69, 100% on one liter nasal
cannula, respiratory rate 15, heart rate in the 40s. In
general she was lying in bed, pleasant in no apparent
distress. HEENT: Pupils were equal, round, and reactive to
light, extraocular movements intact, no nystagmus, oropharynx
was clear with symmetric palate elevation. Neck: Jugular
venous pressure was irregular due to AV dissociation, supple.
Cardiovascular: There was a 2-3/6 systolic ejection murmur
at the left and right sternal borders, no rubs or gallops.
Lungs: Decreased breath sounds at the left base, occasional
crackles in the bases bilaterally. Abdomen: Active bowel
sounds, soft, nontender, nondistended, no organomegaly.
Extremities: No edema. Mental status: Alert to month,
year, not place, stated she was in [**Location (un) **] at rehabilitation.
Neurologic: Examination was nonfocal. Palate raised
symmetrically. There was 3+/5 strength in the intrinsic hand
muscles on the left; 4+/5 on the right intrinsic hand
muscles. Upper and lower extremity strength was [**6-8**]
bilaterally and symmetric. Nonfocal examination, no facial
asymmetry, no word-finding difficulty, no pronator drift.
LABORATORY DATA: On admission white count was 8.3,
hematocrit 31.9, baseline 31.[**2169-12-9**], platelet count
559, MCV 81, neutrophils 69%, bands 0%, lymphocytes 14%,
monocytes 6%. INR was 1.1. PTT 27.3, PT 12.8. Sodium 127,
down from baseline 135, potassium 4.7, chloride 89,
bicarbonate 23, BUN 11, creatinine 1, glucose 116, CK 135, CK
MB 2, troponin less than 0.3.
Head CT without contrast showed no intracranial hemorrhage,
no mass effect, a large foci versus small infarction in the
right occipital lobe, lacunar infarct in the left basal
ganglia region.
EKG showed complete heart block, ventricular rate of 61,
atrial rate of 90, normal axis, QTC 454, QRS 86. Carotid
ultrasound from [**2169-8-5**] showed mild 60-65% stenosis
proximal left right coronary artery, no hemodynamically
significant plaque in the right bulb or proximal internal
carotid artery.
HOSPITAL COURSE: The patient is a 79-year-old woman with a
history of coronary artery disease status post myocardial
infarction. She was admitted after an episode of emesis,
left-sided neglect and seizure activity who was found to be
in complete heart block. The patient was noted to be
hemodynamically stable during the time in the Emergency
Department with systolic blood pressures in the 120s to 150s
and a ventricular rate ranging from the 40s to the 60s,
without any evidence of distress. Since it couldn't be
determined as to whether the patient had complete heart block
as the cause of a possible global ischemia leading to the
unmasking of a focal brain lesion leading to the one-sided
deficit, the patient was transferred to the coronary care
unit for a temporary transvenous wire pacer placement. This
was done on the evening of admission. The patient had a
right internal jugular placed for this purpose and the
transvenous wire was placed into the right ventricle without
difficulties. The patient was monitored overnight, and did
not have any hemodynamic instability requiring the pacer to
be utilized. In the meantime, AV nodal blocking agents
including phenytoin were avoided. The patient had an EKG
done the following morning and had a transthoracic
echocardiogram. The transthoracic echocardiogram
demonstrated a left ventricular ejection fraction of greater
than 55%, a sclerotic aortic valve, and some trace mitral
regurgitation. It was noted that this may be underestimated
due to cardiac echo shadows during the examination.
On the 25th the patient was taken for pacemaker implantation.
The patient had a DDD pacer placed, model 5370, serial
#[**Serial Number 99285**], serial lot #[**Serial Number 99286**]. The patient withstood the
procedure without difficulty, and subsequent to pacer
placement, had a chest x-ray which demonstrated the leads to
be in the appropriate position. The pacer was interrogated
and found to be in good working condition. Subsequent to
pacer placement, the patient's heart rate elevated to the 80s
and 90s, and her systolic blood pressure was consistently in
the 140s to 160s. Thus it was determined in the setting of
this new hypertension, the patient was initiated on a beta
blocker on [**4-2**]. She was started on atenolol 25 q.d.
As for the potential seizure, neurology was consulted in the
Emergency Department. It was determined that the complete
heart block would take precedence over the possible
neurological event. As stated previously on admission, a CT
of the head did not demonstrate any new evidence of infarct
or bleed, and even in the Emergency Department there was no
evidence of left-sided neglect, and only possible mild
decreased strength in the intrinsic hand muscles on the left,
otherwise her examination was nonfocal. She was scheduled
for an EEG.
Due to the evidence of possible lacunar infarcts in the past
in addition to a possible transient ischemic attack which
could have explained the brief period of left-sided neglect
as well as seizure activity, it was determined to start the
patient on pravastatin 20 mg q.d. since the patient was
likely at risk for microvascular disease, especially in light
of her previous myocardial infarction. A lipid panel was
sent, and demonstrated levels within normal limits such as
triglycerides 83, HDL 51 and LDL 96. Of course it may be
slightly depressed in the setting of an acute event. The
patient also had carotid Dopplers performed, at this time the
final [**Location (un) 1131**] is not available, but suggested that there was
still significant plaque in the left internal carotid artery
with narrowing of approximately 60-69%, but no significant
plaques in the right internal carotid artery. There was also
normal antegrade flow in the vertebral arteries. Any further
neurological work-up was deferred as an outpatient.
Also in this setting there was concern that the hyponatremia,
if it occurred rapidly, could have also played a role in her
seizure activity. But her baseline sodium had previously
been low, approximately 135. Urine and electrolytes were
sent and a TSH was sent, though it was assumed that the
patient had recently had a few days of Lasix in the past and
may have just been volume depleted. She was thus given
normal saline with appropriate correction of her sodium to
the mid-130s.
For her asthma the patient was continued on the Flovent
metered dose inhalers b.i.d., albuterol and Atrovent p.r.n.,
and her theophylline was held briefly due to mildly elevated
theophylline. It was reinitiated at discharge. The patient
was then discharged back to rehabilitation after being deemed
unsafe to return home by physical therapy and occupational
therapy.
DISCHARGE DIAGNOSES:
1. Third degree heart block status post DDD pacemaker
placement.
2. Transient ischemic attack versus seizure.
FOLLOW-UP APPOINTMENT: Device clinic on [**4-13**], 9:30 AM;
and with primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1270**].
DISCHARGE MEDICATIONS:
1. Atenolol 25 mg p.o. q.d.
2. Cepacol lozenges p.r.n.
3. Pravastatin 20 mg p.o. q.d.
4. Levofloxacin 250 mg p.o. x 1 day.
5. Dipyridamole aspirin one capsule b.i.d.
6. Tylenol p.r.n.
7. Fluticasone 2 puffs b.i.d.
8. Albuterol metered dose inhaler and Atrovent metered dose
inhaler p.r.n.
9. Aspirin 81 mg p.o. q.d.
10. Theophylline 300 mg b.i.d.
11. Colace 100 mg b.i.d. p.r.n.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12175**], M.D. [**MD Number(1) 37596**]
Dictated By:[**Name8 (MD) 8876**]
MEDQUIST36
D: [**2172-4-2**] 12:26
T: [**2172-4-2**] 12:38
JOB#: [**Job Number 99287**]
|
[
"733.00",
"493.90",
"414.01",
"780.39",
"276.1",
"435.9",
"715.90",
"401.9",
"426.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.26",
"37.78",
"37.72",
"37.83"
] |
icd9pcs
|
[
[
[]
]
] |
8381, 8492
|
8675, 9321
|
3649, 8360
|
1532, 2302
|
8516, 8652
|
117, 909
|
2318, 3631
|
932, 1407
|
1424, 1509
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,787
| 189,443
|
2542
|
Discharge summary
|
report
|
Admission Date: [**2125-10-16**] Discharge Date: [**2125-10-23**]
Date of Birth: [**2044-1-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6473**]
Chief Complaint:
fever, hypotension
Major Surgical or Invasive Procedure:
Hemodialysis
Central line placement
Tunneled hemodialysis line placement
History of Present Illness:
This is a 81 M with pmh of ESRD on HD, AFib, CHF, C diff
colitis, h/o klebsiella urosepsis, recent MRSA line infeciton on
vancomycin, presenting with fever, chills, and hypotension. He
reports feeling well until the morning of [**10-16**], when he awoke
with fevers, chills, and lightheadedness. He also experienced
non-bloody emesis X1. he went to the ED where his temperature
was 101.4, blood pressure was in the 60's. He was immediatley
bolused with 2 liters of NS, had LIJ placed and started on
levophed. He was also given vancomycin, zosyn, and
levofloxacin. ABG showed lactate trending from 2.5 to 1.1 after
fluid resuscitation. On arrival to the patient was afebrile
with BP 109/65, HR 86, 21 100% on face mask, CVP 9. levophed was
weaned down from .05 to .02. Central Venous O2 sat was 85%, and
lactate was 0.9.
Past Medical History:
- Stage IV CKD
- Atrial fibrillation
- h/o GI bleed, diverticulitis
- C. Diff colitis
- h/o stroke 12 years ago w/ right-sided weakness; second stroke
5 years ago
- h/o nephrolithiasis w/ stent and nephrostomy tube
- CAD s/p MI
- sleep apnea not on cpap
- h/o klebsiella urosepsis
- depression
- PFTs [**2117**] with mild restrictive ventilatory defect
-Anemia with h/o iron deficiency
Social History:
Lives with wife [**Name (NI) **], h/o smoking [**12-20**] PPD for 50 years, quit
20 years ago, does not drink alcohol, no drugs.
Family History:
non-contributory
Physical Exam:
Tmax: 36.2 ??????C (97.2 ??????F)
Tcurrent: 34.9 ??????C (94.9 ??????F)
HR: 82 (70 - 93) bpm
BP: 101/54(63) {96/47(58) - 113/69(77)} mmHg
RR: 16 (16 - 27) insp/min
SpO2: 97%
Heart rhythm: A Flut (Atrial Flutter)
Height: 66 Inch
General Appearance: Well nourished, Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles :
, No(t) Wheezes : )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended
Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t)
Clubbing
Skin: Not assessed
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, Tone: Not assessed
Pertinent Results:
[**2125-10-16**] 08:15PM TYPE-CENTRAL VE
[**2125-10-16**] 08:15PM LACTATE-0.9
[**2125-10-16**] 06:00PM CALCIUM-8.3* PHOSPHATE-3.8 MAGNESIUM-1.5*
[**2125-10-16**] 06:00PM CALCIUM-8.3* PHOSPHATE-3.8 MAGNESIUM-1.5*
[**2125-10-16**] 04:10PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2125-10-16**] 04:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2125-10-16**] 04:10PM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2125-10-16**] 03:53PM TYPE-MIX PO2-75* PCO2-43 PH-7.42 TOTAL CO2-29
BASE XS-2 INTUBATED-NOT INTUBA
[**2125-10-16**] 03:53PM LACTATE-1.1
[**2125-10-16**] 03:53PM O2 SAT-93
[**2125-10-16**] 12:43PM COMMENTS-GREEN TOP
[**2125-10-16**] 12:43PM LACTATE-2.5*
[**2125-10-16**] 12:30PM GLUCOSE-111* UREA N-37* CREAT-4.1*#
SODIUM-138 POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-30 ANION GAP-17
[**2125-10-16**] 12:30PM ALT(SGPT)-23 AST(SGOT)-30 ALK PHOS-139*
AMYLASE-56 TOT BILI-0.7
[**2125-10-16**] 12:30PM GLUCOSE-111* UREA N-37* CREAT-4.1*#
SODIUM-138 POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-30 ANION GAP-17
[**2125-10-16**] 12:30PM ALT(SGPT)-23 AST(SGOT)-30 ALK PHOS-139*
AMYLASE-56 TOT BILI-0.7
[**2125-10-16**] 12:30PM proBNP-9288*
[**2125-10-16**] 12:30PM WBC-10.8 RBC-3.13* HGB-9.6* HCT-28.5* MCV-91
MCH-30.5 MCHC-33.5 RDW-18.6*
[**2125-10-16**] 12:30PM NEUTS-93.1* LYMPHS-4.4* MONOS-2.1 EOS-0.2
BASOS-0.1
[**2125-10-16**] 12:30PM PLT COUNT-172
[**2125-10-16**] 12:30PM PT-15.8* PTT-27.0 INR(PT)-1.4*
CXR [**2125-10-20**]
FINDINGS: In comparison with the study of [**10-18**], there has been
placement of a right internal jugular catheter that extends to
the level of the carina in the mid portion of the SVC. Left
jugular catheter has been pulled back so that the tip is near
the junction with the subclavian vein.
The retrocardiac region appears somewhat clearer than on the
previous study.
Brief Hospital Course:
Assessment: 81M w/ ESRD on HD, Diastolic CHF, afib, previous
line infections currently being treated with vancomycin,
presenting with GNR bacteremia.
Hospital course:
The patient was admitted to the medical ICU with fever and
hypotension. He was empirically treated with linezolid for MRSA
and VRE, and zosyn for broad gram negative coverage. He
underwent hemodialysis the day after admission and the line was
removed by interventional radiology at that time. Blood cultures
eventually grew out e.coli, sensitive to gentamicin, zosyn, and
bactrim, and resistent to ampicillin and all cephalosporins. He
was continued on zosyn but then switched to gent for dosing
during HD. A temporary line was placed on [**2125-10-19**] for HD use
and then converted to a tunnelled line on [**2125-10-22**]. The new line
was successfully used for hemodialysis on [**2125-10-23**].
He initally had low BPs and required low doses of levophed, but
this was weaned off on hospital day four. He was initially
covered with linezolid as well while blood cultures were pending
given h/o VRE, but this was changed back to vancomycin to
complete his course for MRSA bacteremia from prior admission.
His last dose of vancomycin was administered on [**2125-10-23**]. He
will continue gentamicin, dosed at hemodialysis, until [**2125-10-31**].
The patient also has a history of atrial fibrillation but has
previously declined warfarin anticoagulation. He was continued
on aspirin during his hospital stay. The patient's anemia was
also evaluated as an inpatient and he made be a candidate for
epogen in the future. His iron studies were consistent with an
anemia of chronic disease. Because he has COPD, the patient was
continued on his tiotroprium inhalers.
The patient also has obstructive sleep apnea and was continued
on CPAP qHS at home settings: CPAP 10 with 4 liters 02 at 150 mL
of dead space. He periodically refused to wear his CPAP mask and
subsequently desatted to the 70s during these episodes.
Medications on Admission:
1. Tiotropium Bromide 18 mcg Capsule,
2. Aspirin 81 mg Tablet, Chewable Sig:
3. Fluoxetine 10 mg Tablet
4. Multivitamin
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
7. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1) inhalation
Inhalation every four (4) hours
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO twice a day.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Gentamicin 40 mg/mL Solution Sig: Ninety (90) mg Injection
QHD (each hemodialysis) for 8 days: Last dose 11/12.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Primary:
Staph aureas bacteremia
E. coli sepsis
.
Secondary:
Atrial fibrillation
Hypertension
Diabetes
Dyslipidemia
End stage renal disease
Discharge Condition:
Stable
Discharge Instructions:
You were admitted because of an infection from your hemodialysis
line. We treated you with antibiotics to clear the infection.
You also developed a second infection and we started you on an
additional antibiotic. We also performed hemodialysis while you
were here.
.
Please take all of your medications as prescribed. Please keep
all of your follow-up appointments. You should continue to take
your antibiotics as prescribed.
.
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:
Provider MASK FITTING TECHNICIAN Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2125-10-24**] 1:00
Provider [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD Phone:[**Telephone/Fax (1) 1579**]
Date/Time:[**2125-12-4**] 1:30
Provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]/DR. [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2126-1-4**] 11:20
Completed by:[**2125-10-25**]
|
[
"403.91",
"496",
"428.30",
"401.9",
"428.0",
"996.62",
"427.31",
"585.6",
"250.00",
"995.91",
"038.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8240, 8334
|
4785, 4936
|
335, 410
|
8519, 8528
|
2826, 4762
|
9160, 9610
|
1841, 1859
|
7275, 8217
|
8355, 8498
|
6805, 7252
|
4953, 6779
|
8552, 9137
|
1874, 2807
|
277, 297
|
438, 1267
|
1289, 1678
|
1694, 1825
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,232
| 182,000
|
38144
|
Discharge summary
|
report
|
Admission Date: [**2132-7-2**] Discharge Date: [**2132-7-3**]
Date of Birth: [**2055-3-15**] Sex: M
Service: SURGERY
Allergies:
Nitroglycerin
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
tearing midchest and back pain
Major Surgical or Invasive Procedure:
Portion of EGD at the bedside in the ICU
History of Present Illness:
Mr. [**Known lastname 805**] is a 77 yo s/p repair of ascending aortic aneurysm
vs type A [**Known lastname **] [**2115**]. He has a known type B thoracic
aortic [**Year (4 digits) **] which has been followed with serial
exams/studies. Over the last 2 months Mr. [**Known lastname 805**] has been
experiencing worsening shortness of breath and not feeling well.
He was admitted for several days one month ago for blood
pressure control, and discharged on [**6-3**]. He reports that
he has been compliant with his medications since then, though
his blood pressures have been running in the 130s-140s when he
checks them at home. He went to his PCP [**5-29**] where he had a CXR
which showed ?increase in aneurysm size and he was sent to [**Hospital1 18**]
ED for eval. A CTA in the ED showed a large 7cm descending
aortic aneurysm w/acute on chronic [**Hospital1 **], starting just
distal to prior graft anastomosis and extending to just above
the celiac axis. He saw both Dr. [**Last Name (STitle) 914**] and Dr. [**Last Name (STitle) **] as an
outpatient and had completed some preoperative studies including
an echo and pMIBI. He presents to the ED today after waking with
a tearing mid chest/back pain. CT scan reveals acute intramural
hematoma superimposed on a chronic Type B [**Last Name (STitle) **]. He is
hemodynamically stable. He reports that the pain persists, and
that morphine only takes the edge off for a short while. He
also attests to shortness of breath that is brought on by the
pain and improves with morphine. He denies any fevers/chills,
and reports that his appetite has been good at home.
Past Medical History:
type A aortic [**Last Name (STitle) **], s/p repair
chronic type b aortic [**Last Name (STitle) **]
7cm descending aortic aneurysm
hypercholesterolemia
hypertension
obesity
coronary artery disease
paraesophageal hernia
sleep apnea
renal insufficiency
diverticulosis
chronic back pain
hematuria
benign prostatic hypertrophy
vertigo
Echo [**2132-5-9**]: EF 60%, nml LV, Grade I diastolic dysfunction,
trivial AI, trace MR
Social History:
Retired constructon worker, Bus Driver. Married with 6 children.
- Tobacco history: None
- ETOH: None
- Illicit drugs: None
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: died when he was 13-14 unclear cause
- Father: unknown
Physical Exam:
At time of initial vascular consult:
Vital Signs: Temp: 96.8 RR: 18 Pulse: 63 BP: 161/93
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Neck: No masses, Trachea midline, Thyroid normal size,
non-tender, no masses or nodules, No right carotid bruit, No
left
carotid bruit.
Nodes: No clavicular/cervical adenopathy, No inguinal
adenopathy.
Skin: No atypical lesions.
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: Non distended, No masses, Guarding or rebound,
No hepatosplenomegally, No hernia, No AAA.
Rectal: Not Examined.
Extremities: No popiteal aneurysm, No femoral bruit/thrill, No
RLE edema, No LLE Edema, No varicosities, No skin changes.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RUE Radial: P.
LUE Radial: P.
RLE Femoral: P. Popiteal: P. DP: P. PT: P.
LLE Femoral: P. Popiteal: P. DP: P. PT: P.
Pertinent Results:
[**2132-7-2**] 11:40AM BLOOD WBC-6.7 RBC-4.11* Hgb-13.0* Hct-36.7*
MCV-89 MCH-31.7 MCHC-35.4* RDW-14.3 Plt Ct-192
[**2132-7-2**] 05:16PM BLOOD WBC-9.3 RBC-3.94* Hgb-12.5* Hct-36.1*
MCV-92 MCH-31.6 MCHC-34.5 RDW-14.3 Plt Ct-197
[**2132-7-3**] 01:43AM BLOOD WBC-9.6 RBC-3.89* Hgb-12.2* Hct-35.8*
MCV-92 MCH-31.3 MCHC-34.1 RDW-14.5 Plt Ct-192
[**2132-7-3**] 05:06AM BLOOD Hct-34.3*
[**2132-7-3**] 02:31PM BLOOD WBC-8.0 RBC-3.04* Hgb-9.5* Hct-28.7*
MCV-95 MCH-31.1 MCHC-33.0 RDW-14.3 Plt Ct-137*
[**2132-7-2**] 11:40AM BLOOD PT-12.8 PTT-24.3 INR(PT)-1.1
[**2132-7-3**] 01:43AM BLOOD PT-13.4 PTT-26.5 INR(PT)-1.1
[**2132-7-3**] 02:31PM BLOOD PT-16.1* PTT-34.7 INR(PT)-1.4*
[**2132-7-2**] 11:40AM BLOOD Glucose-133* UreaN-19 Creat-1.5* Na-142
K-4.8 Cl-108 HCO3-25 AnGap-14
[**2132-7-2**] 05:16PM BLOOD Glucose-114* UreaN-17 Creat-1.5* Na-142
K-3.4 Cl-109* HCO3-24 AnGap-12
[**2132-7-3**] 01:43AM BLOOD Glucose-132* UreaN-22* Creat-1.8* Na-142
K-3.6 Cl-108 HCO3-23 AnGap-15
[**2132-7-2**] 11:40AM BLOOD cTropnT-<0.01
[**2132-7-3**] 01:43AM BLOOD CK-MB-1 cTropnT-<0.01
[**2132-7-2**] 05:16PM BLOOD Calcium-8.8 Phos-3.4 Mg-2.1
[**2132-7-3**] 01:43AM BLOOD Albumin-4.1 Calcium-8.8 Phos-3.6 Mg-2.1
[**2132-7-3**] 01:43AM BLOOD ALT-13 AST-18 LD(LDH)-175 AlkPhos-59
Amylase-99 TotBili-0.4
Wet Read: MDAg WED [**2132-7-2**] 12:40 PM
new acute intramural hematoma in the descending thoracic aorta
(type B)
superimposed on stable type B [**Year (4 digits) **]. No further inferior
extension of
[**Year (4 digits) **] into abdomen.
d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1785**] [**Last Name (NamePattern1) **] (Cardiac surgery, PA) in person 12:37pm
[**2132-7-2**].
Wet Read Audit # 1
Final Report
INDICATION: Severe chest pain, evaluate for worsening
[**Year (4 digits) **].
COMPARISON: [**2132-5-29**].
TECHNIQUE: Volumetric multidetector CT of the chest was
performed after
administration of 100 mL of Visipaque intravenous contrast.
Coronal, sagittal, and oblique reformats were obtained for
evaluation.
CT CHEST WITH INTRAVENOUS CONTRAST: The patient is status post
prior repair of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11916**] type A aortic [**Last Name (NamePattern4) **]. Again seen
is the [**Location (un) 11916**] type B [**Location (un) **] originating at the surgical
site in the aortic arch, just distal to the origin of the left
subclavian artery and terminating at superior margin of the
ostium for the celiac axis. False lumen thrombosis is stable.
New from the prior study is an acute intramural hematoma
extending from the aortic arch superiorly to just proximal to
the termination of the [**Location (un) **] inferiorly (2:82). The
intramural hematoma spans the intimal flap, indicating it is not
increased thrombosis of the false lumen, and is well seen on
2:64 with mass effect on the true and false lumens. The overall
aortic diameter at that level, essentially unchanged, measuring
5.8 cm, previously 5.6 cm. Pulmonary arterial vasculature is
well visualized to the subsegmental level without filling defect
to suggest pulmonary embolism. No pathologically enlarged
mediastinal, axillary or hilar lymph nodes are present. The
heart and pericardium are within normal limits. There is no
pleural or pericardial
effusion. A moderate hiatal hernia is slightly increased in size
since
[**2132-5-29**]. Lung window images demonstrate bibasilar atelectasis.
There is no worrisome nodule, mass, or consolidation. The study
is not tailored for subdiaphragmatic evaluation. The intimal
flap terminates at superior margin of the ostium for the celiac
axis (301b:33) so all mesenteric vessels originate from the true
lumen. Scattered diverticula are seen throughout the colon
without inflammatory changes. The visualized
portions of the appendix are normal. IMPRESSION:
1. New acute type B intramural hematoma superimposed on stable
type B aortic
[**Year (4 digits) **]. Unchanged thrombosis of the false lumen and stable
aortic size.
2. Moderate hiatal hernia is increased from [**2132-5-29**].
3. Diverticulosis without diverticulitis.
Findings discussed with [**First Name8 (NamePattern2) 1785**] [**Last Name (NamePattern1) **] (CT surgery PA) in person,
12:37 p.m.
[**2132-7-2**].
Discussed with Dr. [**Last Name (STitle) 914**] (CT surgery attending) in person, 1
p.m. [**2132-7-2**]
Discussed with Dr. [**First Name4 (NamePattern1) 1692**] [**Last Name (NamePattern1) **] (vascular surgery resident) by
phone 1:15 p.m.
[**2132-7-2**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**]
Approved: WED [**2132-7-2**] 5:34 PM
Imaging Lab
Brief Hospital Course:
Mr. [**Known lastname 805**] is a 77 y/o gentleman who has had an ascending
aortic aneurysm repair in the past and has a known type B
thoracic aortic [**Known lastname **]. He was admitted for
several days one month ago for blood pressure control, and
discharged on [**6-3**]. He reports that he has been compliant
with his medications since then, though his blood pressures have
been running in the 130s-140s when he checks them at home. He
saw both Dr. [**Last Name (STitle) 914**] and Dr. [**Last Name (STitle) **] as an outpatient and had
completed some preoperative studies including an echo and pMIBI.
On [**2132-7-2**], he experienced acute tearing chest pain at his left
upper chest radiating to the back and was told to come to the ER
emergently. He was admitted to the ICU for BP control and an
expedited workup to plan for open TAA repair. He was started on
a nicardipine drip. He was on dilaudid PCA for chest pain
management. Pain was resolved with BP control. Vascular and
cardiac surgery consultation and operative planning continued.
Cardiology saw the patient and in assessing his overall status
and reviewing his outpatient testing felt as if there was no
contraindication to moving forward with aortic surgery to repair
his [**Date Range **].
Overnight on his first hospital night the patient had three
episodes of coffee ground emesis, but no hemodynamic compromise.
GI was consulted. He reported episodic usage of naproxen around
once a week and daily use of aspirin. Otherwise he denies any hx
of peptic ulcer disease or prior GI bleeding. He reported a
history of GERD and daily PPI usage. An aortic-esophageal
fistula seemed extremely unlikely in this case and GI felt as if
gastritis or gastric erosions were more likely the source of
bleeding. Nevertheless we felt it was important to identify and
characterize the nature of the UGIB before proceding with
operative TAA repair and the incipient heparinization, cardiac
bypass etc. Bedside EGD was planned for [**7-3**] with MAC anesthesia
in order to evaluate for potential causes of bleeding prior to
aortic surgery. If no bleeding source visualized, lumbar drains
were to be placed that day as well in preparation for surgery
the following AM. A protonix drip was started. The patient did
not tolerate MAC anesthesia and was choking and gagging
throughout the initial portion of the procedure and he was
deemed to be at a high risk for aspiration. The EGD was aborted
and discussion was had with the patient and his family about
repeating the EGD in the afternoon with elective intubation.
Consent was obtained, he was intubated by the ICU staff, and
preparations were being made to begin the EGD. He had been
vomiting prior to intubation. The mouthpiece was placed to
prepare for the EGD and the patient was being turned slightly
into the right lateral decubitus position and his tele alarmed
showing no pulse or blood pressure, pulse check found there to
be no pulse and a code was called, compressions were initiated,
the patient went into PEA. Multiple rounds of chest
compressions, epi, bicarb, atropine were given. Echo showed
empty RV/LV with no ventricular activity and the code was called
at 2:54 pm
An autopsy was performed identifying the ascending aorta graft
anastamoses to be intact. A Type B [**Month/Year (2) **] arising distal to
the left subclavian artery, with reentry at the celiac trunk was
seen. Rupture of adventitia in the left anterior mediastinum
with abundant hematoma dissecting through the mediastinal soft
tissue and 3 liters of blood filling the chest cavity causing
atelectasis of the left lung. No GI bleeding source was
identified.
Medications on Admission:
MEDICATIONS:
Albuterol PRN
ASA 81'
Zolpidem 5'
Pravastatin 40'
Meclizine 12.5'''P
Nifedipine CR 60'
Lisinopril 40'
Toprol 100'
Nexium 40'
Discharge Disposition:
Expired
Discharge Diagnosis:
PEA arrest secondary to aortic rupture and subsequent
hypovolemic shock
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
Completed by:[**2132-8-4**]
|
[
"578.0",
"414.01",
"785.59",
"403.90",
"278.00",
"530.19",
"585.9",
"327.23",
"272.0",
"300.00",
"441.03",
"V15.82",
"530.81",
"553.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"45.13",
"96.04",
"99.63"
] |
icd9pcs
|
[
[
[]
]
] |
12369, 12378
|
8521, 12180
|
302, 344
|
12493, 12503
|
3677, 8498
|
12560, 12598
|
2603, 2785
|
12399, 12472
|
12206, 12346
|
12527, 12537
|
2800, 3658
|
232, 264
|
372, 1997
|
2019, 2442
|
2458, 2587
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,061
| 189,339
|
21845
|
Discharge summary
|
report
|
Admission Date: [**2135-1-1**] Discharge Date: [**2135-1-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
transfusion of pRBCs
History of Present Illness:
Ms. [**Known lastname 57309**] is a [**Age over 90 **] yo Russian speaking only female with PMH
of CHF, Afib on coumadin, HTN and dementia, presenting from
[**Hospital 100**] Rehab with a one day h/o melena. Per her son, pt was more
lethargic than her baseline on the day prior to admission and
melena was noted at her longterm care facility. Baseline Hct
approximately 37 on last admission. HCT from 25.8 two days ago
and was noted to be 14.7 upon presentation to the ED. She has no
prior h/o GIB, but is anticoagulated for PMH of atrial
fibrillation with RVR. Admission INR 11.2.
.
In the ED was given 2 units of FFP and 2 units of PRBCs as well
as 2LNS Vitamin K and started on a PPI gtt. Initially her BP
was in 70s systolic, after fluids and blood, her BP increased to
100s. No further stools.
Past Medical History:
CAD
CHF EF 25% per son
AFib on Coumadin
HTN
CRI
Cholelithiasis
Depression
Dementia (severity unclear)
Cataracts
Glaucoma
Hyperlipidemia
Social History:
Lives at [**Hospital6 459**]. No toxic habits.
Family History:
non-contributory
Physical Exam:
AFebrile BP 80s/40s, HR 70s
GEN: Cachectic pale woman lying in bed moaning
HEENT: Pale conjunctiva, dry MM, anicteric
CVS: Irreg irreg with regular rate, nl s1s2
LUNGS: CTA b/l (but poor inspiratory effort)
ABD: Soft, NT, ND, NABS
Rectal: Melena, guiac +
Pertinent Results:
[**2135-1-1**] 04:20PM WBC-3.9* RBC-1.51*# HGB-4.7*# HCT-14.7*#
MCV-98 MCH-31.5 MCHC-32.3 RDW-18.6*
[**2135-1-1**] 04:20PM NEUTS-72.5* LYMPHS-24.2 MONOS-2.9 EOS-0.2
BASOS-0.1
[**2135-1-1**] 04:20PM PLT COUNT-183
.
[**2135-1-1**] 04:20PM PT-87.0* PTT-50.4* INR(PT)-11.2*
[**2135-1-1**] 11:16PM HCT-23.7*#
[**2135-1-1**] 11:18PM PT-30.1* INR(PT)-3.1*
.
[**2135-1-1**] 04:20PM CK-MB-NotDone cTropnT-0.22*
[**2135-1-1**] 04:20PM CK(CPK)-68
[**2135-1-1**] 11:16PM CK-MB-8 cTropnT-0.27*
Brief Hospital Course:
This is a [**Age over 90 **] yo woman who presented with melena and an 11 point
Hct drop, anticoagulated with INR = 11.2 on admission. Hospital
course outlined by problem below:
# Melena- Likely GI Bleed in setting of INR of 11.2. GI
consulted and evaluated patient. She recieved 3 units pRBCs
with Hct 34.7 from 14.4 in ED. Coagulopathy reversed with 2
units FFP and Vit K. She was admitted to the ICU for close
monitoring. Two large bore peripheral IVs were maintained for
access. She was given a IV PPI. Serial Hcts were followed and
remained stable. All anti-coagulation was held - including ASA
and coumadin. Anti-hypertensives were also held given unstable
blood volume. Twice daily Hct should be checked tomorrow, as
well as daily Hct for the following 2 days to ensure stablility.
.
# CAD- EKG in ED showed diffuse ST depressions. This resolved
with improvement in her Hct.
.
# Hypernatremia - This was likely due to volume depletion.
Lasix was held. She received free water intravenously with
improvement in her Na. A repeat Na should be checked tomorrow,
and periodically.
.
# AFib on Coumadin- She was continued on digoxin 0.125 mg every
other day for rate controll; coumadin was held. She should not
resume coumadin therapy without discussion with her family re
risks and benefits.
.
# HTN - At baseline treated with Imdur, Lasix, Coreg and
Hydralazine. These were held pending stabilization of her Hct.
.
# ARF on CRI: Her renal function improved with IV hydration.
Her lasix should be held for now; renal function should be
reassessed in [**1-9**] days.
.
# Diet: She was given IV fluid hydration. She was made NPO
pending stabilization of her Hct. She may resume her diet per
prior.
Code Status: DNR/DNI - confirmed with son, [**Name (NI) 57310**] [**Name (NI) 57311**]
[**Telephone/Fax (1) 57312**]
Medications on Admission:
Aspirin 81mg daily
Trazadone 25mg at bedtime
Digoxin 0.125mg every other day
Allopurinol 100mg every other day
Trusopot eye drop
Imdur 60mg daily
Coumadin as directed
Tylenol prn
Milk of magnesia prn
Vitamin B12 50mcg daily
Sorbitol 15ml daily
Lasix 20mg daily
Aranesp 25 mcg weekly
Coreg 25mg [**Hospital1 **]
Hydralazine 10mg tid
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
4. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3
times a day).
5. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 6 days.
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for hr <60, sbp <100.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
11. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO every other
day.
12. Aranesp SureClick -Polysorbate 25 mcg/0.42 mL Pen Injector
Sig: One (1) injection Subcutaneous once a week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
coumadin induced coagulopathy
melena
hypernatremia
.
Secondary
CAD
CHF EF 25%
AFib on Coumadin
HTN
CRI
Cholelithiasis
Depression
Dementia (severity unclear)
Cataracts
Glaucoma
Hyperlipidemia
Discharge Condition:
Hct 33.8 at 2pm on Monday.
Discussed discharge plan by telephone with NP [**First Name5 (NamePattern1) 1894**] [**Last Name (NamePattern1) 57313**]
and Dr. [**Last Name (STitle) **].
Discharge Instructions:
You were hospitalized for blood in your stool; we found that the
level of coumadin in your blood was too high, which caused you
to bleed. We reversed this level and your bleeding stopped on
its own. we transfused you with blood products to keep you blood
counts high. You were also given free water for dehydration.
.
We think it is most useful for you to not restart the coumadin,
as it give you a risk of bleeding again. Please also do not take
your aspirin until instructed to do so by your doctor.
.
We are also holding most of your antihypertensives for now since
you had some low blood pressures while here. Your primary doctor
will tell you when to resume these.
.
Please take all medicines as prescribed and keep all your
followup appointments. If you experience any furhter blood in
your stools, or if you are lightheaded or dizzy, please notify
your doctor or go to the ED.
Followup Instructions:
Please follow-up with Nurse [**First Name4 (NamePattern1) 1894**] [**Last Name (NamePattern1) 57313**]
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"578.9",
"585.9",
"790.92",
"584.9",
"V58.61",
"427.31",
"276.50",
"428.0",
"294.8",
"428.32",
"272.4",
"403.90",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
5475, 5541
|
2199, 4037
|
274, 296
|
5785, 5970
|
1676, 2176
|
6903, 7145
|
1366, 1384
|
4419, 5452
|
5562, 5764
|
4063, 4396
|
5994, 6880
|
1399, 1657
|
228, 236
|
324, 1125
|
1147, 1285
|
1301, 1350
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,800
| 193,403
|
46521+58922
|
Discharge summary
|
report+addendum
|
Admission Date: [**2109-6-25**] Discharge Date: [**2109-7-7**]
Date of Birth: [**2028-5-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Diltiazem
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2109-7-2**] Coronary artery bypass grafting x3: Left internal mammary
artery graft to left anterior descending, reverse saphenous vein
graft to the right coronary artery and the marginal branch.
[**6-26**] Cardiac Cath
History of Present Illness:
81 yo F with h/o PAF s/p multiple cardioversions and failed drug
therapy with increasing CHF symptoms and recent drop in EF to
30%. The patient states that
she has had increased dyspnea on exertion, fatigue, and cough
without sputum. Also has had increasing abdominal girth, but has
lost 7 lbs in the past couple of months due to poor appetite.
She is referred for cardiac catheterization today which revealed
3VD and we are asked to consult for surgical revascularization.
Past Medical History:
Hypertension
Paroxysmal Atrial Fibrillations/p failed treatement with sotalol
and dronedarone s/p multiple DCCV
Nonischemic Cardiomyopathy
Osteoporosis, recent lumbar compression fracture [**2109-3-16**], s/p
pelvic fracture 5 years ago
Lumbar degeneration s/p injections
H/o Papillary thyroid Carcinoma
[**Last Name (un) 8061**] syndrome
Basal Cell CA s/p excisions
rotator cuff injury without repair
Hiatal Hernia
Gastroesophageal reflux disease
s/p total thyroidectomy with lymph node resection s/p oral
chemotherapy and radiation s/p radioactive iodine [**2103**]
Pelvic organ prolapse, s/p hysterectomy with anterior/posterior
colporrhaphy
s/p bilateral cataract surgery
s/p Tonsillectomy
Social History:
- widowed, ex-office manager
- has 1 son, [**Name (NI) **] ([**Telephone/Fax (1) 98803**])
- [**Name2 (NI) **] smoked
- no EtOH
- no illicit drug use
Family History:
There is family history of premature coronary artery disease or
sudden death.
- Father died from MI at 53
- younger brother had CABG and catheterization at age 76
Physical Exam:
Pulse:100 Resp:18 O2 sat:94%RA, 97% 2L
B/P Right:149/85 Left:135/70
Height:5'0" Weight:49kg
General:NAD, alert and cooperative
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
Abdomen: Soft [x] non-distended x[] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
Neuro: Grossly intact
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: none Left:none
Pertinent Results:
[**2109-7-5**] 05:10AM BLOOD WBC-9.3 RBC-4.22 Hgb-12.6 Hct-36.8 MCV-87
MCH-29.9 MCHC-34.4 RDW-18.1* Plt Ct-192
[**2109-7-4**] 04:00PM BLOOD WBC-8.9 RBC-3.99* Hgb-12.2 Hct-34.4*
MCV-86 MCH-30.6 MCHC-35.5* RDW-18.3* Plt Ct-160
[**2109-7-5**] 05:10AM BLOOD PT-30.5* PTT-33.7 INR(PT)-3.0*
[**2109-7-4**] 03:06AM BLOOD PT-17.7* PTT-31.8 INR(PT)-1.6*
[**2109-7-2**] 01:55PM BLOOD PT-15.2* PTT-40.0* INR(PT)-1.3*
[**2109-7-2**] 12:30PM BLOOD PT-15.0* PTT-29.4 INR(PT)-1.3*
[**2109-7-2**] 05:50AM BLOOD PT-14.0* PTT-68.6* INR(PT)-1.2*
[**2109-7-6**] 04:50AM BLOOD Glucose-85 UreaN-23* Creat-0.8 Na-134
K-3.7 Cl-98 HCO3-27 AnGap-13
[**2109-7-5**] 05:10AM BLOOD Glucose-84 UreaN-24* Creat-1.0 Na-132*
K-4.5 Cl-96 HCO3-26 AnGap-15
[**6-26**] Cath: 1. Selective coronary angiography of this right
dominant system
demonstrated three vessel coronary artery disease. The LMCA had
no angiographically apparent coronary artery disease. The LAD
had a calcific proximal 80% lesion. There was mild disease in
the distal vessel. The LCx had a proximal 80% lesion after a
severely retroflexed takeoff. The distal vessel was widely
patent. The RCA had diffuse disease with serial 50% lesions in
the proximal, mid and distal portion. 2. Limited resting
hemodynamics revealed mildly elevated right sided filling
pressures with RVEDP 14 mmHg. The left sided filling pressures
were moderately elevated with PCWP of 18 mmHg. The cardiac
index was calculated using an assumed oxygen consumption and was
2.1 l/min/m2. The central aortic pressure was normal at 136/60
mmHg.
[**6-27**] Carotid U/S: There is less than 40% stenosis within the
internal carotid arteries bilaterally.
[**6-27**] Chest CT: 1. Minimal calcification dilated ascending aorta.
2. Possible right upper lobe bronchogenic carcinoma. 3. Severe
cardiomegaly, predominantly left atrial and left ventricular,
possible pulmonary arterial hypertension, severe coronary
atherosclerosis. 4. Severe left basal atelectasis due to a
combination of moderate left pleural effusion and lower lobe
bronchomalacia. 5. Cystic liver lesions, not clearly benign
biliary cysts. Further evaluation recommended. 6. Possible 4 mm
mid esophageal polyp (4:80).
[**6-29**] Head MRI: No evidence of acute infarcts or enhancing brain
lesion. No mass effect or hydrocephalus. Mild changes of small
vessel disease and a small right parietal cortical chronic
infarct.
Intra-op TEE
Pre Bypass: The left atrium is dilated. The right atrium is
dilated. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is moderate
global left ventricular hypokinesis (LVEF = 30% %). The right
ventricular cavity is mildly dilated with normal free wall
contractility. The ascending aorta is mildly dilated. There are
complex (>4mm) atheroma in the aortic arch. The descending
thoracic aorta is mildly dilated. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. There is no aortic valve stenosis. Moderate (2+)
eccentric aortic regurgitation is seen. The aortic regurgitation
jet is eccentric and therefore difficult to quantify; unable to
obtain a useable pressure half time or decleration time on the
aortic valve. The mitral valve leaflets are mildly thickened.
Mild to moderate ([**12-29**]+) mitral regurgitation is seen. There are
pericardial calcifications.
Post Bypass: Patient is AV paced on Epinepherine 0.03
mcg/kg/min. Biventricular function appears slightly improved
LVEF 40% on ionotropes. Ventricular septum appears diskinetic,
consistent with ventricular pacing. Mitral regurgitation and
Aortic Regurgitation are unchanged from baseline. Tricuspid
regurgitation is now mild to moderate. Aortic contours intact.
Remaining Exam is unchanged. All findings discussed with
surgeons at the time of the exam.
date INR coumadin dose
7/7 -- 3mg
[**7-4**] 1.6 3
[**7-5**] 3.0 0.5
[**7-6**] 2.5 1
[**7-7**] 2.7 0.5
Brief Hospital Course:
81 year old female who was admitted on [**2109-6-25**] complaining of
shortness of breath with PAF s/p multiple cardioversions and
failed drug therapy with increasing CHF symptoms and recent drop
in EF to 30%. On [**6-26**] she underwent a cardiac cath which
revealed severe coronary artery disease and she was referred for
surgical intervention. She was appropriately medically managed
and underwent extensive pre-operative work-up. On [**7-2**] she was
brought to the operating room where she underwent a coronary
artery bypass graft x 3. Please see operative report for
surgical details. Within 24 hours she was weaned from sedation,
awoke neurologically intact and extubated. Chest tubes were
removed on post-op day one. Beta-blockers and diuretics were
initiated and she was diuresed towards her pre-op weight. On
post-op day two she was transferred to the telemetry floor for
further care. She did develop post-operative a-fib and was
started on amio and dig. She had an episode of bradycardia, and
amiodarone and digoxin were discontinued. Electrophysiology was
consulted for assistance with medical management. She was
anti-coagulated with coumadin. She worked with physical therapy
for strength and mobility. She was not started on an ACE
inhibitor, as her blood pressure would not tolerate it, and the
primary goal was to titrate her beta-blocker as tolerated. This
will be addressed as an outpatient. By the time of discharge on
POD 5, the wound was healing and pain was controlled with oral
analgesics. She was discharged to rehab for further recovery.
All follow up instructions and appointments were advised.
Medications on Admission:
- Esomeprazole magnesium (Nexium) EC, 40 mg, 1 cap, QD
- Furosemide 20 mg, 2 tabs, QAM
- Levothyroxine (synthroid), 150 mcg, 1 tab, 6 days/wk; 0.5 tab
on Sundays
- Metoprolol succinate SR, 25 mg, 1 tab, QD
- Ranitidine HCl 150 mg, 1 cap, QD
- Risedronate (actonel) 35 mg, 1 tab, once weekly
- Warfarin 3 mg, 1 tab, qd (LAST DOSE on [**6-22**] pre cardiac cath)
- Calcium citrate- Vit D3, 315mg-200 unit, 2 tab, [**Hospital1 **]
- Cyanobalamin (Vit B12), 1000 mcg, 1 tab, QD
- MVI- minerals- Lutein (Centrum silver), 1 tab, 3x wkly
- Vit C- Vit E- Copper- ZnOx- Lutein (PreserVision)-
226mg-200u-5mg-0.8mg-34.8mg cap, qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): MD
to dose daily for goal INR [**1-30**], for dx: a-fib.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO QSUN
(every Sunday).
8. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO Q MON-SAT
().
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day:
40mg [**Hospital1 **] x 1 week, then 40mg daily ongoing.
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day: 40mEq
daily x 1 week, then 20mEq daily ongoing.
13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
14. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week.
15. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
16. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
17. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
18. PreserVision 226-200-5 mg-unit-mg Capsule Sig: One (1)
Capsule PO once a day.
19. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypas Graft x 3
Hypertension
Paroxysmal Atrial Fibrillations/p failed treatement with sotalol
and dronedarone s/p multiple DCCV
Nonischemic Cardiomyopathy
Osteoporosis, recent lumbar compression fracture [**2109-3-16**], s/p
pelvic fracture 5 years ago
Lumbar degeneration s/p injections
H/o Papillary thyroid Carcinoma
[**Last Name (un) 8061**] syndrome
Basal Cell CA s/p excisions
rotator cuff injury without repair
Hiatal Hernia
Gastroesophageal reflux disease
s/p total thyroidectomy with lymph node resection s/p oral
chemotherapy and radiation s/p radioactive iodine [**2103**]
Pelvic organ prolapse, s/p hysterectomy with anterior/posterior
colporrhaphy
s/p bilateral cataract surgery
s/p Tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - no erythema or drainage, black eschar at inferior pole
Leg -Left - healing well, no erythema or drainage.
Edema 1+ bilateral LEs
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 call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon:
Dr. [**Last Name (STitle) **] on Thursday, [**8-8**] at 1:15
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2109-8-14**] 1:00
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1407**] [**Telephone/Fax (1) 1408**] in [**12-29**] weeks
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 120**] or [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 3342**]
in [**12-29**] weeks
Thoracic surgery Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 3020**] in [**2-28**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Check INR [**2109-7-8**], MD to dose coumadin daily for goal INR [**1-30**]
for a-fib
Completed by:[**2109-7-7**] Name: [**Known lastname 15802**],[**Known firstname 1940**] B. Unit No: [**Numeric Identifier 15803**]
Admission Date: [**2109-6-25**] Discharge Date: [**2109-7-7**]
Date of Birth: [**2028-5-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Diltiazem
Attending:[**First Name3 (LF) 741**]
Addendum:
It should be noted that the patient experienced an acute on
chronic exacerbation of her CHF.
Her heart failure should be further classified as systolic heart
failure. This condition was further compromised by her atrial
fibrillation, especially when her ventricular response rate was
rapid.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1502**]
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2109-8-7**]
|
[
"443.0",
"428.0",
"428.23",
"530.81",
"518.1",
"414.01",
"413.9",
"244.0",
"518.89",
"733.00",
"V10.87",
"401.9",
"427.31",
"425.4",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"36.15",
"88.56",
"37.23",
"39.61",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
14617, 14833
|
6797, 8430
|
294, 517
|
11827, 12077
|
2771, 6774
|
12916, 14594
|
1921, 2085
|
9100, 10912
|
11050, 11806
|
8456, 9077
|
12101, 12893
|
2100, 2752
|
235, 256
|
545, 1020
|
1042, 1738
|
1754, 1905
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,312
| 133,997
|
1746
|
Discharge summary
|
report
|
Admission Date: [**2183-11-16**] Discharge Date: [**2183-11-25**]
Date of Birth: Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 9919**] is a 73 year old
Caucasian male with a history of diabetes mellitus,
hypertension, and hypercholesterolemia who was in usual state
of health until [**2183-7-9**], when he wanted to join a gym.
Due to his age, he was requested to have a stress test which
showed abnormal results, including regional wall motion
abnormalities, severe hypokinesis in the anterior wall, and
apex, and anterolateral central septal walls on the
echocardiogram. Due to the result of this echocardiogram,
the patient underwent a cardiac catheterization [**7-23**],
showing 90% proximal right coronary artery stenosis, diffuse
disease in mid-RCA and 40% distal right coronary artery
stenosis, 30% proximal left anterior descending stenoses, 90%
mid-LAD stenosis and 60% distal left anterior descending
stenosis. There was also 90% stenosis in the diagonal
branches. For these lesions, the patient received PTCA with
two stents placed in the right coronary artery, PTCA with
Rotablator to the left anterior descending with two stents.
During this procedure, the D1 branch was obstructed and
required balloon and stenting.
The patient tolerated his procedure well and was doing well
after his catheterization until [**2183-11-16**], when he
presented with a temperature of 101.0 F., to the Emergency
Department with right lower quadrant abdominal pain similar
to his diverticulitis which he has had before. While
drinking Baricon contrast in preparation for an abdominal CT
scan in the Emergency Department, the patient developed 10 on
10 chest pain while he had no history of chest pain ever in
the past, with a [**Street Address(2) 2051**] depressions in leads V3 to V6, [**Street Address(2) 7093**] depressions in leads II, III and AVF. The patient was
given an aspirin, 5 mg of intravenous Lopressor, he was
heparinized and given three sublingual Nitroglycerin
initially with resolution of pain.
However, his pain recurred and his ST depressions became more
pronounced. The patient was rushed to the Catheterization
Laboratory. In the Catheterization Laboratory on [**2183-11-16**], the patient was found to have a cardiac output of
4.3, a pulmonary wedge pressure of 22 and a PA pressure of
42/22. A study of the patient's coronaries showed mild
disease of the left main coronary artery. The left anterior
descending had 40% proximal stenosis and 90% in-stent
restenosis with a 99% ostial D1 disease. The left circumflex
was without critical disease. The right coronary artery had
a focal 90% in-stent restenosis. The patient underwent PTCA
of these lesions. During the procedure, the patient became
hypotensive requiring Dopamine for pressure support. He also
dropped his oxygen saturation transiently requiring urgent
intubation. This intubation was complicated by a lip
laceration. At this time, an intra-aortic balloon pump was
placed.
Overall, the patient received intervention of a kissing
balloon inflation in left anterior descending and D1 with 30%
residual stenosis in D1 as well as a balloon in the right
coronary artery with zero percent residual stenosis. The
patient was transferred to the Coronary Care Unit following
his catheterization for further care.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Diabetes mellitus.
4. Diverticulosis in [**2178**].
5. Coronary artery disease.
MEDICATIONS ON ADMISSION:
1. Aspirin.
2. Glyburide 2.5 mg twice a day.
3. Zantac.
4. Lipitor.
5. Zestril.
6. Glucophage.
7. A recent course of Amoxicillin stopped on [**11-22**] for
right lower lobe pneumonia.
SOCIAL HISTORY: The patient quit cigarette smoking 25 years
ago. He lives with his wife currently.
FAMILY HISTORY: His father died of myocardial infarction at
age 53.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: On admission to the Coronary Care
Unit, temperature of 98.7 F.; heart rate of 90; blood
pressure of 112/56; saturating 100% on 100% FIO2. The
patient was intubated and sedated. Head, Eyes, Ears, Nose
and Throat revealed no icterus; the patient had moist mucous
membranes. The patient has a left upper lip laceration which
was oozing slightly on anti-coagulation. Chest examination
revealed rhonchorous breath sounds in the right anterior
chest with decreased breath sounds at the right lung base.
Cardiovascular examination revealed regular rate and rhythm.
There was no murmur appreciated. Abdomen examination
revealed a soft abdomen with diffuse normoactive bowel sounds
with questionable suprapubic tenderness. Extremity
examination revealed warm extremities with no edema.
LABORATORY: Studies on admission showed a hematocrit of
39.6, a white count of 9.4, platelet count of 311.
Differential on the white count included 87% neutrophils and
10% bandemia. Chemistry on admission revealed a sodium of
137, potassium 4.6, chloride of 100, bicarbonate of 27, BUN
of 17, creatinine 0.9 and glucose of 139. Coagulation
studies revealed an INR of 1.2, PTT of 31.2. Initially on
admission to the Emergency Department, the patient had a
troponin of 5 and first CK was 65.
His hemoglobin A1C was 6 measured in [**2183-9-8**]. His
LDL was 50, triglycerides of 115, total cholesterol of 119
and HDL of 46.
COURSE IN HOSPITAL: The patient was transferred directly
from the catheterization laboratory to the Coronary Care
Unit. With acute coronary syndrome, the patient had received
therapeutic intervention with percutaneous transluminal
coronary angioplasty of his two diseased vessels. The
patient was continued on aspirin, Lipitor, heparin,
Integrilin and Plavix. Cardiothoracic Surgery was consulted
for potential bypass surgery. The patient was supported with
intra-aortic balloon pump as well as two peripheral pressors,
Dopamine and Levophed on initial arrival to the Coronary Care
Unit.
The patient was intubated in the Coronary Catheterization
Laboratory for airway protection. In the Coronary Care Unit
we continued sedation and mechanical ventilation until
patient was further stabilized.
With the patient's presenting symptoms of left lower quadrant
pain to the Emergency Department, and an elevated white count
with 10% of bandemia, it was highly suspected that the
patient had a recurrence of his diverticulitis. He was put
on intravenous levofloxacin and Flagyl for treatment of his
diverticulitis and was made n.p.o. except for medications. A
CT scan of his abdomen was not obtained at this time due to
the patient's instability for transport. The patient's
diabetic medicines were held and he was covered on Regular
insulin sliding scale.
An echocardiogram was obtained on [**2183-11-17**], to
evaluate the patient's cardiac function post his acute
myocardial injury. He was found to have an ejection fraction
of 25 to 30%. Overall, his left ventricular systolic
function was severely depressed. There was severe global
left ventricular hypokinesis with some preservation of basal
septal lateral and posterior wall motion. There was no
significant valvular regurgitations or stenoses seen on this
echocardiogram.
On [**2183-11-17**], the patient's right femoral arterial
and venous sheath was discontinued. A right internal jugular
central line was inserted on this date with placement of a
Swan-Ganz catheter to further monitor the patient's
hemodynamics. The patient remained intubated and sedated
with intra-aortic balloon pump as well as two pressors for
blood pressure support. On the Swan-Ganz catheter, the
patient was found to have low pulmonary artery diastolic
pressure which raises a question of volume depletion in the
setting of a possible inferior myocardial infarction. The
patient was bolused with normal saline for volume repletion.
On the same date, the patient was noted to have dropped his
hematocrit from 39 on presentation to the Emergency
Department to 27.9 on the evening of [**2183-11-17**].
There were no sources of bleeding notable except for minor
oozing from his left lip laceration. The patient was
transfused one unit of packed red blood cells. The patient
responded very well to volume repletion with normal saline as
well as a unit of packed red blood cells and was able to be
weaned off intra-aortic balloon pump on [**2183-11-19**].
He still required pressure support with 5 mics of Dopamine.
The patient's CK in his serum peaked at a total of 1035 on
the morning of [**2183-11-18**]. As the patient became
hemodynamically stabilized and is now weaned off the
intra-aortic balloon pump, the patient was weaned to
extubation and was successfully extubated on [**2183-11-19**]. On the same day, the patient was weaned off all
pressors.
By [**11-20**], the patient was hemodynamically stable. His
pressure was now able to tolerate a low dose beta blocker as
well as an ACE inhibitor. He was requiring some supplemental
oxygen by nasal cannula. This was thought to be due to a
minor congestive heart failure for which he received Lasix
for gentle diuresis. During his entire stay in the Coronary
Care Unit the patient was kept on intravenous Levofloxacin
and Flagyl. His white blood cell count was slowly resolving.
His blood cultures were all negative. By [**2184-11-19**],
when the patient was extubated and weaned off sedation, the
patient reported no left lower quadrant discomfort. He had
normoactive bowel sounds and a benign abdomen on examination.
The patient's diet was advanced from n.p.o. to full liquids
by [**11-20**]. At this time, all of his p.o. medications
including his diabetic medications were restarted. The
patient tolerated his medications very well.
The patient was transferred out of the Coronary Care Unit to
the Cardiac Floor on the [**11-21**]. At this time, the
patient had requested specifically to have Dr. [**Last Name (STitle) **], who is
a family friend, to be his cardiologist. Dr. [**Last Name (STitle) **] accepted
the patient on [**11-21**], and became his new attending
physician. [**Name10 (NameIs) **] patient, meanwhile, continues to recover.
His antibiotics were converted to oral antibiotics. His diet
was advanced to a regular diet as tolerated. The patient was
evaluated by Physical Therapy and was ambulating well on the
floor. His oxygen saturation improved with gentle diuresis
and by [**11-22**], his oxygen saturation was normal at 94%
on room air. He no longer required any supplemental oxygen.
On [**11-24**], the patient underwent a repeat
echocardiogram. On this echocardiogram, he was found to have
severe depressed left ventricular systolic function. He was
found to have left ventricular hypokinesis with akinesis of
the interior and apical inferior wall with relative sparing
of the base. His right ventricular systolic function was
found to be normal. Based on this study, the patient was
started on Coumadin for anti-coagulation. It was now
determined that the patient should eventually undergo
coronary bypass surgery in the future, but should not go on
this admission. The patient is expected to be discharged
home and recover from his current myocardial infarction and
undergo coronary artery bypass surgery electively.
On the [**11-24**], the patient complained of hoarse
voice and difficulty swallowing. Per Dr.[**Name (NI) 9920**] request, an
ENT consultation was made. The patient was found to have no
abnormalities on examination. The patient was discharged on
[**2183-11-25**], to home with Visiting Nurses Association
nursing. At discharge, his condition was stable. The
patient was feeling well. He had no gastrointestinal
symptoms. He was to follow-up with Dr. [**Last Name (STitle) **] as his
cardiologist for discussion of appropriate date for his
future elective coronary artery bypass surgery.
DISCHARGE DIAGNOSES:
1. Acute coronary syndrome.
2. Diverticulitis.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q. day.
2. Glyburide 2.5 mg p.o. q. a.m.
3. Lipitor 10 mg p.o. q. day.
4. Zestril 40 mg p.o. q. day.
5. Glucophage 100 mg p.o. q. day.
6. Lasix 40 mg p.o. q. a.m., 20 mg p.o. q. p.m.
7. Plavix 75 mg p.o. q. day.
8. Zantac 150 mg p.o. twice a day.
9. Coumadin 4 mg p.o. on [**2183-11-25**], then 4 mg on
[**2183-11-26**], then 2 mg p.o. q. day with an INR check
within one week.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 11-300
Dictated By:[**Name8 (MD) 9921**]
MEDQUIST36
D: [**2184-1-15**] 15:51
T: [**2184-1-17**] 09:17
JOB#: [**Job Number 9922**]
|
[
"272.0",
"996.72",
"401.9",
"250.00",
"562.11",
"V45.82",
"414.01",
"785.51",
"410.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"88.57",
"37.23",
"36.05",
"96.04",
"99.20",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3844, 3951
|
11878, 11928
|
11951, 12578
|
3533, 3725
|
3974, 11857
|
155, 3354
|
3376, 3507
|
3742, 3827
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,244
| 162,567
|
28986
|
Discharge summary
|
report
|
Admission Date: [**2175-6-16**] Discharge Date: [**2175-6-27**]
Date of Birth: [**2115-6-6**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
ESRD here for kidney transplant
Major Surgical or Invasive Procedure:
renal transplant [**2175-6-16**]
History of Present Illness:
60F w/ESRD [**12-28**] polycystic kidney disease, on dialysis since
[**2170**], presenting for kidney transplant. She was recently
re-activated on the transplant list after a cardiac
catheterization was normal. Information obtained from the
patient with yes/no questions and one-word answers, as she is
aphasic after a CVA, as well as from her son and husband. She
has been in her usual state of health recently. She and her
family deny any fever, chills, cough, SOB, chest pain, trouble
breathing, abdominal pain, nausea, vomiting, diarrhea, fatigue,
change in bowel or bladder habits, weakness, numbness, or
altered
mental status.
Past Medical History:
CVA [**12-28**] brain aneurysm, clipped at [**Hospital1 112**]; HTN; h/o seizure
after dialysis, none in past 2 years
PSH: multiple access procedures; aneurysm clipping
Social History:
Social: Lives with husband. [**Name (NI) **] is very supportive and is with
her now, and will be available after surgery.
Family History:
Family: Father died of kidney problems. Mother died of cancer.
Physical Exam:
Vitals: T 97.6, HR 78, BP 121/77, RR 20, O2 97RA
Gen: alert and oriented x3, nad, answers appropriately with
yes/no or one-word answers
CV: rrr, no murmur
Resp: cta bilaterally, good respiratory effort
Abd: obese, soft, NT, ND, +BS
Extr: warm, well-perfused, 2+ pulses
DRE: no gross blood
Pertinent Results:
On Admission: [**2175-6-16**]
WBC-6.1 RBC-4.45 Hgb-13.7 Hct-39.2 MCV-88 MCH-30.8 MCHC-35.0
RDW-14.2 Plt Ct-127*
PT-13.6* PTT-25.0 INR(PT)-1.2*
UreaN-65* Creat-12.9*# Na-146* K-4.9 Cl-106 HCO3-24 AnGap-21*
ALT-32 AST-20 Albumin-4.4 Calcium-10.5* Phos-5.4* Mg-2.6
Phenytoin-<0.6*
At Discharge: [**2175-6-27**]
WBC-5.1 RBC-3.48* Hgb-10.6* Hct-30.8* MCV-88 MCH-30.4 MCHC-34.4
RDW-15.1 Plt Ct-151
PT-11.8 PTT-30.7 INR(PT)-1.0
Glucose-109* UreaN-26* Creat-6.1*# Na-139 K-4.1 Cl-101 HCO3-24
AnGap-18
Calcium-8.8 Phos-4.8* Mg-2.0
tacroFK-7.2
Brief Hospital Course:
60 y/o female with ESPD secondary to polycystic kidney disease
who now undergoes a
Renal transplant right iliac fossa. Intra- abdominal 6-French
double-J stent. She was taken to the OR with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Once the kidney was placed, the kidney pinked up and immediately
began making urine, however the kidnbey was placed
intra-peritoneally as the patient had previus surgery with
placement of a VP shunt so there were dense adhesions. Also of
note, the bladder was difficult to identify as there was
extensive amount of adipose tissue in the midline and the
bladder was very, very deep in the pelvis.
Patient tolerated the procedure and she was transferred to PAVCU
in stable condition.
Post-operatively the urine output was noted to be approximately
80-100 cc daily until about post op day 9 when output increased
to about 400 cc daily.
The wound started having large volume drainage, and a specimen
was sent for creatinine, however this did not appear to be
urine.
Ultrasounds of the kidneys have demonstrated normal waveforms
with some perinephric fluid.
The wound was opened and a VAC placed on POD 6 as the dressing
changes were multiple daily and skin was erythemotous from the
drainage. Output since the VAC placement has been 100-600 cc
daily of sero-sanguinous drainage. She received 2 days of Ancef
for the erythema but this was d/c'd as wound looked improved
with the VAC.
The patient was dialyzed on POD 1 for potassium elevation and
has remained on routine hemodialysis since that time using a
tunneled dialysis catheter.
The dilantin she was taking prior to transplant was transitioned
to Keppra due to the effects of dilantin on prograf levels. The
transition was made early.
Immunosuppression was started peri-operatively. She received 5
doses af ATG for delayed graft function. MMF was started pre-op
and Prograf levels were dosed by level.
The patient underwent transplant kidney biopsy on [**6-26**]. Results
of biopsy reported as ATN, C4D staining is negative. As there is
no evidence of rejection the patient can be discharged with
close follow up
Patient was screened and accepted for rehab for mobility issues
and help with VAC maintenance, hemodialysis and medication
teaching.
Medications on Admission:
nephro caps, calcium acetate, metoprolol 50''', dilantin ER
100'''
Discharge Medications:
1. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(TU,FR).
7. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
9. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. tacrolimus 5 mg Capsule Sig: One (1) Capsule PO twice a day:
Levels q Monday and Thursday. Do not change dose unless directed
by transplant clinic.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
ESRD
s/p renal transplant
delayed graft function
seizure disorder
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:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if patient has
any of the following:
fever(101 or greater), chills, nausea, vomiting, diarrhea,
inability to take any of her medications, increased abdominal
pain or distension, abdominal wound smells foul or drainage
increases, weight gain of 3 pounds in a day or any questions
Patient to have blood drawn every Monday and Thursday, slips
included with discharge paperwork. Labs to be couriered to [**Hospital1 18**]
Dialysis to be performed q Monday, Weds, Friday using tunneled
dialysis line
VAC to be changed q 3 days
Monitor I&Os and send copy with patient
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2175-7-6**] 10:30 [**Hospital Unit Name **] [**Location (un) 436**], [**Last Name (NamePattern1) **], [**Location (un) 86**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2175-7-6**] 1:20, [**Hospital Unit Name **] [**Location (un) 436**], [**Last Name (NamePattern1) **], [**Location (un) 86**]
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2175-7-20**] 9:00 [**Hospital Unit Name **] [**Location (un) 436**], [**Last Name (NamePattern1) **], [**Location (un) 86**]
Completed by:[**2175-6-27**]
|
[
"403.91",
"996.81",
"438.89",
"E878.0",
"438.11",
"584.5",
"753.13",
"438.20",
"345.90",
"276.7",
"585.6",
"V45.11",
"568.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.23",
"39.95",
"55.69",
"00.93"
] |
icd9pcs
|
[
[
[]
]
] |
5919, 6001
|
2336, 4596
|
333, 368
|
6111, 6111
|
1777, 1777
|
6944, 7692
|
1386, 1452
|
4714, 5896
|
6022, 6090
|
4622, 4691
|
6294, 6921
|
1467, 1758
|
2070, 2313
|
262, 295
|
396, 1035
|
1791, 2056
|
6126, 6270
|
1057, 1229
|
1245, 1370
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,088
| 156,169
|
32343+57798
|
Discharge summary
|
report+addendum
|
Admission Date: [**2189-12-2**] Discharge Date: [**2189-12-11**]
Date of Birth: [**2111-4-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**12-2**] cardiac cath
[**12-4**] CABGX3 LIMA-Diagonal, SVG-LAD, SVG-RCA
History of Present Illness:
Pt is a 78M with HTN, DM, hyperlipidemia, COPD, MAT, SVT, PVD
s/p b/l BKA. Had been having increasing shortness of breath and
angina with exertion over the past few months, reports that he
will get tightness across his chest when he uses his wheel chair
or performs simple activities like brushing his teeth. Treats
these episodes with alcohol and NTG.
Had dobutamine stress test on [**2189-10-2**] after a complaing of
shortness of breath. Peak heart rate 66% of target with no
CP,arrythmias, or ST changes. Test terminated for shortness of
breath. Nuclear test revealed a small reversible interolateral
wall defect. Pt scheduled for elective cardiac catheterization
[**12-2**] however had presented to [**Hospital6 17032**] on
[**11-30**] with c/o [**6-4**] substernal chest pain which awakened him from
sleep, it was relieved with 1 shot of whiskey and sublingual
nitroglycerin. After admission to hospital pt experienced
recurrent chest pain relieved with NTG, lopressor x3, he was
ruled out for MI with serial CEs, started on heparin drip and
transferred to [**Hospital1 18**] for cardiac catheterization.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative. Pt denies ever experiencing
withdrawl from EtOH or seizures, last drink [**11-30**].
*** 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:
Diabetes
MAT
CAD
CHF, last ECHO EF 60% ([**4-1**])
SVT
HTN
Hyperlipidemia
DVT/PE
s/p b/l BKA
COPD
Early Alzheimer's
PVD
Prostate CA s/p resection
Gout
Depression/anxiety
Anemia
Obesity
.
Cardiac Risk Factors: +Diabetes, +Dyslipidemia, +Hypertension
Social History:
Social history is significant for the absence of current tobacco
use. There is a history of heavy alcohol consumption, per report
pt consumes [**1-27**] liter of EtOH daily, last drink [**11-30**], reports
drinking more since his chest pain has been escalating. Denies
having shakes or withdrawl seizures. Says he was able to quit
drinking for ~6 months in the past. Pt is divorced and lives
alone, has services at home. Uses wheelchair at home.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS 157/102 (on 100ml/hour nitro gtt) 90 22 99% 3L Wt 250 lbs
Gen: Obese man, intermittently restless/agitated, pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Face erythematous, + telangiectasias. MM dry.
Neck: Thick, unable to appreciate and JVD, no carotid bruits
CV: Distant heart sounds, RRR, no murmurs.
Chest: CTAB no crackles, ascultated anteriorly
Abd: Obese, soft. No organomegally appreciated. No fluid wave.
BS present
Ext: No femoral bruits. s/p b/l BKA. R groin site without
hematoma, c/d/i
Skin: No stasis dermatitis, ulcers, scars, or xanthomas. B/L
erythema of stumps L>R, plaque-like appearance with some central
clearing of coalescing leasions, suspicious for [**Female First Name (un) **].
Lidoderm patch on R stump.
Neuro: A+OX2, slight stutter, emotional lability
restless
CNII-XII intact
moving all extremities purposefully
Pertinent Results:
[**2189-12-10**] 02:57AM BLOOD WBC-6.7 RBC-3.83* Hgb-11.2* Hct-34.5*
MCV-90 MCH-29.3 MCHC-32.6 RDW-18.7* Plt Ct-334#
[**2189-12-11**] 08:25AM BLOOD PT-13.9* PTT-39.4* INR(PT)-1.2*
[**2189-12-11**] 08:25AM BLOOD UreaN-26* Creat-1.8*
Brief Hospital Course:
Patient is a 78M with MMP notably CAD, DM, HTN, hyperlipidemia
and COPD who had an abnormal stress test in [**10-2**] who presented
to chest pain on [**11-30**], ruled out for MI, cardiac cath showing
3VD.On [**12-4**] he was taken to the operating room where he
underwent a CABG x 3. He was transferred to the ICU in critical
but stable condition on propofol, epinephrine and neosynephrine
infusions. On POD #1, he was extubated and then reintubated
several hours later for respiratory distress. On POD #2 he was
pancultured for a fever of 102. He was started on vanocmycin and
zosyn for VAP coverage. He was again extubated and weaned from
his drips on POD #3. He was transferred to the floor on POD #4.
He was started on coumadin and heparin for a history of DVTs. By
post-operative day #7 he was ready to be transferred to a rehab
facility.
Medications on Admission:
From home:
Amitriptyline 20mg QHS
NTG patch 0.6mg/hr on at 7am, off at 7pm ****
Simvastatin 20mg daily
Spironolactone 25mf every other day
Glipizide 5mg daily
Mirtazepine 15mg daily
Tolterodine ER 4mg
Gabapentin 900mg TID
Fluticasone INH 220mcg 2 puffs [**Hospital1 **]
Warfarin 4mg daily T,W, Thurs, Sat, Sun.
Warfarin 2mg daily M, F
Carvedilol 12.5mg [**Hospital1 **]
Allopurinol 300mg daily
Prednisone 5mg daily
Lansoprazole 30mg
Lidoderm 5% patch, 1 patch 12 hours per day
Thiamine 100mg TID
Zolpidem 5mg QHS
Diltiazem XT 180mg daily
Iron 65mg 2 tabs daily
Nystatin swish and swallow QID
Nystatin cream to stump prn
Donepezil 5mg daily
Ropinirole 1mg daily
Tramadol 50mg daily
Furosemide 20mg daily
Dipyridamole 100mg [**Hospital1 **]
MVI daily
Senna daily
omeprazole 40mg daily
NTG SL 0.4mg q5 min prn CP
On transfer:
alprazolam 0.5mg TID
nortriptyline 25mg QHS
NTG patch 0.2mg on at 8am, off at 8pm
Simvastatin 20mg QHS
Spironolactone 25mg every other day
Glipizide 5mg daily (held this am)
Mirtazepine 15mg QHS
Tolterodine ER 4mg
Gabapentin 1200mg TID
Fluticasone INH 220mcg 2 puffs [**Hospital1 **]
Carvedilol 12.5mg [**Hospital1 **]
Allopurinol 300mg daily
Prednisone 7.5mg daily
Lansoprazole 30mg QAM
Lidoderm 5% patch, 1 patch 12 hours per day
Thiamine 100mg TID
Zolpidem 5mg QHS
Iron 65mg 2 tabs daily
Nystatin swish and swallow 5mL QID
Nystatin cream to stump prn
Donepezil 5mg daily
Ropinirole 1mg daily
Tramadol 50mg TID
Dipyridamole 100mg [**Hospital1 **]
MVI daily
Senna daily
docusate
clopidogrel 75mg daily
aspirin 81mg daily
Discharge Medications:
1. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
2. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Capsule(s)
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6HRS () as needed for pain.
10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours).
11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
15. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily):
titrate daily dose for PE/DVT history for a goal INR of [**2-27**].5.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
CAD now s/p CABG
post-operative fever
post-operative respiratory failure
chronic diastolic heart failure
PMH:DM, SVT, COPD, Prostate CA, GERD, PE/DVT 4 months ago,
multiple atrial tachycardia, early Alzheimer's, Anemia,
Depression/Anxiety, Gout.
PSH: s/p Bilateral BKA, s/p Prostate resection.
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No heavy lifting or driving until follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 17029**] 2 weeks
Dr. [**Last Name (STitle) 11493**] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Completed by:[**2189-12-11**] Name: [**Known lastname 12401**],[**Known firstname 5204**] Unit No: [**Numeric Identifier 12402**]
Admission Date: [**2189-12-2**] Discharge Date: [**2189-12-11**]
Date of Birth: [**2111-4-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4551**]
Addendum:
please see updated list of medications
Discharge Medications:
1. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
2. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Capsule(s)
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6HRS () as needed for pain.
10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours).
11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
15. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily):
titrate daily dose for PE/DVT history for a goal INR of [**2-27**].5.
Disp:*120 Tablet(s)* Refills:*0*
16. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs qs* Refills:*2*
17. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
18. Tramadol 50 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*0*
19. Aricept 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
20. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*0*
21. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD ().
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
22. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
23. Ropinirole 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 5025**] & Rehab Center - [**Location (un) **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 358**] MD [**MD Number(1) 359**]
Completed by:[**2189-12-11**]
|
[
"428.0",
"518.5",
"285.9",
"V49.75",
"272.4",
"486",
"274.9",
"331.0",
"414.01",
"428.43",
"401.9",
"443.9",
"496",
"300.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.56",
"36.12",
"96.04",
"96.71",
"39.63",
"88.72",
"37.22",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
11568, 11809
|
4223, 5070
|
332, 408
|
8440, 8448
|
3967, 4200
|
8733, 9327
|
2916, 2998
|
9350, 11545
|
8123, 8419
|
5096, 6645
|
8472, 8710
|
3013, 3948
|
282, 294
|
436, 2164
|
2186, 2437
|
2453, 2900
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,850
| 128,608
|
1989
|
Discharge summary
|
report
|
Admission Date: [**2152-12-5**] Discharge Date: [**2152-12-9**]
Date of Birth: [**2090-3-9**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Lisinopril / Biaxin
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
Colonoscopy
Packed red blood cell transfusions
History of Present Illness:
62 yo M with [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease and diverticulosis
transferred from an OSH with BRBPR concerning for a lower GI
bleed. Patient experienced some flu-like illness over [**Holiday **]
and reports taking Ibuprofen for her symptoms. This morning, she
was baby-sitting with another elderly female friend when she
reported having new onset crampy bilateral lower quadrant
abdominal pain this afternoon, followed by one large, cathartic
bloody BM at 2:30 PM today. She placed a diaper and after the
bloody BM walked to another room when she felt LH, saw 'all
white' and then had a witnessed syncopal event by her friend.
She was told she syncopized for a few seconds, without a head
strike. She was not post-ictal, had no tongue biting, seizure
activity, or loss of bladder, but was still having BRBPR at the
time. She was transported to [**Hospital3 **] by ambulance. At
the OSH, she was also reported to have an episode of near
syncope with SBPs to the 70s and HR to the 50s (likely thought
to be vagal) along with multiple episodes of continued BRBPR.
Labs at OSH significant for Hct of 33.4. She was transfused 2 U
PRBCs prior to transfer, but no other plasma products. Per the
patient, her VWD is very mild and only has required ddAVP prior
to surgery in the past. Pt c/o some sore throat after the
lavage, but denies fevers, chills, chest pain, shortness of
breath (but did aspirate some of the NG fluid during the
lavage), lower extremity swelling, or dysuria.
.
In the emergency department, VS were: 102 92/46 10 100% on RA.
Pt received Zofran 4 mg IV x1. Labs sig for WBC of 15.1 and Hct
of 32.5 (baseline of 33.4 at OSH). NG lavage negative. 2 PIVs
placed. Patient had one large bloody BM in the ED. GI and
surgery were consulted. In the MICU, pt was noted to have active
bleeding with 2 episodes of BRPBR, approximately 500 ccs each.
Her Hct dropped ~10 pts from 32.5 -> 23.9 within four hours of
admission requiring urgent transfusion of 4 PRBCs, initiation of
humate-P (human pooled VW factor and Factor VIII), and urgent CT
angiogram.
Past Medical History:
- [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease
- breast cancer (right breast, lobular carcinoma in situ,
removed [**2139**])
- hypertension
- hyperlipidemia
- asthma
- knee pain, s/p knee surgery x5
- bronchiectasis s/p right lung lobectomy [**2119**]
- s/p tonsillectomy
- back pain, L4-5 mild disc protrusion, annular tear
- migraine headaches since age 15
- right rotator cuff tendinopathy
Social History:
Currently on disability for 10 years. Does Reiki meditation. Had
knee injury, 5 knee surgeries. Currently works as a part time
child caretaker. 2 grown children with grand children. Widowed,
husband passed away. Denies EtOH, tobacco, or IVDU/illicit drug
use.
Family History:
Mother: multiple strokes
Father: prostate ca
1 sis: breast ca
1 sis: died of colon ca
1 cousin: pancreatic ca
One Sister and her Son with [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) **] disease.
Physical Exam:
O: Tc: 97.9 BP: 131-146/69-83 HR: 70 RR: 20 O2: 94%
General: NAD, pleasant, AAOx3
HEENT: EOMI, MMM, clear OP
CV: RRR, +S1, S2, no m/r/g
Resp: CTA bilaterally
Abd: soft, NT/ND, +BS, no HSM, no guarding
Ext: WWP, 2+ DP pulses, no peripheral edema
Neuro: CNII-XII intact, motor/sensation grossly intact
Pertinent Results:
Admission Labs:
[**2152-12-5**] 07:45PM BLOOD WBC-15.1* RBC-3.80* Hgb-11.4* Hct-32.5*
MCV-86 MCH-30.1 MCHC-35.2* RDW-13.5 Plt Ct-333
[**2152-12-6**] 12:25AM BLOOD WBC-9.8 RBC-2.83*# Hgb-8.3*# Hct-23.9*#
MCV-85 MCH-29.5 MCHC-34.9 RDW-13.4 Plt Ct-255
[**2152-12-5**] 07:45PM BLOOD PT-13.0 PTT-20.6* INR(PT)-1.1
[**2152-12-5**] 07:45PM BLOOD Glucose-131* UreaN-19 Creat-0.6 Na-139
K-4.2 Cl-108 HCO3-22 AnGap-13
[**2152-12-6**] 05:27AM BLOOD Calcium-7.0* Phos-3.3 Mg-1.8
Clotting Labs:
Pre ddAVP/Humate P
[**2152-12-5**] 07:45PM BLOOD VWF AG-137 VWF CoF-176
[**2152-12-5**] 07:45PM BLOOD FacVIII-188*
Post:
[**2152-12-6**] 11:45AM BLOOD VWF AG-169* VWF CoF-304*
[**2152-12-6**] 11:45AM BLOOD FacVIII-180*
CTA: IMPRESSION:
1. No definite evidence of active extravasation seen. Dense
fluid within the colon suggests hemorrhagic products in the
distal colon.
2. Diverticulosis, with no evidence of diverticulitis.
EKG: Sinus rhythm with ventricular premature beats in a
quadrigeminal pattern. No previous tracing available for
comparison. Clinical correlation is suggested.
Colonoscopy: Findings:
Protruding Lesions Grade 1 internal hemorrhoids were noted.
Excavated Lesions Multiple diverticula with medium openings
were seen in the ascending colon. Diverticulosis appeared to be
of moderate severity. There was a small amount of fresh blood
seen in the ascending colon and this was the only area of the
colon with bleeding. The cecum and the rest of the colon had no
blood in it. Multiple diverticula were seen in the sigmoid
colon. Diverticulosis appeared to be of moderate severity.
Impression: Diverticulosis of the ascending colon
Diverticulosis of the sigmoid colon
Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum
Discharge Labs:
[**2152-12-9**] 06:55AM BLOOD WBC-7.5 RBC-3.74* Hgb-11.1* Hct-31.9*
MCV-85 MCH-29.6 MCHC-34.8 RDW-15.3 Plt Ct-228#
[**2152-12-8**] 01:57AM BLOOD PT-12.3 PTT-24.2 INR(PT)-1.0
[**2152-12-9**] 06:55AM BLOOD Glucose-104* UreaN-4* Creat-0.5 Na-140
K-3.4 Cl-105 HCO3-29 AnGap-9
[**2152-12-9**] 06:55AM BLOOD Calcium-8.1* Phos-2.6* Mg-2.2
Brief Hospital Course:
62 yo F with [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease who presents with
continued BRBPR.
.
#. GI bleed: Patient with brisk lower GIB in the setting of
known bleeding diathesis. Nasogastric lavage was negative so
the patient was not started on a PPI. Patient received ddAVP as
well as Humate-P in setting of previous diagnosis of [**First Name5 (NamePattern1) **]
[**Last Name (Prefixes) 4516**] Disease. Patient received 10 units packed red
blood cell transfusions to keep her hematocrit stable. She had
a CT angiogram that did not show active extravasation. A
colonoscopy on [**12-7**] showed diverticula throughout with old blood
in the colon. The bleed was thought to be secondary to a
diverticular bleed. The patient had no more episodes of
bleeding and her hematocrit remained stable.
.
#. Bleeding diathesis: Pt with history of easy bruising and
bleeding from reported VWD, uses ddAVP around time of procedures
only and has never required resuscitation before. She was
started on DDAVP and Humate-P as above. Heme-onc was consulted
and felt that her factor VIII and vWF levels were not consistent
with vWF deficiency but family and personal history were
consistent with bleeding diathesis. Humate-P and DDAVP were
discontinued. HemOnc suggested she should get outpatient workup
for functional platelet analysis with platelet aggegation
studies.
.
Transitional Issues
Would recommend outpatient platelet aggregation studies to
evaluate for a qualitative platelet abnormality, given that the
laboratory testing done does not support the diagnosis of [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] disease.
Medications on Admission:
ALBUTEROL SULFATE - (Prescribed by Other Provider) - 90 mcg HFA
Aerosol Inhaler - 2 puffs(s) 4-6 hours as needed for SOB, wheeze
or cough spells
ALBUTEROL SULFATE - (Prescribed by Other Provider) - 2.5 mg/3 mL
(0.083 %) Solution for Nebulization - 1 wheeze
IPRATROPIUM-ALBUTEROL - (Prescribed by Other Provider) - 0.5
mg-3 mg (2.5 mg base)/3 mL Solution for Nebulization - 1 wheeze
NIFEDIPINE - 90 mg Tablet Extended Rel 24 hr - 1 Tablet(s) by
mouth once a day
TERAZOSIN - (Prescribed by Other Provider) - 1 mg Capsule - 1
Capsule(s) by mouth twice a day
Advair Diskus 100/50 1 puff [**Hospital1 **]
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
2. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization Sig: One (1) vial Inhalation every 4-6 hours as
needed for shortness of breath or wheezing.
3. nifedipine 90 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
4. terazosin 1 mg Capsule Sig: One (1) Capsule PO twice a day.
5. Advair Diskus 100-50 mcg/dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Diverticular bleeding, ?[**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease
Secondary: Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 10935**],
It was a pleasure taking care of you during your
hospitalization. You were admitted after having bright red
blood per rectum. You were admitted to the Intensive Care Unit
for treatment. You received blood transfusions to keep your
blood levels stable. You were also treated with ddAVP and
Humate-P because of your history of [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease.
You had a CT Angiogram and a colonoscopy that did not show any
active bleeding. The colonoscopy did show diverticuli
(outpouchings of the colon) that were thought to be the source
of your bleeding. You were seen by our Hematologists and they
do not believe you have [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease based on some
blood tests. You may have another problem with platelet
function that should be evaluated as an outpatient.
We made no changes to your medications.
You should eat a high-fiber diet.
- For Outpt Hematology:
The levels that were obtained with inpatient testing:
Factor levels (drawn before receiving ddAVP or Humate-P)
- Factor VIII antigen: 188
- vWF antigen: 137
- ristocetin co-factor: 176
Factor levels (drawn at noon after two doses of ddAVP and
Humate-P)
- Factor VIII antigen: 180
- vWF antigen: 169
- ristocetin co-factor: 304
Followup Instructions:
Please follow up with your PCP in the next week.
You need to follow up with your outpatient
Hematologist/Oncologist to have platelet aggregation studies to
evaluate for a qualitative platelet abnormality. You should do
this in the next 2-3 weeks.
Completed by:[**2152-12-12**]
|
[
"285.1",
"V10.3",
"287.5",
"562.12",
"286.4",
"493.90",
"272.4",
"E932.5",
"276.1",
"455.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
8820, 8826
|
5894, 7565
|
317, 366
|
8994, 8994
|
3777, 3777
|
10506, 10787
|
3231, 3442
|
8216, 8797
|
8847, 8973
|
7591, 8193
|
9145, 10483
|
5537, 5871
|
3457, 3758
|
250, 279
|
394, 2492
|
3794, 5520
|
9009, 9121
|
2514, 2938
|
2954, 3215
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,546
| 112,382
|
15026
|
Discharge summary
|
report
|
Service: Date: [**2161-7-2**]
Date of Birth: [**2089-2-6**] Sex: F
Surgeon: [**Last Name (LF) 3662**], [**First Name3 (LF) 3661**] 12-269
CHIEF COMPLAINT: Headache, nausea, vomiting, chest pain
HISTORY OF PRESENT ILLNESS: Patient is a 72-year-old female
with a history of atrial fibrillation, bradycardia, resulting
in syncope, status post pacemaker placement on [**6-15**], who
complains of headache, nausea, vomiting, and jaw and chest
pain. Patient stated that these symptoms came on over the
course of a one-hour period. She laid down and was unable to
get out of bed secondary to weakness. Patient then went to
[**Hospital1 43954**], where her blood pressure was found to be
60/palp. Echocardiogram there was consistent with an
effusion. She was given 2 liters of normal saline and
started on dopamine and transferred to [**Hospital1 36918**] Emergency Room, where a repeat echocardiogram
showed a moderate-size effusion, but no evidence of
tamponade.
Patient was given 6 more liters of IV fluid of normal saline
and dopamine was continued at 10 mcg per hour. In the
Emergency Department, patient had an episode of nausea and
vomiting, denied fever, abdominal pain, dysuria, neck
stiffness, chest pain at the time of admission, or cough and
was transferred to the medical Intensive Care Unit for
further management.
PAST MEDICAL HISTORY: Significant for atrial fibrillation,
recent pacemaker placement in [**Hospital6 1129**]
on [**6-15**], gastroesophageal reflux disease,
hypercholesterolemia.
ALLERGIES: No known drug allergies.
MEDICATIONS: Sotalol 160 mg p.o. b.i.d., Toprol, Coumadin 5
mg p.o. q.d., Nexium one tab p.o. q.d.
FAMILY HISTORY: Significant for her father with coronary
artery disease, sister and brother with history of
unspecified thyroid disorder.
SOCIAL HISTORY: No tobacco or alcohol use, lives alone at
home, has no children
PHYSICAL EXAMINATION: Vital signs: Afebrile, blood pressure
124/55 on dopamine, pulse 68, respirations 20, O2 saturation
96% on 4 liters. In general, an elderly female, lethargic
but arousable. HEENT exam: Pupils equal, round and reactive
to light and accommodation. Mucous membranes dry. Neck was
supple, no evidence of jugular venous distention. Heart:
Normal S1, S2, no murmurs, rubs or gallops. Lungs clear to
auscultation bilaterally. Abdomen soft, nontender,
nondistended, normal active bowel sounds. Extremities:
Trace 1+ edema. Extremities cool
LABORATORY DATA ON ADMISSION: White blood count 19.3,
hematocrit 34.7, platelet count 353,000. Neutrophils 89,
bands 2, sodium 141, potassium 4.2, chloride 111, bicarb 14,
BUN 13, creatinine 0.7, glucose 162, calcium 7.3, magnesium
1.8, phosphorus 2.8. INR 2.0, PTT 31.2, ALT 73, AST 64,
alkaline phosphatase 80, lipase 33, amylase 24, total
bilirubin 0.7.
Urinalysis significant for 6 to 10 white blood cells, small
leukocyte esterase.
BK (no. 1) was 69, BK (no. 2) 63, troponin less than 0.3
times two.
Arterial blood gas: pH 7.38, CO2 29, O2 74, lactate 2.0.
Electrocardiogram: Atrial fibrillation with a rate of 109,
normal axis, Q wave in lead 3, no acute ST or T wave changes.
Head CT scan: No mass, no shift or bleed.
Chest x-ray: Cardiomegaly, right internal jugular line in
place, increased cephalization, peribronchial cuffing.
IMPRESSION: Patient is a 72-year-old female with persistent
hypertension admitted with evidence of a pericardial
effusion, possibly secondary to pacer placement.
HOSPITAL COURSE: 1) Cardiovascular: Patient was volume
resuscitated over the course of two days with 8 liters of IV
fluids and was also on a dopamine drip, which was gradually
weaned over the course of three days. By [**6-28**], her
dopamine drip had been stopped. No IV fluids were needed and
her pressures were now in the systolic blood pressure range
of the 130s. Repeat echocardiogram showed no change in the
size of her pericardial effusion with no evidence of
tamponade. However, there was a note made that there was
perforation of the right ventricular free wall with the pacer
wire on repeat echocardiogram on [**6-29**]. The pericardial
effusion was also noted to be significantly smaller in size
on that date.
Patient also had note of increased pulmonary edema and O2
requirements secondary to significant volume resuscitation,
was able to diurese on her own with improvement of her
hypoxia as well as her lung exam.
On [**6-30**], [**2160**], her pacer leads were repositioned within
the right ventricle. There was no evidence of tamponade or
increasing pericardial effusion after the procedure was done.
The following day, patient had a repeat echocardiogram, which
confirmed these findings.
At the time of discharge, patient's pressure was normotensive
and her O2 saturation was 94 to 95% on room air, including on
ambulation. Patient will be sent home on sotalol 160 mg
b.i.d., is still in atrial fibrillation; however, will likely
need to be switched from sotalol to a different medication
such as amiodarone in the near future, potentially after her
LFTs have normalized after the hepatic congestion has
cleared. Will also start Lopressor for rate control and
anticoagulation with Lovenox and Coumadin.
2) Infectious Diseases: Patient was noted to have a urinary
tract infection, was treated with Levofloxacin for a
seven-day course, was also given Vancomycin peri-procedure
for repositioning of her leads and was sent home on Keflex.
DISCHARGE DIAGNOSIS: 1) Hemopericardium secondary to
pacer lead perforation through
right ventricle
2) Atrial fibrillation
DISCHARGE CONDITION: Good. Patient was once again
normotensive and will follow up with Dr. [**First Name (STitle) 437**] in about one
month and with the Electrophysiology service at [**Hospital3 **]
in about one week and will follow up with the [**Hospital 197**] clinic
in three days for adjustment of her Coumadin dosing.
DISCHARGE MEDICATIONS: Sotalol 160 mg p.o. b.i.d., Lopressor
25 mg p.o. b.i.d., Coumadin 5 mg p.o. q.d., Enoxaparin 80 mg
subcutaneously b.i.d., Levofloxacin 500 mg p.o. q.d. times
two days, Keflex 500 mg p.o. t.i.d. times two days, Zantac
150 mg p.o. b.i.d.
[**Last Name (LF) 3662**], [**First Name3 (LF) 3661**] 12-269
Dictated By:[**First Name3 (LF) 11194**]
MEDQUIST36
D: [**2161-7-2**] 10:59
T: [**2161-7-5**] 17:20
JOB#: [**Job Number 43955**]
|
[
"458.2",
"530.81",
"401.9",
"427.31",
"423.0",
"996.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.75"
] |
icd9pcs
|
[
[
[]
]
] |
6314, 6804
|
5756, 6290
|
2044, 5732
|
201, 2021
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,508
| 118,298
|
49891
|
Discharge summary
|
report
|
Admission Date: [**2118-6-10**] Discharge Date: [**2118-6-17**]
Date of Birth: [**2036-9-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
s/p AVR(tissue)/CABGx3(LIMA->LAD, SVG->OM, PDA) [**6-10**]
History of Present Illness:
Mr. [**Known lastname **] is an 81 year-old gentleman with a history of aortic
stenosis, angina, and an abnormal stress echo. He was referred
to [**Hospital1 18**] for surgical correction of his pathology.
Past Medical History:
coronary artery disease
aortic insufficiency
hypertension
BPH
GERD
rheumatic fever as child
bladder obstruction 8 yrs ago
barrette's esophagus
gout
s/p TURP 20 yrs ago
tonsillectomy
Social History:
Mr. [**Known lastname **] is a retired school teacher and lives alone.
Family History:
Mr. [**Known lastname **] brother underwent a CABG at age 60.
Physical Exam:
Elderly [**Male First Name (un) 4746**] in NAD
AVSS
HEENT: NC/AT, PERRLA, EOMI
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+= bilat. without bruits.
Lungs: Clear to A+P
CV:RRR without R/G, +SEM
Abd:+BS, soft, nontender without masses or hapatosplenomegaly
Ext:without C/C/E, pulses 2+= bilat. throughout
Neuro:nonfocal
Discharge
AVSS: 98.7,145/72,64,RR20,95% R/A O2SAT
Lungs: Bibasilar crackles
CV:RRR
Abd:+BS, soft, nontender,ND
Ext:Trace (B) LE edema
Neuro:A&O X3,NAD
Wounds: sternal and EVH incision C/D/I, sternum stable. No
[**Doctor Last Name **]/click
Pertinent Results:
[**2118-6-16**] 06:45AM BLOOD WBC-7.1 RBC-4.34* Hgb-12.6* Hct-37.5*
MCV-86 MCH-29.1 MCHC-33.6 RDW-13.0 Plt Ct-288#
[**2118-6-10**] 11:19AM BLOOD WBC-15.6*# RBC-3.31* Hgb-9.5* Hct-27.9*
MCV-84 MCH-28.6 MCHC-33.9 RDW-13.0 Plt Ct-263
[**2118-6-16**] 06:45AM BLOOD Plt Ct-288#
[**2118-6-10**] 12:01PM BLOOD Plt Ct-238
[**2118-6-10**] 12:01PM BLOOD PT-15.6* PTT-48.2* INR(PT)-1.4*
[**2118-6-16**] 06:45AM BLOOD Glucose-94 UreaN-25* Creat-1.4* Na-136
K-4.3 Cl-100 HCO3-25 AnGap-15
[**2118-6-11**] 02:28AM BLOOD Glucose-130* UreaN-25* Creat-1.3* Na-135
K-4.4 Cl-110* HCO3-20* AnGap-9
[**2118-6-10**] 07:00AM BLOOD %HbA1c-5.6
[**Known lastname **],[**Known firstname **] P [**Medical Record Number 104224**] M 81 [**2036-9-15**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2118-6-15**] 8:23
AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2118-6-15**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 104225**]
Reason: eval pulmonary edema
[**Hospital 93**] MEDICAL CONDITION:
81 year old man with s/p avr, cabg
REASON FOR THIS EXAMINATION:
eval pulmonary edema
Provisional Findings Impression: AJy WED [**2118-6-15**] 12:19 PM
New left lower lobe opacity likely atelectasis with effusion. No
evidence for
pulmonary edema.
Final Report
HISTORY: 81-year-old male, status post AVR and CABG, evaluate
for pulmonary
edema.
COMPARISON: Comparison is made to portable AP chest from [**6-11**]
and [**2118-6-14**] as well as preop PA and lateral chest radiographs from [**5-20**], [**2117**].
FINDINGS:
The right IJ catheter has been removed.
New opacification of the left lower lung obscuring the left
hemidiaphragm and
costophrenic angle is likely due to atelectasis and pleural
effusion, less
likely pneumonia. Hazy opacification obscuring the right lower
lung could be
due to either pleural effusion layering posteriorly or loculated
in the major
fissure. The remainder of the lungs is clear. Moderate
cardiomegaly is
stable, without evidence for volume overload. There is no
pneumothorax.
Metal wiries and vascular clips denote prior sternotomy and
coronary
bypass grafts.
IMPRESSION:
1. New left lower lobe atelectasis and pleural effusion, less
likely
pneumonia.
2. Increased right pleural effusion, possibly fissural.
3. Stable moderate cardiomegaly; no pulmonary edema.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: [**Doctor First Name **] [**2118-6-16**] 3:28 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 104226**] (Complete)
Done [**2118-6-10**] at 9:13:59 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: [**2036-9-15**]
Age (years): 81 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: AVR/CABG
ICD-9 Codes: 786.05, 786.51, 799.02, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2118-6-10**] at 09:13 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 #: 2008AW1-: Machine: AW1
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
[**Last Name (NamePattern4) **] - Ascending: *3.6 cm <= 3.4 cm
[**Last Name (NamePattern4) **] - Descending Thoracic: *2.6 cm <= 2.5 cm
Aortic Valve - Peak Gradient: *40 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 25 mm Hg
Aortic Valve - Valve Area: *1.0 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
[**Last Name (NamePattern4) **]: Mildly dilated ascending [**Last Name (NamePattern4) 5236**]. Simple atheroma in
descending [**Last Name (NamePattern4) 5236**].
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Moderate-severe AS
(area 0.8-1.0cm2). Moderate (2+) AR.
MITRAL VALVE: Mild (1+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Right ventricular chamber size and free wall motion are normal.
The ascending [**Last Name (NamePattern4) 5236**] is mildly dilated. There are simple atheroma
in the descending thoracic [**Last Name (NamePattern4) 5236**].
There are three aortic valve leaflets. The aortic valve leaflets
are severely thickened/deformed.
There is moderate to severe aortic valve stenosis . Peak
gradient = 40, mean = 25. Moderate (2+) aortic regurgitation is
seen.
Mild (1+) mitral regurgitation is seen. There is no pericardial
effusion.
Post-CPB:
The patient is A-Paced, on no infusions.
Good biventricular systolic fxn.
Trace MR.
[**First Name (Titles) **] [**Last Name (Titles) 5235**].
A prosthetic aortic valve is well-seated with no AI and no leak.
Mean residual gradient = 8.
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) **] [**2118-6-10**] 11:28
[**Known lastname **],[**Known firstname **] P [**Medical Record Number 104224**] M 81 [**2036-9-15**]
Cardiology Report ECG Study Date of [**2118-6-10**] 1:09:08 PM
There are three atrial paced beats followed by sinus
bradycardia. Consider
prior inferior myocardial infarction. Non-specific ST-T wave
changes. Compared
to the previous tracing of [**2118-5-19**] atrial pacing is new.
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
39 0 88 446/409 0 6 -15
Brief Hospital Course:
Mr.[**Known lastname **] was admitted for on [**6-10**] and underwent elective
AVR(tissue)/CABGx3(LIMA->LAD, SVG->OM, RCA).See operative report
for further details. He tolerated the procedure well and was
transferred to the CVICU. He was extubated on the post op
night. The following day he had confusion and word finding
difficulties. Neurology was consulted and recommended all
narcotics to be discontinued. Over the next 2 days his mental
status cleared. On POD#2 he had his chest tubes d/c'd and on
POD#3 his epicardial pacing wires were d/c'd and he was
transferred to the floor. He continued to progress and required
PT to work with him for strength and mobility. He was ready for
discharge to rehab on POD#7.
Medications on Admission:
Avapro 150 mg PO daily
Proscar 5 mg PO daily
Tricor 145 mg PO daily
Nexium 40 mg PO daily
Metoprolol 25 mg PO daily
ASA 81 mg PO daily
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay - [**Hospital1 392**]
Discharge Diagnosis:
aortic insufficiency, s/p AVR
coronary artery disease, s/p CABG
hypertension
hyperlipidemia
BPH
gastric esophageal reflux disease
rheumatic fever as a child
bladder obstruction 8 yrs ago
barrette's esophagus
gout
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 appointment after discharge from rehab
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**]: ([**Telephone/Fax (1) 104227**]
Dr.[**First Name (STitle) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2118-7-14**]
1:45
Completed by:[**2118-6-17**]
|
[
"348.30",
"E935.2",
"274.9",
"272.4",
"585.9",
"600.00",
"424.1",
"413.9",
"530.81",
"403.90",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61",
"36.15",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
9560, 9640
|
8653, 9375
|
332, 393
|
9897, 9904
|
1619, 2604
|
10416, 10744
|
938, 1001
|
2644, 2679
|
9661, 9876
|
9401, 9537
|
9928, 10393
|
6913, 8630
|
1016, 1600
|
282, 294
|
2711, 6864
|
421, 629
|
651, 834
|
850, 922
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
203
| 120,358
|
20628+57182
|
Discharge summary
|
report+addendum
|
Admission Date: [**2160-4-15**] Discharge Date: [**2160-5-2**]
Date of Birth: [**2102-4-27**] Sex: M
Service: NSU
HISTORY OF PRESENT ILLNESS: Patient is a 57-year-old man on
Coumadin for AVR, MVR, valve replacement in [**2159-2-22**] who
at 5 p.m. had an onset of speech difficulty and at 7:30 p.m.,
his wife found him on the floor with right-sided weakness,
eyes open and nonverbal. He was brought to [**Hospital3 417**]
Hospital via EMS. Vitals at 10:30 in the ED were 146/85,
heart rate 64, respiratory rate 20, and saturations 94% on
room air. He subsequently had a decompensation and was
intubated.
CT scan revealed a large left-sided intraparenchymal
hemorrhage. Labs were noted for an INR of 5.9. Given 10 mg of
vitamin K subcutaneously and 2 units of FFP. Loaded with
Dilantin and transferred to [**Hospital1 188**] for further management.
PAST MEDICAL HISTORY: Rheumatic heart disease status post
AVR, MVR, and CABG x1 vessel in [**2159-2-22**] on Coumadin.
ALLERGIES: No known allergies.
VITAL SIGNS ON ADMISSION: BP 149/86, heart rate 72,
respiratory rate 16, and saturations 100%, intubated on
ventilator. Intubated, young-appearing man attempting to pull
at the ET tube with his left hand. HEENT: Nonicteric. Neck:
Supple, no carotid bruits. Chest was clear to auscultation.
Cardiovascular: Regular rate and rhythm, harsh S1 and S2
sounds, no murmur. Abdomen: Soft, nontender, positive bowel
sounds. Extremities: No edema. Neurologically: Does not open
eyes to voice or painful stimulation. Cranial nerves: Pupils
2 mm down to 1 bilaterally. EOMs full. Positive doll's eyes.
Corneal reflexes: Absent bilaterally. Facial symmetry: ET
restricts the lower face, but upper face appears wrinkling,
symmetrically. Gag reflex: Gagging on the ET. Motor:
Increased tone in all four extremities. Moves left side
spontaneously, reaching and grabbing for the ET tube with the
left hand. No spontaneous movement of the right hemibody.
Decerebrate posturing of the right arm with pain and flexes
knees and ankle with pain applied to both legs. Purposely
withdraws, localizes with the left arm.
CT shows 5 x 7 cm large left frontal subcortical hemorrhage
which stands 10 slices midline shift to the right, no
hydrocephalus.
Patient was seen emergently in the ED and was taken to the OR
for a craniotomy. Postop, patient had no eye opening. Moves
left upper and lower extremities spontaneously and
purposefully with right-sided hemiparesis. Pupils equal and
brisk. Not following commands. Exam on 15 mg of propofol.
Patient was kept with a SBP of less than 120 and q.1h. neuro
checks with repeat head CT in the morning.
Patient had a repeat head CT on [**4-18**] that showed no change
in the large left intraparenchymal hemorrhage with associated
subfalcine herniation and minimal uncal herniation.
On [**2160-4-23**], the patient underwent tracheostomy and PEG
without complication. The patient remained in the ICU until
[**4-24**] when he was transferred to the step-down unit.
Neurologically, he remained unchanged, occasionally opening
his eyes. Purposeful on the left side, hemiparesis on the
right side.
In the neuro step-down, he remained neurologically unchanged.
He had a LP done on [**4-24**] that showed an opening pressure of
27, closing pressure of 14. Twenty cc of CSF was sent. He had
a repeat LP done the following day with an opening pressure
of 32, closing pressure was not recorded. He was seen by the
ID service for a question of meningitis. He also had climbing
LFTs. General surgery was consulted. They recommended getting
a right upper quadrant ultrasound which was done and was read
as negative.
GI was consulted for the elevated LFTs. They felt they were
maybe related to his ceftazidime that he was getting for his
MRSA and urine infection. That was discontinued, and the
patient was kept on vancomycin for MRSA in his sputum and
blood. His LFTs came down slowly. He should have them checked
every week. He also will need to be restarted on Coumadin for
his heart valve. Head CT is pending for [**2160-5-2**]. The
results will decide when he will start on his Coumadin.
He was seen by physical therapy and occupational therapy, and
he will require an acute rehab stay. He will remain on
vancomycin for a total of 14 days. Vancomycin should continue
until [**2160-5-9**]. He is on 1000 mg IV q.8. Other
medications: Metoprolol 25 mg p.o. b.i.d., hold for heart
rate less than 60, SBP less than 110, nystatin swish and
swallow 5 cc q.i.d., famotidine 20 mg p.o. b.i.d., heparin
5000 units subcutaneously t.i.d., Keppra 500 mg p.o. b.i.d.,
insulin-sliding scale, senna 1 tablet p.o. b.i.d., ferrous
sulfate 325 p.o. daily, Colace 100 mg p.o. b.i.d.
Patient's condition was stable at the time of discharge. He
will follow up with Dr. [**Last Name (STitle) 1327**] in [**1-25**] weeks with a repeat
head CT.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 12001**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2160-5-2**] 11:49:50
T: [**2160-5-2**] 12:36:44
Job#: [**Job Number 55128**]
Name: [**Known lastname 10318**],[**Known firstname 10319**] Unit No: [**Numeric Identifier 10320**]
Admission Date: [**2160-4-15**] Discharge Date: [**2160-5-7**]
Date of Birth: [**2102-4-27**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10321**]
Addendum:
patient's condition was stable at the time of discharge his
discharge was delayed until [**5-7**] to allow INR to become
therapeutic. His INR is currently 1.4 He should be between
2.0-2.5 He is currently on 7.5mg of coumadin. He should have
weekly LFT's checked. His last dose of Vancomycin is [**2160-5-9**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
[**Name6 (MD) 863**] [**Last Name (NamePattern4) 864**] MD [**MD Number(1) 865**]
Completed by:[**2160-5-7**]
|
[
"438.20",
"V43.3",
"V45.81",
"573.3",
"398.90",
"518.84",
"482.41",
"V09.0",
"401.9",
"431",
"286.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.06",
"38.93",
"43.11",
"01.24",
"99.04",
"03.31",
"96.72",
"99.07",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
5841, 6050
|
164, 872
|
1549, 5818
|
1053, 1533
|
895, 1038
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,380
| 196,943
|
52343
|
Discharge summary
|
report
|
Admission Date: [**2112-3-19**] Discharge Date: [**2112-4-1**]
Service: MEDICINE
Allergies:
Morphine Sulfate / Lipitor / Amiodarone
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Abdominal pain, SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 61836**] is an 87 year-old man, with prior h/o HTN, HL, CAD
s/p CABG in [**2084**] and multiple PCIs, ischemic cardiomyopathy
(15-20%), VT s/p ICD placement in [**10-30**] and VT ablation in [**2108**]
and again [**2-/2112**] and afib on coumadin who presented for
abdominal pain concerning for acute bowel ischemia initally
admitted to the ACS surgery service with concern for acute
mesenteric ischemia on [**3-19**] now in respiratory distress
following volume overload and abrupt initiation of home
anti-hypertensives.
.
He initally presented to [**Hospital1 18**] ED with complaint of abdominal
pain that worsened with walking, eating or lying down. CT and
CTA of abdomen revelaed diffused mesenteric calcification c/w
atherosclerosis and he was noted to have an elevated lactate to
2.4 that was uptrending concerning for bowel ischemia. He was
admitted to the ACS surgical service and received serial
abdominal exams.
.
His anti-hypertensive medications were initally held, and his
abdominal exams remained stable to improved. He received
maintenence IVF at 75cc/hr in addition to 4 x 1L LR boluses. He
is presently 5600ml net positive in terms of volume status since
admission. His anti-hypertensive medications were restarted on
on [**3-21**] and subsequently discontinued on morning of [**3-22**] [**2-24**] to
hypotension. A cardiology consult was requested when the patient
remained relatively hypotensive with [**Name (NI) 5462**] in the 90s despite
stopping home medications and was complaining of shortness of
breath. Cardiology advised diuresis with possible inotropic
support and reinitiation of beta-blockade once BP stable.
.
He was subsequently observed to have continued shortness of
breath despite despite a dose of IV lasix and he was transfered
to the CCU for further managment of hi decompensated CHF. VS on
transfer were SBP:98 HR:100 RR:30 SpO2:94% on 3L NC.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
Hypertension
Hyperlipidemia
Coronary artery disease s/p anterolateral MI in [**2084**] s/p CABG
and multiple PCIs
Ischemic cardiomyopathy, EF 15-20% on [**8-/2111**] TTE
Ventricular tachycardia s/p ICD in [**2099**], VT ablation in [**2108**] and
[**2112**]
Chronic atrial fibrillation on Coumadin
1+ AR, 2+ MR, 3+ TR on [**8-/2111**] TTE
-CABG: SVG-OM, SVG-LAD, and SVG-PDA in [**2084**]
-PERCUTANEOUS CORONARY INTERVENTIONS:
- [**9-/2105**]: Patent SVG->PDA; RCA, SVG-OM and SVG-LAD were known
occluded. No intervention.
- [**8-/2105**]: 3vCAD and diastolic dysfunction; DES to SVG-RCA
ostium; c/b VF not responsive to ICD shocks and requiring
external defibrillation.
- [**10/2101**]: Rotational atherectomy & PTCA of OM1 upper and lower
poles.
- [**8-/2101**]: PTCA and stents x3 to mid, proximal, and upper pole of
OM1; SVG-PDA diffusely diseased with 90% touchdown stenosis
requiring PTCA & stent.
-PACING/ICD: S/p [**Company 1543**] [**Last Name (un) 24119**] DR 7278 single chamber ICD in
[**2099**].
3. OTHER PAST MEDICAL HISTORY:
Anxiety
Gastritis
Osteoarthritis
Cataracts s/p bilateral extraction
Social History:
Lives with his wife, has 2 children (1 deceased), spends 4
months a year in [**State 108**]. Used to work as a state policeman.
-Tobacco history: Denies.
-ETOH: Rare.
-Illicit drugs: Denies.
Family History:
Father with "heart disease." Mother with CHF>
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Exam:
VS: T:96.8 BP:83/57 P:104 RR:26 SpO2:99% on 50% on face mask
GENERAL: Resting comfortably, NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink. Lips and ears with blueish hue.
NECK: Supple, no LAD
CARDIAC: Irregular, [**2-28**] holosystolic murmur LLSB, [**3-27**]
holosystolic murmur LLSB. No r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
WOUND: c/d/i, no bruits, hematoma
Discharge Exam:
Gen: lethargic, NAD
HEENT: supple, JVD to mandible. Sclera icteric, skin jaundiced.
CV: irreg irreg, distant HS, [**3-27**] pansystolic murmur at base.
RESP: [**Month (only) **] BS right base, no crackles or wheezes, poor effort
ABD: soft, NT, no guarding or rebound. Liver not palpable.
EXTR: no edema
NEURO: A/O
Pulses: palpable.
Skin: warm/dry, no edema
Pertinent Results:
Admission Labs ([**2111-3-19**]):
CBC: WBC-6.5 RBC-4.69 Hgb-13.0* Hct-42.1 MCV-90 MCH-27.6
MCHC-30.8* RDW-15.6* Plt Ct-181 Neuts-74.9* Lymphs-13.9*
Monos-8.3 Eos-1.9 Baso-0.9
Coags: PT-28.8* PTT-34.7 INR(PT)-2.8*
Chem: Glucose-133* UreaN-29* Creat-1.6* Na-128* K-4.0 Cl-95*
HCO3-21* ALT-46* AST-42* LD(LDH)-239 AlkPhos-218* TotBili-2.2*
DirBili-1.0* IndBili-1.2
Digoxin-0.5*
Lactate-3.3*
Other Labs:
[**2112-3-22**] 09:50PM BLOOD ALT-321* AST-450* CK(CPK)-82 AlkPhos-160*
Amylase-42 TotBili-5.2*
[**2112-3-23**] 03:54AM BLOOD ALT-426* AST-851* LD(LDH)-869* CK(CPK)-90
AlkPhos-160* TotBili-5.9* DirBili-2.9* IndBili-3.0
[**2112-3-24**] 04:03AM BLOOD ALT-712* AST-916* LD(LDH)-580*
AlkPhos-154* TotBili-5.9*
[**2112-3-25**] 06:20AM BLOOD ALT-576* AST-561* LD(LDH)-324*
AlkPhos-150* TotBili-6.5*
[**2112-3-27**] 05:35AM BLOOD ALT-600* AST-549* AlkPhos-189*
TotBili-12.2* DirBili-6.7* IndBili-5.5
[**2112-3-28**] 03:30AM BLOOD ALT-575* AST-519* LD(LDH)-552*
AlkPhos-190* TotBili-14.3*
Cardiac Markers:
[**2112-3-22**] 08:30PM BLOOD CK-MB-5 cTropnT-0.01 proBNP-4082*
[**2112-3-22**] 09:50PM BLOOD CK-MB-5 cTropnT-0.02*
[**2112-3-23**] 03:54AM BLOOD CK-MB-6 cTropnT-0.02*
[**2112-3-27**] 10:25AM BLOOD CK-MB-3
.
Microbiology:
- BCx negative x 3
- UCx negative x 2
.
Radiology:
RUQ U/S ([**3-18**]):
IMPRESSION:
1. No sign of acute cholecystitis.
2. Normal liver.
3. Trace ascites.
.
CT Abd/Pelvis ([**3-18**]):
IMPRESSION:
1. Evaluation for patency of vessels and vessel lumen is limited
in the
setting of lack of intravenous contrast. Non-specific small
amount of
perihepatic and intraabdominal ascites. Small right pleural
effusion.
2. No definite evidence of bowel ischemia on this noncontrast CT
exam. If
concern persists for bowel ischemia, repeat CT recommended with
IV contrast.
.
CTA Abd/Pelvis ([**3-19**]):
IMPRESSION:
1. Celiac axis, SMA, and [**Female First Name (un) 899**] are patent.
2. Several nondistended loops of small bowel within the right
lower quadrant demonstrate adjacent focal free fluid and remain
relatively mild thickened since the recent prior examination
four hours prior. Bowel wall thickening is nonspecific and may
be seen in embolic mesenteric ischemia. Persistence is
suspicious, though not definitive.
.
RUQ U/S ([**3-23**]):
CONCLUSION: Findings are compatible with worsening congestive
hepatopathy. Pulsatile bidirectional portal flow consistent
with tricuspid regurgitation with severe right heart failure.
.
ECHO ([**3-27**]):
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is severely depressed (LVEF=
15-20%). The right ventricular cavity is dilated with depressed
free wall contractility. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. 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. Moderate to severe [3+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. [In the setting of at least moderate to severe
tricuspid regurgitation, the estimated pulmonary artery systolic
pressure may be underestimated due to a very high right atrial
pressure.]
Compared with the prior study (images reviewed) of [**2111-9-7**],
the right ventricle appears dilated and hypokinetic on the
current study. The estimated pulmonary artery pressures are
lower, but are likely UNDERestimated given the severity of
tricuspid regurgitation.
.
Abdominal U/S with Duplex ([**3-27**]):
IMPRESSION:
1. The hepatic vessels are patent. Portal venous and hepatic
venous flow
suggestive of severe right heart failure.
2. Small amount of ascites.
.
Discharge labs (drawn on [**3-28**] several days before discharge as pt
made CMO status and labs were no longer checked):
WBC-7.2 RBC-4.75 Hgb-13.6* Hct-41.8 MCV-88 MCH-28.6 MCHC-32.5
RDW-15.9* Plt Ct-115* PT-26.6* PTT-37.6* INR(PT)-2.6*
Glucose-105* UreaN-59* Creat-2.7* Na-127* K-4.7 Cl-86* HCO3-17*
AnGap-29*
ALT-575* AST-519* LD(LDH)-552* AlkPhos-190* TotBili-14.3*
Albumin-3.7 Calcium-8.9 Phos-4.4# Mg-2.5
Lactate-8.5*
Brief Hospital Course:
CCU Course:
ID: Patient is an 87 year-old man witha PMH of HTN, HL, CAD s/p
CABG and multiple PCIs, ischemic CM (EF 15-20%), VT s/p ICD in
[**2099**] and ablation in [**2108**] and [**2112**], and chronic afib who was
transfered to the CCU for management of decompensated CHF.
.
# Acute on chronic systolic CHF: Patient has a documented LVEF
of 15-20% from [**8-/2111**] who was admitted to the CCU with acutely
worsened shortness of breath in the setting of receiving iv
fluids while NPO. He was started on a lasix gtt at 5mg/hr, will
uptitrate as needed with a goal of -1-2L daily. He was
transitioned to an oral regimen with torsemide and did well for
2 days. His LFTs then increased and his total bili increased
from 6 to 12 suggesting worsening liver congestion. A bedside
echo was performed which showed severely hypokinetic right
ventricle which in setting of sudden worsening of his hepatic
congestion confirmed on RUQ U/S was consistent with RV failure.
Formal ECHO documented worsening of RV dilation and hypokinesis.
Pt was transitioned back to ICU and started on lasix. Further
aggressive measures were not taken in light of goals of care
discussions with family. Status was changed to CMO and pt was
transitioned back to floor and palliative care consult obtained.
Decision was made to leave the hospital with palliative care on
hospice so all medications except comfort meds were stopped. Pt
kept on torsemide to help with breathing, but other than that,
all meds except lorazepam, oxycodone, and polyethylene glycol
were stopped. Decision was made that patient would not be
readmitted for worsening clinical situation and that every
effort at home would be made to insure patient comfort.
.
#Congestive Hepatopathy: Patient had elevated LFTs and further
work-up with RUQ revealed congestive hepatopathy. His LFTs
initially trended down somewhat with diuresis but then came back
up after he was transitioned to a po regimen. His total bili had
increased from 6 to 12 and he was transferred back to the CCU
for more aggressive diuresis and closer monitoring. RUQ at that
time confirmed that portal venous system was patent and noted a
worsening of the congestive hepatopathy thought [**2-24**] to worsened
RV failure. Since pt was made CMO status later that day, no
further invasive testing was performed. As above, pt later went
home on hospice.
.
# Goals of Care: Lengthy discussion was undertaken with
patient's wife and children during which it was decided that the
patient should be made DNR/DNI. In addition to providing care
for Mr. [**Known lastname 61836**], we are requested to invasive therapy to a
minimum. After readmission to the CCU later in admission,
discussions with family led to pt being made CMO status.
Palliative care came to see patient and discussions were
initiated about possible inpatient hospice. Decision was made to
go home on hospice and the palliative care service was involved
in discussions about measures to ensure comfort at home.
.
# RHYTHM: Underlying rhythm is atrial fibrillation, CHADS2 score
= 3. Warfarin was held due to elevated INR in setting of the
congestive hepatopathy with INRs in the 2s.
.
# CAD s/p MI and CABG: In setting of worsening heart failure and
LFTs, many of home cardiac meds were held. Once pt made CMO
status, all non-essential or non-comfort medications were
stopped.
.
Medications on Admission:
Aspirin 81 mg daily
Carvedilol 6.25mg TID
Lisinopril 2.5 mg daily
Nitroglycerin SL 0.4 mg q5min x 3 prn chest pain
Coumadin 5 mg qhs
Digoxin 125 mcg every other day
Furosemide 20 mg [**Hospital1 **]
Omeprazole 40 mg PO qD
Lorazepam 0.5 mg 1-2x/day prn anxiety
Spironolactone 25 mg daily
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*2*
3. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
4. torsemide 20 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
5. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours)
as needed for shortness of breath or wheezing.
Disp:*30 Tablet(s)* Refills:*2*
6. digoxin 125 mcg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY
(Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
Discharge Disposition:
Home With Service
Facility:
Hospice of [**Location (un) 1121**]
Discharge Diagnosis:
Mesenteric ischemia
Acute on Chronic Systolic Congestive Heart Failure: no ACE
inhibitor because of renal failure
Coronary Artery Disease
Hypotension
Atrial fibrillation
Hepatic congestion
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 had abdominal pain from a decrease in the blood flow to your
intestines. This has slowly resolved and your diet has improved.
You received some fluid when you were sick and needed to have
extra lasix to remove the fluid. We have restarted some
medicines to help your heart pump better. There was fluid around
your liver and in your abdomen which caused elevation of your
liver enzymes and a yellow tinge to your skin.After discussion
with you and your family, it was decided that the main goal of
your medical care is comfort. Therefore, you have no more
physician visits and your medical conditions will be managed at
home. Please eat and drink whatever you would like.
We made the following changes to your medicines:
1. Stop taking aspirin, coumadin, carvedilol, lisinopril,
furosemide and spironolactone
2. Take Torsemide 40 mg daily to prevent buildup of fluid
3. Take Lorazapam as needed to sleep at night
4. Take oxycodone as needed for trouble breathing
5. Take polyethylene glycol daily to prevent constipation
Followup Instructions:
No follow up appts are needed per [**Hospital 3225**] hospice status
|
[
"428.23",
"573.8",
"V45.81",
"V45.82",
"715.90",
"V45.02",
"458.8",
"272.4",
"427.31",
"557.1",
"V58.61",
"412",
"428.0",
"V49.86",
"401.9",
"782.4",
"414.8",
"414.00",
"584.9",
"V66.7"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13765, 13831
|
9247, 12598
|
266, 273
|
14064, 14064
|
5039, 5428
|
15297, 15369
|
3649, 3810
|
12935, 13742
|
13852, 14043
|
12624, 12912
|
14248, 15274
|
3825, 4646
|
2316, 3325
|
4662, 5020
|
207, 228
|
301, 2208
|
14079, 14224
|
3356, 3425
|
2230, 2296
|
3441, 3633
|
5440, 9224
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,304
| 178,320
|
13110
|
Discharge summary
|
report
|
Admission Date: [**2125-5-23**] Discharge Date: [**2125-5-25**]
Date of Birth: [**2066-4-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Demerol / Adhesive Tape
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Direct admission for cardiac catheterization.
Major Surgical or Invasive Procedure:
Cardiac catheterization with Cypher stent x 2.
History of Present Illness:
59-year-old female with a history of DMII complicated by
end-stage-renal disease, on peritoneal dialysis while undergoing
work-up for renal transplant, PVD, hyperlipidemia, glaucoma, and
anxiety transferred from the CMI service for hyperglycemia. She
had a planned admission to the CMI service for a cardiac cath
after having an abnormal adenosine stress on [**2125-3-1**] when she was
found to have an EF of 49% with mild inferior wall hypokinesis
and small perfusion defect in the basal inferolateral wall.
During the cath patient was discovered to have multiple lesions
in her LAD and received 2 cypher stents. After the cath the
patient was noted to have blood sugars in the 600's. She was
transferred to the MICU for close monitoring. Of note, she
received 10 units of humalog on the floor prior to transfer.
.
On interview patient says she feels a little nauseated and have
some intermittent right leg cramping. She is also having some
pain at the catheterization site.
Past Medical History:
1. Type 2 diabetes mellitus
2. Hypertension
3. Hyperlipidemia
4. End-stage renal disease, on peritoneal dialysis - failed
hemodialysis
5. Retinopathy, blind in right eye
6. Glaucoma of the left eye
7. Cataracts, status post left eye surgery
8. Peripheral neuropathy
9. Peripheral vascular diasease status post stent to left
anterior tibial artery
10. Anxiety
11. Chronic nausea
Social History:
She is married and lives at home with her husband. She does not
work. She does not smoke or drink.
Family History:
Her mother died of heart disease in her 60s.
Physical Exam:
VS: T: 96.3 P: 59 BP: 131/59 RR: 11 O2 sat: 99% on RA
GEN: lying in bed, eyes closed
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, MMM
CV: RRR, nl s1, s2, no m/r/g
PULM: CTAB to anterior exam, no w/r/r with good air movement
throughout
ABD: soft, tender near catheterization site, otherwise NT, ND, +
BS
EXT: warm, dry, +2 distal pulses on L, DP pulse dopplerable on
R, cath site with sheath in place
NEURO: alert & oriented, CN grossly intact, 5/5 strength
throughout. + decreased sensation in stocking and glove
distribution,
PSYCH: appropriate affect
Pertinent Results:
Labwork on admission:
[**2125-5-23**] 02:18PM GLUCOSE-531* UREA N-68* CREAT-5.1* SODIUM-141
POTASSIUM-5.0 CHLORIDE-106 TOTAL CO2-23 ANION GAP-17
[**2125-5-23**] 05:47PM CALCIUM-9.0 PHOSPHATE-5.4* MAGNESIUM-2.2
[**2125-5-23**] 02:18PM PLT COUNT-277
.
[**2125-5-23**] Cardiology C.CATH
Full report pending.
Cypher stent x 2 placed in LAD.
.
Labwork on discharge:
[**2125-5-25**] 03:06AM BLOOD WBC-11.2* RBC-3.31* Hgb-9.9* Hct-29.1*
MCV-88 MCH-29.9 MCHC-34.0 RDW-14.2 Plt Ct-293
[**2125-5-25**] 03:06AM BLOOD Glucose-172* UreaN-57* Creat-6.4* Na-141
K-4.4 Cl-104 HCO3-23 AnGap-18
[**2125-5-25**] 03:06AM BLOOD Calcium-8.9 Phos-5.7* Mg-1.9
Brief Hospital Course:
1. Hyperglycemia: The patient is a type 2 diabetic and was
instructed to hold her home insulin regimen the night prior to
catherization. She never had an anion gap. The patient's
glucose levels improved after resuming her home insulin regimen
and FSG was 131 prior to discharge. There were no localizing
signs or symptoms of infection and cardiac enzymes and EKG
remained stable. She was continued on reglan for diabetic
gastroparesis.
.
2. Relative hypotension: The patient's systolic blood pressure
dropped to the 80s after peritoneal dialysis with removal of 1.7
liters of fluid. The patient's blood pressure responded to
fluid resuscitation. The patient's hematocrit remained stable
and there was no concern for retroperitoneal hemorrhage. The
patient was kept an additional night for monitoring. Blood
pressure remained stable with systolics 110s prior to discharge.
.
3. Coronary artery disease: The patient underwent cardiac
catheterization for renal transplant evaluation. The patient
received two Cypher stents to the LAD. She was started on
Plavix to continue at least a three month course and Aspirin was
increased from 81 mg to 325 mg. The patient was continued on
Toprol XL and Simvastatin.
.
4. End-stage renal disease: The patient is on peritoneal
dialysis as an outpatient. The patient was continued on
nephrocaps, Calcitriol, and Sevelamer. The patient was followed
by the Renal service during admission and received PD per
schedule. Sevelamer was increased per Renal recommendations.
.
5. Glaucoma: No active issues. The patient was continued on
Prednisolone and Brimonidine eye drops.
.
6. Depression/Anxiety: No active issues. The patient was
continued on Bupropion, Venlafaxine, and Provigil.
Medications on Admission:
1. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
2. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
3. Renagel 800 mg Tablet Sig: Two (2) Tablet PO three times a
day.
4. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic DAILY (Daily).
6. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Modafinil 100 mg Tablet Sig: One (1) Tablet PO qd ().
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Risperidone 0.25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
13. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
14. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
15. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Twenty (20) units Subcutaneous twice a day: With humalog
sliding scale as per previous regimen.
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
3. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
4. Renagel 800 mg Tablet Sig: Two (2) Tablet PO three times a
day.
5. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic DAILY (Daily).
7. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Modafinil 100 mg Tablet Sig: One (1) Tablet PO qd ().
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. Risperidone 0.25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
12. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
13. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
14. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
15. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
16. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Twenty (20) units Subcutaneous twice a day: With humalog
sliding scale as per previous regimen.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Coronary artery disease status post Cypher stent x 2
.
Secondary:
1. Type 2 diabetes mellitus
2. Hypertension
3. Hyperlipidemia
4. End-stage renal disease, on peritoneal dialysis - failed
hemodialysis
5. Retinopathy, blind in right eye
6. Glaucoma of the left eye
7. Cataracts, status post left eye surgery
8. Peripheral neuropathy
9. Peripheral vascular diasease status post stent to left
anterior tibial artery
10. Anxiety
11. Chronic nausea
Discharge Condition:
Afebrile, vital signs stable.
Discharge Instructions:
You were admitted for a cardiac catheterization as part of your
kidney transplant evaluation. During the catheterization two
stents were placed. You need to take plavix for at least three
months; do not discontinue this medication unless instructed by
your cardiologist.
Please contact a physician if you experience fevers, chills,
chest pain, shortness of breath, worsening back pain, lower
extremity numbness or pain, or any other concerning symptoms.
Please take your medications as prescribed.
- You were started on plavix 75 mg daily.
- Your aspirin was increased from 81 mg to 325 mg daily.
- Your sevelemer was increased.
- No other changes were made to your medications.
.
Please keep your follow-up appointments as below.
Followup Instructions:
Previously scheduled appointments:
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2125-6-11**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2125-6-21**] 1:40
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2125-6-21**] 2:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
|
[
"414.01",
"272.4",
"V45.1",
"362.01",
"250.40",
"272.0",
"V49.83",
"357.2",
"300.4",
"585.6",
"403.91",
"443.9",
"250.60",
"250.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.46",
"36.07",
"00.66",
"99.20",
"37.23",
"00.40",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
7812, 7818
|
3270, 5001
|
349, 398
|
8315, 8347
|
2604, 2612
|
9130, 9692
|
1939, 1985
|
6348, 7789
|
7839, 8294
|
5027, 6325
|
8371, 9107
|
2000, 2585
|
2971, 3247
|
264, 311
|
426, 1403
|
2626, 2957
|
1425, 1804
|
1820, 1923
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,378
| 183,438
|
21978
|
Discharge summary
|
report
|
Admission Date: [**2118-9-12**] Discharge Date: [**2118-9-21**]
Date of Birth: [**2059-3-24**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Metastatic renal cell cancer to thoracic spine.
Major Surgical or Invasive Procedure:
1. Transpedicular decompression at T11-T12.
2. Fusion T5-L2.
3. Segmental multiple thoracic laminotomies.
4. Instrumentation T5-L2.
5. Autograft.
6. Epidural catheter placement.
History of Present Illness:
Metastatic renal cell cancer to thoracic spine.
Past Medical History:
PMHx:
1. Renal cell carcinoma- Diagnosed ~11 months ago. [**1-/2117**], pt
was admitted to the hospital ([**Hospital1 1774**]) with right chest pain and
shoulder pain. Imaging at that time revealed a large right sided
kidney tumor. He underwent angioinfarction in the same admission
on [**2117-2-1**]. 2 weeks discharge on [**2117-2-20**], Mr. [**Known lastname **] presented
to the hospital and was found to have a large PE. He was in the
ICU for several days and was subsequently discharged with
anticoagulation. On [**2117-4-2**], pt underwent right nephrectomy
and IVC thrombectomy with IVC clip placement. Within several
months, MRI revealed ? of liver metastasis and lung metastases.
Pt started on Avastin chemo and received day 15 of cycle 8 on
[**2118-7-18**].
2. IVC clot, on coumadin.
3. Hyperlipidemia
4. nephrolithiasis
Social History:
Mr. [**Known lastname **] has been married for 15 years. He has two children
from his first marriage. No EtOH. No alcohol. He lives in
[**Location 1456**], [**State 350**] and works as a fireman.
Family History:
CAD in multiple family members as well as peripheral vascular
disease.
One uncle with a cancer, but pt unsure of what type it was.
Physical Exam:
a+o x 3 NAD.
V.S.S afebrile
incision [**Name (NI) 1830**]
Pt is moving extremities well.
Pertinent Results:
[**2118-9-12**] 08:37PM URINE HOURS-RANDOM
[**2118-9-12**] 08:37PM URINE GR HOLD-HOLD
[**2118-9-12**] 08:37PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2118-9-12**] 08:37PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2118-9-12**] 06:00PM GLUCOSE-106* UREA N-16 CREAT-1.1 SODIUM-139
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-23 ANION GAP-15
[**2118-9-12**] 06:00PM ALBUMIN-4.2
[**2118-9-12**] 06:00PM WBC-6.6# RBC-4.55* HGB-13.9* HCT-39.7* MCV-87
MCH-30.6 MCHC-35.1* RDW-13.4
[**2118-9-12**] 06:00PM PLT COUNT-184#
Brief Hospital Course:
Pt admitted [**9-12**] pt's coumadin stopped [**9-9**] pt started on heparin
gtt [**9-12**]. Ptahad embolization of thoracic tumor [**9-15**] and
decompression thoracic spine [**9-16**]. Pt's coumadin restarted [**9-18**].
pt dc'd to rehab [**9-20**]
Medications on Admission:
coumadin 5 mg qd
Discharge Medications:
1. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours) as needed for pain.
Disp:*10 Patch 72HR(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
6. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): hold for INR >3.
Disp:*30 Tablet(s)* Refills:*2*
7. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day) as needed for hx svc thrombus.
Disp:*90 U/ML* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Metastatic renal cell cancer to thoracic spine
Discharge Condition:
stable
Discharge Instructions:
Keep wound clean and dry. Wear TLSO brace when out of bed.
Physical Therapy:
Therapy - wear TLSO brace when out of bed. Stretching and
strengthening. Activity as tolerated. No excessive bending,
lifting, or twisting.
Treatments Frequency:
Fentanyl 100mcg apply 1 patch q72h
Docusate sodium 100mg 1 tab po bid
Famotadine 20mg 1 tab po bid
Metoprolol 25mg 0.5 tab po bid
Oxycodone Acetaminophen 5/325 [**2-6**] tab po q4-6h prn pain
Wafarin sodium 5mg 1 tab po daily, hold for INR >3
Heparin sodium (porcine) 5,000 units/ml 1 injection tid, hx of
svc thrombus
Thoracic wound. Daily wound check. Change dressing as needed.
Steri strips to be removed in Dr.[**Name (NI) 12040**] office in two weeks.
Followup Instructions:
Follow up in Dr.[**Name (NI) 12040**] office in two weeks as scheduled.
[**Telephone/Fax (1) 3573**]
Completed by:[**2118-9-20**]
|
[
"724.01",
"724.4",
"276.5",
"V12.51",
"198.5",
"285.9",
"V10.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.79",
"81.64",
"99.04",
"03.90",
"88.49",
"81.05",
"03.09"
] |
icd9pcs
|
[
[
[]
]
] |
3828, 3908
|
2609, 2861
|
367, 547
|
3999, 4007
|
1971, 2586
|
4758, 4889
|
1715, 1847
|
2928, 3805
|
3929, 3978
|
2887, 2905
|
4031, 4091
|
1862, 1952
|
4109, 4252
|
4274, 4735
|
280, 329
|
575, 624
|
646, 1483
|
1499, 1699
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,755
| 190,393
|
53069
|
Discharge summary
|
report
|
Admission Date: [**2185-6-3**] Discharge Date: [**2185-6-11**]
Date of Birth: [**2112-6-14**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10842**]
Chief Complaint:
flank pain
Major Surgical or Invasive Procedure:
s/p ETT intubation
s/p Left percutaneous nephrostomy tube
s/p RIJ [**First Name3 (LF) 14938**] & LIJ [**First Name3 (LF) 14938**]
History of Present Illness:
72-year-old female with past medical history significant for
type II diabetes, dCHF, severe anemia [**3-15**] beta thalassemia trait
and myelodysplastic syndrome, HTN, asthma, and hyperlipidemia
who presents now to ED with 1 day left sided flank pain, fevers
and suspected pyelonephritis in setting of obstructive renal
stone. She initially denied any fevers/chills, but did report
nausea without vomiting. Of note patient has history of
pansensitive E.Coli UTI dating back to [**11/2184**] per OMR notes.
Urology workup from same timeframe included CT pelvis that
showed tiny stone in the left ureterovesical junction causing
mild left pelviectasis and delayed excretion from the left
kidney. Additional non-obstructing stones were also seen in the
left kidney as well.
.
In the ED, initial vs were: T [**Age over 90 **]F, PR 65, BP 146/48, RR 16, O2
saturation 100% RA . Patient was nauseous and given 2mg IV
Zofran x2, 4mg IV Morphine x1 for pain. Her UA was hazy and
showed large amount blood, moderate leuks, few bacteria,
negative nitrites. was postive and was started on 1g IV
Ceftriaxone. She had notable labs in ED for lactate 5.2, WBC
14.4 (60% neuts, 16% lymphs and 8 bands). HCT 28 / elevated from
baseline , and Cr 1.6 (recent baseline fluctuates between
1.3-1.8). She spiked fevers in ED to 104F range and given 650mg
Tylenol and 400mg ibuprofen,a right IJ placed for access.
After CT Abd/Pelvis revealed [**First Name9 (NamePattern2) 5692**] [**Location (un) 1131**] of hydronephrosis,
hydroureter and 0.4 mm left UVJ ureteral stone. Urology was
consulted and considered placing a stent, but anesthesia felt
uncomfrotable intubating her and it was decided to proceed with
IR. Additionally, urology recommended adding 80mg Gentamicin
and flomax. The patient subsequently became hypotensive with
SBP high 70's and was started on levophed 0.06mcg/kg/min. Vital
signs at the time of transfer to IR suite were: Temp 101.6 F, HR
78, BP 94/61, RR 22 99% 3L.
.
The patient was brought to the IR suite with SBP high 90's and
on 0.15mcg of levophed. INR was 2.2 so given 4 Units FFP,
recheck was 1.8 so given another 2 units FFP. Also given unit of
platelets, 2 unit PRBCs and 2 units cryoprecipitate in setting
of bleeding from IJ site and worse DIC labs. Urology placed a 5
french stent to help decompress patient via cystoscopy approach
to help stabilize her while awaiting IR nephrostomy placement. A
sample of pus from stent was sent off for culture. IR
successfully placed a left nephrostomy tube and then urology
removed temporary stent.
.
Initial vitals on arrival to ICU were: T 97.2F, HR 68, BP
140/60, and settings on A/C were Tv 450 x 18 RR, PEEP 5, Fi02
100%. RR at 18.
.
She was still on Levophed pressor and was fully sedated and
intubated. A thrombin dressing was packed tightly over RIJ with
limited evidence of oozing BRB. Foley was removed and right
nephrostomy draining blood tinged urine.
Past Medical History:
-diabetes type II
-peripheral neuropathy
-laparoscopic cholecystectomy [**2184**]
-Anemia [**3-15**] beta thalassemia trait
-MDS
-Essential thrombocytosis
-H.pylori s/p treatment
-Type 2 diabetes diagnosed [**2167**].
-Asthma.
-Hypertension.
-osteoporosis.
-lumbar spinal stenosis.
-hypercholesterolemia.
-s/p appendectomy at age 10.
Social History:
She lives with her son. She has been widowed for 7 years. She
has a 46-year-old son and a 44-year-old daughter. She has no
grandchildren. She worked in the school department for many
years and specifically worked in daycare.
She is a nonsmoker, nondrinker.
Family History:
Mother had thalassemia as well, unable to obtain additional
history
Physical Exam:
Vitals: T 97.2F, HR 68, BP 140/60, and settings on A/C were Tv
450 x 18 RR, PEEP 5, Fi02 100%. RR at 18.
General: sedated, intubated, very pale appearing
HEENT: Sclera anicteric, MMM, oropharynx clear /intubated
Neck: supple, JVP ~ 12cm, no LAD, oozing blood around edge RIJ
site
Lungs: Crackles at bases bilaterally, no wheezes, ronchi
CVS: Regular rate and rhythm, normal S1/S2, [**3-19**] mild systolic
murmur at apex, no rubs, no gallops
Abdomen: soft, non-tender, non-distended, normoactive bowel
sounds present, no hepatomegaly appreciated
Flank: left side nephrostomy tube c/d/i
GU: foley in place, nephrostomy tube on left draining sanguinous
urine
Ext: warm, well perfused, 2+ pulses, 1+ edema bilaterally
Pertinent Results:
[**2185-6-3**] CXR at 1pm : FINDINGS: There is no focal consolidation
or superimposed edema. There is calcified plaque at the aortic
arch. The cardiac silhouette is enlarged but stable. No effusion
or pneumothorax is noted. Degenerative changes are seen
throughout the thoracic spine. IMPRESSION: No radiographic
evidence of heart failure or pneumonia. Stable cardiomegaly.
.
[**2185-6-3**] CT pelvis W/O contrast : [**Month/Day/Year 5692**] .4 mm left UVJ ureteral
stone with mild hyrdoureter and hydronephrosis, new since [**Month (only) **]
[**2184**]. Significant splenomegaly, unchanged.
.
[**12/2184**] CT pelvis:
1. Tiny stone in the left ureterovesical junction causing mild
left
pelviectasis and delayed excretion from the left kidney.
Additional
non-obstructing stones in the left kidney.
2. Renal hyperdense and hypodense cysts, better assessed on
recent MRI.
3. Splenomegaly without evidence of splenic rupture or
subcapsular hematoma
.
[**11/2184**] ECHO/TTE: EF >60% . Mild-moderate pulmonary artery
systolic hypertension. Normal biventricular cavity sizes with
preserved global and regional biventricular systolic function.
Mild mitral regurgitation
.
EKG: rate 64, NSR, incomplete LBBB, no ST
elevations/depressions, slight left axis
.
Echo [**2185-6-6**]:
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened
(sclerotic) but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2184-11-16**], no
change.
.
Abd/Pelv CT without contrast [**2185-6-5**]:
1. Interval development of bilateral moderate-sized pleural
effusions with
subjacent atelectatic changes.
2. Interval development of ascites. No focal fluid collections
are seen.
3. Decompression of left pelvicaliceal system after placement of
percutaneous nephrostomy tube with dislodged left UVJ calculus
into the distal left ureter.
4. Stable splenomegaly.
5. Diffuse subcutaneous soft tissue edema reflecting anasarca.
.
.
Radiology Report CHEST (PA & LAT) Study Date of [**2185-6-10**] 6:11 PM
.
FINDINGS: Mild cardiomegaly. New bilateral diffuse interstitial
opacities
with basilar predominance. Small bilateral pleural effusions are
new.
Interval removal of indwelling monitoring and support devices.
IMPRESSION: New interstitial edema and small pleural effusions.
No
complication.
Brief Hospital Course:
Ms. [**Name13 (STitle) **] is a 72 yo W with PMH of Type II DM, MDS,
B-thalassemia trait who is called out of the MICU after
resolution of septic shock [**3-15**] pyelonephritis from obstructive
nephrolithiasis, now s/p stent and nephrostomy tube placement.
1. septic shock secondary to obstructive nephrolithiasis: Pt
was admitted with septic shock from urosepsis from obstructive
pyelonephritis. Lactate up to 5 range, fevers to 104,
leukocytosis to 14 with 8 bands. Now s/p 4 liters NS in ED.
Antibiotics given in ED with IV Ceftriaxone and gentamicin.
Patient had associated N/V, flank pain. She is now status post
IR nephrostomy placement which was complicated by worse
shortness of breath prior to procedure so patient was intubated
in IR suite. Sepsis is now complicated by emerging DIC picture.
Urology & IR following closely. Patient s/p temporary stent in
IR, then L percutaneous nephrostomy tube placed. Admitted to
MICU where received aggresive fluid resuscitation, maintained
initially on gent/zosyn, then just zosyn for antibiotic
coverage. Urine grew out pan sensitive Ecoli and Blood from
A-line grew out GPCs. Pt had RIJ removed due to concern for
line infection and LIJ was placed under sterile conditions.
After replacement of the [**Name (NI) 14938**], pt was able to be weaned from
pressors and started having increased UOP from nephrostomy and
foley. Pt was gently diuresed, she was successfully extubated
on [**6-7**]. Pt was transitioned from zosyn to ampicillin and than
to oral amoxicillin with plan for 14 day course ([**6-3**]- [**6-16**]).
Patient will follow up with urology as an outpatient for
definitive treatment.
2. Afib with RVR: likely related to acute illness & volume
overload and pt was loaded with Amiodarone over wkd and went
back into sinus. During SBT on [**6-7**], pt developed AF and after
discussion with primary cardiologist, started on oral load of
Amiodarone with plan for titration in 2wks, overall goal for
rhythm control and avoid risks of anti-coag. Rate control with
goal HR in 60- 80s achieved with metoprolol 25mg TID. TTE on
[**6-6**] showed preserved LVEF, LA normal. Through the remainder of
hospital stay, continued gentle diuresis with lasix 40mg IV prn
to meet net fluid balance of - 1L/day. Remained in NSR on
discharge.
3. Respiratory distress: Resolving. Pt developped respiratory
distress while in the IR suite when she became tachypneic and
had decreased oxygen saturations which were likely due to fluid
overload as patient has known dCHF and had received 4L IVFs, 6
Units FFP. Pt self extubated on [**6-7**] and was able to be weaned
off oxygen quickly. Despite meeting diuresis goals of -1 to
-1.5 L/day, the patient remained subjectively dyspneic with
signs of volume overload on exam. CXR on [**6-10**] showed new
interstitial edema and small pleural effusions, so she was
diuresed further on morning of discharge with improvement in
symptoms.
4. ARF: Presented with acute renal failure secondary to
hydronephrosis and severe septic shock. With reversal of
pathophysiology, creatinine improved form peak 2.5 to 1.1 on
discharge.
5. Transaminitis: Likely [**3-15**] shock. LFTs continue trending down
but she will need further monitoring as an outpt.
6. Anemia / MDS: Pt with longstanding history of transfusion
requiring MDS with anemia. She was transfused for goal hct>23.
Diff remains abnormal at baseline.
7. Asthma: Pt with history of asthma who was intubated for
tachypnea and volume overload. There is still some evidence of
cardiac vs asthmatic wheeze. Continued on Albuterol nebs while
diuresing.
8. Type II DM: Outpatient oral medications held on admission and
patient maintained on basal insulin with sliding scale through
duration of hospital stay.
Medications on Admission:
MEDICATIONS / PER OMR Review:
Medications - Prescription
AMLODIPINE - (Prescribed by Other Provider; Dose adjustment -
no
new Rx) - 10 mg Tablet - one Tablet(s) by mouth once daily
EPOETIN ALFA [PROCRIT] - (Prescribed by Other Provider: [**Last Name (NamePattern4) **].
[**Last Name (STitle) 410**]; Dose adjustment - no new Rx; 60,000 unit total) - 40,000
unit/mL Solution - SQ weekly dose increased to 60,000 units
FENOFIBRATE NANOCRYSTALLIZED [TRICOR] - (Prescribed by Other
Provider) - 145 mg Tablet - 1 Tablet(s) by mouth daily pt states
she takes 160 mg once daily
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth twice daily
after
breakfast and dinner
FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth twice a day
GLYBURIDE-METFORMIN - (Prescribed by Other Provider) - 5 mg-500
mg Tablet - 2 Tablet(s) by mouth twice a day
NEBIVOLOL [BYSTOLIC] - (Prescribed by Other Provider) - 10 mg
Tablet - one Tablet(s) by mouth once daily after breakfast
ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth daily
.
Medications - OTC
CALCIUM 600 + D - (Prescribed by Other Provider) - 600 mg
(1,500
mg)-200 unit Tablet - one Tablet(s) by mouth twice daily, after
breakfast and dinner
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] - (Prescribed
by Other Provider; OTC) - 600 mg-400 unit Tablet - [**2-12**] Tablet(s)
by mouth once daily after breakfast
MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) -
Tablet - 1 Tablet(s) by mouth daily No IRON
OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - (OTC) - 20 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth daily before
breakfast
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 14 days.
3. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Epoetin Alfa Injection
7. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours) for 6 days: take until [**2185-6-16**].
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Glyburide-Metformin 5-500 mg Tablet Sig: Two (2) Tablet PO
twice a day.
10. Outpatient Lab Work
please draw CBC weekly (first to be drawn on [**2185-6-15**]) and
transfuse for Hct < 25
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
14. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED).
16. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) INH Inhalation Q6H (every 6 hours) as
needed for wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]-Combridge
Discharge Diagnosis:
Primary Diagnoses:
septic shock with DIC
obstructive nephrolithiasis with hydronephrosis
e. coli urinary tract infection
Secondary Diagnoses:
MDS
type II DM
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:
Ms. [**Known lastname 109348**], it was a pleasure taking care of you during your
recent hospitalization at [**Hospital3 **]. You were admitted to the
hospital with left sided back pain and were found to have a
kidney stone blocking the outflow of urine and causing a severe
infection. You were monitored in the intensive care unit,
initially requiring medications to help maintain your blood
pressure and a breathing tube. The urologists put a stent in
one of your ureters and placed a tube to help drain urine from
the right kidney. While you were sick, you developed a heart
arrhythmia called atrial fibrillation and you were started on
amiodarone to help the rhythm return to normal. You were
treated with antibiotics, which you will need to take for a
total of two weeks. You will eventually need to have the kidney
stone surgical removed.
Please make the following changes to your medication regimen:
1. Take amoxicillin 500mg twice daily [**2185-6-16**] to complete a 14
day course of antibiotics
2. Start amiodarone 400mg daily for two weeks. Please ask your
cardiologist what dose of medication you should continue to take
3. Start metoprolol 25mg three times daily
4. Stop bystolic
Take all of your other medications as previously prescribed
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2185-6-14**] at 8:00 AM
With: [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], RN [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
Location: CARDIOLOGY ASSOCIATES OF GREATER [**Location (un) **]
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**0-0-**]
Appointment: [**2185-6-15**] 10:30am
- UROLOGY -
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2185-6-22**] at 1 PM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"402.91",
"038.9",
"733.00",
"041.4",
"416.8",
"282.5",
"428.0",
"592.1",
"427.31",
"518.81",
"286.6",
"590.10",
"591",
"356.9",
"592.0",
"995.92",
"238.75",
"250.00",
"272.4",
"785.52",
"493.90",
"428.33",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"59.8",
"96.71",
"96.04",
"38.93",
"55.03"
] |
icd9pcs
|
[
[
[]
]
] |
14817, 14870
|
7880, 11638
|
326, 457
|
15072, 15072
|
4882, 7857
|
16541, 17452
|
4060, 4129
|
13353, 14794
|
14891, 15013
|
11664, 13330
|
15255, 16518
|
4144, 4863
|
15034, 15051
|
276, 288
|
485, 3411
|
15087, 15231
|
3433, 3768
|
3784, 4044
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,881
| 102,679
|
23473
|
Discharge summary
|
report
|
Admission Date: [**2123-2-12**] Discharge Date: [**2123-2-16**]
Date of Birth: [**2070-11-18**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
52yo F presents s/p Gamma Nail L femur fx, tibial plateau ORIF
after removal of temporary external fixator, and body fx from
MVC dated [**2123-1-16**], now complaining of R knee wound infection.
Major Surgical or Invasive Procedure:
I&D R Knee
History of Present Illness:
Pt was seen by Dr [**Last Name (STitle) 1005**] three days prior to admission in
clinic with concern of an infected surgical wound. Denied fever,
chills, nausea, vomiting, numbness, tingling. Pt states her
coumadin was stopped 2 [**Last Name (un) 32460**] prior to admission. Pt has noticed
increased discharge from wound. The pt has remained afebrile.
Past Medical History:
s/p Gamma Nail L Femur, tibial plateau ORIF,and C2 body fx
Hypothyroidism
Hyrpertension
MRSA
Social History:
nc
Family History:
nc
Physical Exam:
98.8*96*148/50*14*93RA
AAOx3 NAD
PERRLA, EOMI, collar in place
Healing laceration to left forehead/temple
CTAB
RRR, S1 S2
Abd soft, non-tender
+2 radial and DP pulses
R knee immobilized with wound producing slight purulence
LLE has small healing lac
Pertinent Results:
[**2123-2-12**] 11:10AM PT-16.4* PTT-27.1 INR(PT)-1.7
[**2123-2-12**] 11:10AM PLT COUNT-386
[**2123-2-12**] 11:10AM HYPOCHROM-1+ POIKILOCY-1+
[**2123-2-12**] 11:10AM NEUTS-72.0* LYMPHS-21.3 MONOS-3.0 EOS-3.5
BASOS-0.2
[**2123-2-12**] 11:10AM WBC-6.3 RBC-4.09* HGB-11.8* HCT-35.5* MCV-87
MCH-28.9 MCHC-33.2 RDW-15.5
[**2123-2-12**] 11:10AM GLUCOSE-98 UREA N-14 CREAT-0.6 SODIUM-141
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-33* ANION GAP-11
[**2123-2-12**] 05:20PM VANCO-18.6*
[**2123-2-12**] 4:30 pm SWAB Site: KNEE R KNEE.
GRAM STAIN (Final [**2123-2-12**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary):
BACTERIA. RARE GROWTH.
BEING ISOLATED FURTHER IDENTIFICATION TO FOLLOW.
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
[**2123-2-9**] 4:20 pm SWAB RIGHT LEG.
**FINAL REPORT [**2123-2-11**]**
GRAM STAIN (Final [**2123-2-9**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2123-2-11**]):
STAPH AUREUS COAG +. SPARSE GROWTH.
Please contact the Microbiology Laboratory ([**6-/2424**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
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
RADIOLOGY Final Report
FEMUR (AP & LAT) LEFT [**2123-2-13**] 3:20 PM
FEMUR (AP & LAT) LEFT
Reason: eval for fracture
[**Hospital 93**] MEDICAL CONDITION:
52 year old woman with pain on extension
REASON FOR THIS EXAMINATION:
eval for fracture
HISTORY: A 52-year-old woman with pain on extension. Please
evaluate for fracture.
AP AND LATERAL VIEWS OF THE LEFT FEMUR: Comparison is made to
intraoperative films on [**2123-1-16**]. There is an intramedullary rod
and femoral neck screw in place, stabilizing a mid shaft
fracture. Fracture is comminuted, bony fragments in the soft
tissues lateral and anterior to the fracture site.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 32202**]
Approved: SUN [**2123-2-14**] 8:01 AM
RADIOLOGY Final Report
C-SPINE, TRAUMA [**2123-2-13**] 3:20 PM
C-SPINE, TRAUMA
Reason: eval for fx
[**Hospital 93**] MEDICAL CONDITION:
52 year old woman with pain on extension
REASON FOR THIS EXAMINATION:
eval for fx
HISTORY: 52-year-old woman status post trauma with pain on
extension. Please evaluate for fracture.
THREE VIEWS OF THE CERVICAL SPINE: The exam is technically
limited. No gross fracture or dislocation is seen. The
retropharyngeal soft tissues are normal. The cervical spine
appears straight, but the patient is recumbent.
IMPRESSION:
Technically limited exam but no gross fracture seen.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 32202**]
Approved: SUN [**2123-2-14**] 8:01 AM
Brief Hospital Course:
Pt was admitted to the Ortho/Trauma Service under Dr [**Last Name (STitle) 1005**]
and scheduled for a I&D washout of the R knee. The pt was
started on Vanco/Gent antibiosis in the ED and was subsequently
changed to Vanco only on admission. The pt tolerated the
procedure well withouut any apparent complications. On POD#2,
the drain was pulled and the wound was examined to be healing
satisfactorily. PT attempted to evaluate the pt, but the pt
refused. The Venous Access team evaluated the pt, was unable to
place a PICC at bedside and recommended placement via IR. Repeat
femur and c-spine were ordered and neither showed any
significant change and were reviewed by Dr [**Last Name (STitle) 1005**] prior to
discharge.
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
5. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4-6H
(every 4 to 6 hours) as needed.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
7. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
9. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) Intravenous
twice a day for 4 weeks.
10. Outpatient Lab Work
Vanco Trough Q Wednesday
Report results to Dr [**Last Name (STitle) 1005**]
617*667*5589
11. PICC Care
PICC line flush
As per protocol.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
R Knee Sx Site Infection
s/p Gamma Nail L femur, tibial plateau ORIF, and C2 body fx
HTN
Hypothyroidism
Discharge Condition:
Good.
Discharge Instructions:
Seek medical attention if you experience fever, chills, nausea,
vomiting, new or worsening, symptoms.
Place no weight on your right leg.
Use your crutches as directed.
Keep your leg elevated as much as possible.
Continue to wear your collar AT ALL TIMES for 12 weeks.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Where: [**Hospital6 29**]
ORTHOPEDICS Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2123-3-2**] 11:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12005**] Where: LM [**Hospital Unit Name 12006**] Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2123-2-23**] 10:40
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2123-2-15**]
|
[
"998.59",
"E878.8",
"682.6",
"V54.13",
"401.9",
"244.9",
"V54.17"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"86.22"
] |
icd9pcs
|
[
[
[]
]
] |
6661, 6708
|
4967, 5690
|
516, 529
|
6856, 6863
|
1353, 2014
|
7179, 7719
|
1064, 1068
|
5713, 6638
|
4324, 4365
|
6729, 6835
|
6887, 7156
|
1083, 1334
|
282, 478
|
4394, 4944
|
2049, 2137
|
557, 911
|
2173, 3523
|
933, 1028
|
1044, 1048
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,517
| 183,289
|
36198
|
Discharge summary
|
report
|
Admission Date: [**2118-2-15**] Discharge Date: [**2118-2-23**]
Date of Birth: [**2059-7-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
PNA
Major Surgical or Invasive Procedure:
A line
intubation/extubation
PICC placement x2
History of Present Illness:
Patient admitted from OSH intubated. Per OSH records 58 yo M
presented on [**2118-2-14**] with 3-4 day of cough, SOb and rigors.
Brother had similar sx. Heavy smoker. On admisstion to OSH, was
dx with PNA treated with CTX, azitrho and clinda and admitetd to
ICU. Overnight became agitated likely [**3-14**] EtOH withdrawal,
followed CIWA protocol, progressed to respiratory distress, was
intubated - difficult and traumatic.
OSH Labs:
NA 131, K 3.5, Cl 93 Bicarb 25, Glc 186, BUN 19, Cr 0.8, Mg 2
WBC 6.6 hct 47.2 plt 222
Trop 0.02
BNP: 88
Tbili 1.4 AP 75, ALT 19, AST 32, Mg 2
ABG: 7.27/68/118 - after intubated
Venous Lactate 4.9
OSH Imaging:
CXR: Acute RLL infiltrate
EKG: Sinus tach at 135
Head CT: No actue intracrainial process, L maxillary sinusitis,
mild involutionary changes
On admission to [**Hospital1 18**], patient is intubated therefore unable to
obtain additional history or ROS.
Past Medical History:
Childhood Asthma
H/o (+) Hep A antibody - otherwise Hep screen negative
Hyperlipidemia
Social History:
Lawyer, + tobacco 1ppd, 6 vodka/day, ? hx of cocain abuse, long
term girlfriend, lives with her.
Family History:
NC
Physical Exam:
On Presentation:
Vitals: T: BP:96/52 HR:77 O2Sat: 98%
GEN: Well-appearing, well-nourished, no acute distress,
intubated
HEENT: EOMI, PERRL, sclera anicteric. No LAD.
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 rhoncorous
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords , 2+ distal pulses B UE/LE
NEURO: sedated, no assessed
SKIN: no rashes, sebbhoric keratosis on abdomen
Pertinent Results:
[**2118-2-15**] 08:06PM GLUCOSE-183* UREA N-24* CREAT-0.9 SODIUM-145
POTASSIUM-4.4 CHLORIDE-109* TOTAL CO2-26 ANION GAP-14
[**2118-2-15**] 08:06PM estGFR-Using this
[**2118-2-15**] 08:06PM CALCIUM-8.2* PHOSPHATE-3.1 MAGNESIUM-2.4
[**2118-2-15**] 08:06PM WBC-3.8* RBC-3.55* HGB-12.6* HCT-37.9*
MCV-107* MCH-35.6* MCHC-33.4 RDW-12.9
[**2118-2-15**] 08:06PM NEUTS-91.3* LYMPHS-5.9* MONOS-2.6 EOS-0.1
BASOS-0.2
[**2118-2-15**] 08:06PM PLT COUNT-199
[**2118-2-15**] 08:06PM PT-14.6* PTT-34.1 INR(PT)-1.3*
[**2118-2-15**] 08:06PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.027
[**2118-2-15**] 08:06PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-SM
[**2118-2-15**] 08:06PM URINE RBC-54* WBC-15* BACTERIA-FEW YEAST-NONE
EPI-1
[**2118-2-15**] 08:06PM URINE MUCOUS-RARE
[**2118-2-15**] 08:00PM TYPE-ART TEMP-37.2 PO2-102 PCO2-54* PH-7.32*
TOTAL CO2-29 BASE XS-0 INTUBATED-INTUBATED
<br>
[**2118-2-22**] TEE: No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is normal
(LVEF>55%). There are simple atheroma in the descending thoracic
aorta. 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. There is no pericardial effusion.
Impression: No masses or vegetations are seen on the aortic or
the mitral valve. Normal overall LV systolic function
<br>
[**2118-2-18**] Echo (TTE):
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Tissue Doppler imaging suggests a
normal left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets appear structurally normal with good
leaflet excursion. No masses or vegetations are seen on the
aortic valve. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is an anterior
space which most likely represents a fat pad.
IMPRESSION: No valvular pathology or pathologic flow identified.
Normal biventricular cavity sizes with preserved global and
regional biventricular systolic function.
CLINICAL IMPLICATIONS:
Based on [**2116**] 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.
<br>
[**2118-2-15**] 8:06 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2118-2-19**]**
Blood Culture, Routine (Final [**2118-2-19**]):
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.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
<br>
Initial Bx [**2-15**] + STAPHYLOCOCCUS, COAGULASE NEGATIVE
BCx positive on [**2-17**]
BCx [**2-19**] + - Vanc started on this date
[**2-20**] - NG at time of d/c
[**2-21**] - NG at time of d/c
[**2-22**] - NG at time of d/c
<br>
[**2-21**] prior PICC cath tip - no growth.
Brief Hospital Course:
Initial Bx [**2-15**] + STAPHYLOCOCCUS, COAGULASE NEGATIVE
BCx positive on [**2-17**]
BCx [**2-19**] + - Vanc started on this date
[**2-20**] - NG at time of d/c
[**2-21**] - NG at time of d/c
[**2-22**] - NG at time of d/c
<br>
Assessment/Plan:
58 yo M with alcohol withdrawal and pneumonia transferred from
OSH, called out of the ICU, found then with high grade
bacteremia with coag neg staph - treatment with vancomycin
(14day) and 10d ceftriaxone - d/c to [**Hospital 19586**] rehab. Details
as below.
<br>
# Pneumonia, bacterial w/assoc respiratory failure and
sepsis/bacteremia : Seen on OSH CXR as RLL infiltrate. Now with
coag-neg staph bacteremia as well. Treated initially with
ceftriaxone, azithromycin and clindamycin.
- ceftriaxone and clindamycin started [**2-15**]
-Started on vancomycin [**2-19**]
Sensitivities showing clinda resistance - d/c clinda
- contin Vanc and CTX
-plan for completing [**9-19**] day course of ceftriaxone (more for
PNA) - end date [**2118-2-25**]
-plan for 14 day course for vanc for bacteremia - end date
[**2118-3-5**]
-TTE negative; TEE done on [**2-22**] - also NEG for veg (confirmed
14d course)
-Sputum negative.
- incentive spirometery, pulmonary toilet
-picc placed [**2-23**] for abx at rehab
<br>
# Alcohol Withdrawal/ecoh dependency: resolved now, pt doing
well..
-Thiamine, folate, MVI
-SW consulted
<br>
# Hyperlipidemia: Continue home statin.
<br>
#. History of Cocaine Abuse:
Urine cocaine scrn negative
-Avoid beta-blocker
-Addictions consulted.
.
# FEN:
-Regular cardiac heart healthy diet.
<br>
# Access: new picc placed (with prior just PIV for >48h) at time
of d/c.
# PPX: Heparin sq. Senna/colace. PT consulted - plan for rehab
placement today
<br>
# Code: FULL
# Communication: girl friend [**Name (NI) **] [**Name (NI) 4469**] [**Telephone/Fax (1) 82073**]
Medications on Admission:
HOME MEDS:
Lipitor 20mg qd
Topical Antifungal
MEDS on TRANSFER:
Nicotine patch 21 mg
Robitussin
Tylenol
MVI
Thiamine
Folic Acid
Solumedol 60iv q8h
Ativan 2-4mg iv q1h prn
Valium 5mg iv q5min prn
Versed gtt
Lopressor 5mg iv q4h prn
Xopenex nebs
Protonix 40mg iv q12h
Ceftriaxone 1g iv qd
Azithro 500mg iv qd
Clinadmycin 900mg iv q8h
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation every six (6) hours as needed for wheeze.
4. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
10. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 2 days.
11. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 10 days.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Discharge Disposition:
Extended Care
Facility:
Meadowbrook - [**Location (un) 2624**]
Discharge Diagnosis:
# Pneumonia w/assoc respiratory failure and sepsis; intubated
during hospitalization
# Bacteremia with Coag Negative Staph
# Alcohol withdrawl, agitation
# Hyperlipidemia
Discharge Condition:
stable
Discharge Instructions:
Continue with your [**Hospital 19586**] rehab and finish your antibiotics
as prescribed. If you re-develop new shortness of breath with
fevers, worsenened cough, chest pains - please contact your
doctor or return to an emergency facility.
<br>
Please do not consume any alcohol products.
Followup Instructions:
1. Please call your PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] at [**Hospital3 4107**] at
[**Telephone/Fax (1) 4475**] to arrange a follow-up appointment 2-3 weeks
following discharge from the re-hab facility.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]
Completed by:[**2118-2-23**]
|
[
"933.1",
"507.0",
"291.81",
"482.9",
"995.91",
"E912",
"272.4",
"707.03",
"707.22",
"518.81",
"305.60",
"303.91",
"038.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9780, 9845
|
6446, 8290
|
319, 368
|
10060, 10069
|
2089, 4769
|
10408, 10825
|
1538, 1542
|
8674, 9757
|
9866, 10039
|
8316, 8363
|
10093, 10385
|
1557, 2070
|
4792, 6423
|
276, 281
|
396, 1092
|
1101, 1297
|
1319, 1408
|
1424, 1522
|
8381, 8651
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,032
| 190,116
|
44599
|
Discharge summary
|
report
|
Admission Date: [**2154-11-2**] Discharge Date: [**2154-11-5**]
Date of Birth: [**2103-12-13**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
none
History of Present Illness:
PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 95485**]
.
HPI: 50 y.o. male with chronic LBP, a remote h/o gastric ulcer
and EtOH abuse p/w about 9 episodes of bright red blood per
rectum since yesterday evening around 11PM (each cup-full). He
denies any trauma or prior h/o BRBPR. He describes it as mostly
fresh blood without significant amount of stool. Pt was in USOH
until 3 days ago when his chronic LBP worsened which prompted
him to take [**1-20**] Naprosyn per day. He also c/o nausea and
decreased appetite last night, followed by two episodes of
nonbloody (clear liquid) vomiting. No abdominal pain. Only mild
lightheadedness.
.
In the ED, his VS were T99.8, HR 78, BP 153/82, RR 18, 95%RA. He
was guaiac positive on exam with BRB. NG lavage revealed red
fluid but no clots. It initially cleared with 400 cc, but then
recurred and continued to be slightly blood tinged, although
still with no clots. His Hct remained largely stable with 43.2
initially to only 38.9 about 6h later. Two large bore IVs were
placed. Pt's blood was typed and screened. He received one dose
of 40mg Protonix IV. GI has evaluated pt and it was decided to
scope pt on Monday. He remained hemodynamically stable with BP
150s/70s and HR in the 80s. Plan was to admit to medicine.
However, he had another episode of large BRBPR in the toilet
around 9PM. In addition, his NG lavage continued to return
blood-tinged fluid and decision was made to admit to ICU for
overnight monitoring.
.
On arrival to the ICU, he remained hemodynamically stable. His
NG tube contained a small amount of blood-tinged fluid.
.
ROS: Positive as above. Otherwise denies CP or SOB. Also no
F/C/N. About 7 lbs weight loss over 1 yr due to dieting.
Incidentally, he noted a small right buttock mass which he
developed after falling two weeks ago, denies any injections.
Past Medical History:
- EtOH abuse
- H/o crack cocaine
- Remote h/o 'stomach ulcer' in his 20s (does not remember
having an endoscopy or surgery but negative colonoscopy 25 yrs
ago)
- Chronic back pain
- s/p knee surgeries - on disability
- Depression with chronic suicidal ideations
- Bipolar disorder
- Posttraumatic stress disorder (rape at age 7)
Social History:
Pt drinks 1 pint etoh/daily. He also smokes 1.5 packs daily. H/o
prior crack cocaine (last 1 month ago). No IVDU. He had been
incarcerated for several [**Last Name (un) 20934**]. Mother is very ill and anxious.
Pt does not want to inform her of his hospitalization since he
worries that it might affect her health.
Family History:
No h/o ulcers. Father is deceased secondary to esophageal
cancer.
Physical Exam:
Admission
VS: Temp: 97.5 BP: 149/87 HR: 73 RR: 16 O2sat: 99%RA
GEN: comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: Flat jvd, supple
RESP: coarse BS b/l, mild wheezes
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: 5/5 strength throughout. No sensory deficits to light
touch appreciated.
GU: Guaiac positive in ED, mild tenderness to palpation on right
buttock with small palpable mass but no bruising, erythema,
purulence or skin breaks
.
Discharge
VS: Temp: 96.2 BP: 112/72 HR: 78 RR: 16 O2sat: 98%RA
Pertinent Results:
CBC:
[**2154-11-2**] 02:00PM BLOOD WBC-11.4* RBC-4.60 Hgb-15.0 Hct-43.2
MCV-94 MCH-32.6* MCHC-34.6 RDW-14.0 Plt Ct-232
[**2154-11-2**] 08:00PM BLOOD Hgb-13.5* Hct-38.9*
[**2154-11-2**] 11:06PM BLOOD WBC-11.7* RBC-4.33* Hgb-14.5 Hct-42.2
MCV-97 MCH-33.4* MCHC-34.3 RDW-13.9 Plt Ct-230
[**2154-11-3**] 06:42AM BLOOD WBC-11.6* RBC-4.17* Hgb-13.2* Hct-40.3
MCV-97 MCH-31.7 MCHC-32.8 RDW-13.8 Plt Ct-232
[**2154-11-3**] 02:17PM BLOOD Hct-40.9
[**2154-11-4**] 05:30AM BLOOD WBC-10.0 RBC-4.20* Hgb-14.3 Hct-40.9
MCV-97 MCH-34.0* MCHC-34.9 RDW-13.8 Plt Ct-235
[**2154-11-5**] 09:30AM BLOOD Hct-44.6
.
Chem 7
[**2154-11-2**] 02:00PM BLOOD Glucose-87 UreaN-18 Creat-0.9 Na-137
K-5.6* Cl-104 HCO3-19* AnGap-20
[**2154-11-3**] 06:42AM BLOOD Glucose-86 UreaN-13 Creat-0.7 Na-143
K-3.4 Cl-109* HCO3-21* AnGap-16
[**2154-11-4**] 05:30AM BLOOD Glucose-94 UreaN-8 Creat-0.7 Na-144
K-3.1* Cl-113* HCO3-23 AnGap-11
[**2154-11-5**] 05:38AM BLOOD Glucose-86 UreaN-12 Creat-0.9 Na-145
K-3.6 Cl-109* HCO3-26 AnGap-14
.
LFT's:
[**2154-11-2**] 02:00PM ALT(SGPT)-28 AST(SGOT)-49* ALK PHOS-93
AMYLASE-59 TOT BILI-0.7
[**2154-11-2**] 02:00PM LIPASE-48
.
MISC:
[**2154-11-2**] 02:00PM ASA-NEG* ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2154-11-2**] 06:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2154-11-2**] 06:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE->80 BILIRUBIN-NEG UROBILNGN-0.2 PH-6.5
LEUK-NEG
[**2154-11-2**] 06:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
.
EGD:
Mucosa suggestive of Barrett's esophagus (biopsy)
Granularity, erythema and congestion in the whole stomach
compatible with gastritis. Otherwise normal EGD to third part of
the duodenum
.
Colonoscopy
Diverticulosis of the sigmoid colon
Granularity, friability, erythema, congestion and petechiae in
the sigmoid colon and descending colon compatible with colitis
of unclear etiology possibly ischemic
Polyp in the hepatic flexure (polypectomy)
Polyp in the descending colon (polypectomy)
Brief Hospital Course:
50 y.o. male with chronic LBP, a remote h/o gastric ulcer and
EtOH abuse p/w multiple episodes of BRBPR and positive NGL after
NSAID intake for LBP. Pt was hemodynamically stable but
admitted to the MICU for observation. He received [**Hospital1 **] PPI IV.
His Hct remained stable in the ICU and his was transfered to the
floor the next day. He received an EGD and colonoscopy. The EGD
did not show any bleeding source. The colonoscopy showed two
polyps and possible ischemic colitis which may have been the
source of bleeding. The patient was counseled to avoid
substances that can cause ischemic colitis - NSAIDS,HCTZ,
cocaine, etc. He will follow up with Dr [**Last Name (STitle) **] regarding the
pathology results. He had no further episodes of bleeding while
the in the hospital. Due the fact NSAIDs were held, he received
morphine for his chronic back pain; his was discharged with
Tylenol, a new prescription for a Lidocaine patch as well as a
pain clinic appointment. He did have mild abdominal pain which
resolved prior to discharge. This pain was evaluated with CT,
LFT's, amylase and lipase all of which were normal. He was
scheduled to have his right buttock mass evaluated with
ultrasound as an outpatient if it does not resolve in the next
two weeks.
Medications on Admission:
- Naproxen 500mg q6h prn (about 3-4 tablets daily)
- Tramodol 50mg q8h prn
- Clonazepam 2 tabs daily
- Citalopram 2 tabs daily
- Topamax 1 tab qAM, 2 tabs qHS
Allergies: Zoloft -> N/V/D
Discharge Medications:
1. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8
Hours).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Topiramate 100 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
4. Topiramate 100 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
5. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
7. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily): Please put the patch on your lower
back in the morning and take it off in the evening: it needs to
be on for 12hours and off for 12 hours.
Disp:*30 Patch 24 hr(s)* Refills:*2*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain.
9. Lidocaine patch
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal bleeding - likely ischemic colitis
Discharge Condition:
improved - no further GI bleeding, stable blood pressure and HCT
Discharge Instructions:
You were admitted for gastrointestinal bleeding. You had an EGD
and colonoscopy. You EGD showed no abnormalities. The
colonoscopy showed that you most likely have ischemic colitis
but the pathology results need to be follow up on. The
colonoscopy also showed polyps and you will need another
colonoscopy in one year. You should avoid Naproxen, aspirin or
ibuprofen. You should take Tylenol 500mg-1000mg up to four times
a day, do not exceed 4000mg daily.
.
You were also found to have a mass in your right buttock. If it
does not resolve, you will need to have this evaluated by
ultrasound. You have an appointment with ultrasound in 2 weeks.
Followup Instructions:
You should follow up Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 798**] on [**2154-11-11**]
10:10am.
.
You should follow up with the pain clinic [**2154-11-13**] 11:00am.
Please call ([**Telephone/Fax (1) 19088**] to confirm the appointment.
.
You have an ultrasound in the [**Hospital Unit Name 1825**] [**Location (un) 470**]. Please
call ([**Telephone/Fax (1) 6713**] if you do not need this appointment.
Provider: [**Name Initial (NameIs) 703**] (H3) GENERAL 2 RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2154-11-21**] 1:30
|
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"V15.41",
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"309.81",
"724.2",
"296.80",
"338.29",
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"530.85",
"211.3",
"305.01",
"305.63",
"562.10"
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icd9cm
|
[
[
[]
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[
"45.16",
"45.25",
"45.42"
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icd9pcs
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[
[
[]
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8132, 8138
|
5736, 7007
|
324, 330
|
8234, 8301
|
3681, 5713
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8993, 9544
|
2935, 3003
|
7244, 8109
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8159, 8213
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7033, 7221
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8325, 8970
|
3018, 3662
|
257, 286
|
358, 2234
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2256, 2587
|
2603, 2919
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,281
| 181,080
|
43643
|
Discharge summary
|
report
|
Admission Date: [**2132-9-9**] Discharge Date: [**2132-9-25**]
Date of Birth: [**2059-9-3**] Sex: M
Service: MEDICINE
Allergies:
simvastatin
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Malaise, hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
73 yo M with h/o CMV, prostate ca s/p XRT and hormonal therapy,
DM, presenting with 3 months of worsening fatigue,
constitutional symptoms, and recent hypotension.
Pt was interviewed with the presence of his wife, who helped to
answer much of the questions. Pt stated that in [**Month (only) 547**], he noted
vision changes, as diagnosed with CMV retinitis. He was started
on valganciclovir, with improvement of vision changes, but later
had worsening malaise. Pt attributed his symptoms to the
medication and stopped valgancilovir three weeks ago.
Reportedly, pt had undetectable CMV viral load in the blood
prior to d/c'ing the medication. Pt continued to have chill,
malaise, night sweats, ~10 lbs weight loss in last month,
anorexia, and intermittent diarrhea. There was however no
fever, rigor, abdomminal pain, upper or lower GIB.
In [**2128**], pt had similar symptoms per PCP note, although pt could
not recall these history. He reportedly had a axillar lymph
node biopsy, and was found to have CMV lymphadenitis with no
[**Doctor Last Name **]-Sternberg cells and negative flow cytometry. In [**Month (only) 958**]
[**2132**], a CT abd showed splenomegaly to 14 cm, which in [**2132-8-10**]
has increased to 17.5 with mediastinal lymphadenopathy,
periaortic lymphadenopathy and a 2.9X3.8 splenic mass.
In the ED, initial VS were: 98.7 87 78/49 16 100% RA. Lab was
notable for WBC 1.8 with 29% neutrophil, mild anemia with HCT
33.4, transaminitis with ALT 211, AST 451, ALP 829, T-bili 6.5,
normal coag, and Alb 3.1, hyponatremia to 128, and lactate 2.4.
He had normal CXR and normal RUQ US. He was given Vancomycin,
Cefepime and hydrocortisone 100 mg, and 1 liter IVF. His blood
pressure improved to SBP ~110 after the 1 liter IVF. Because of
hypotension and transaminitis, he was transferred to the ICU.
On arrival to the MICU, patient's VS were 100.6, 100, 110/58,
21, 99% on RA
Review of systems:
(+) Per HPI
(-) Denies fever, Denies headache, sinus tenderness, rhinorrhea
or congestion. Denies shortness of breath, cough, dyspnea or
wheezing. Denies chest pain, chest pressure, palpitations.
Denies constipation, abdominal pain, dark or bloody stools.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
Lymphadenopathy
Cytomegalovirus disease
DM
Hypercholesterolemia
HTN
HLD
cardiomyopathy
OA
Social History:
Worked as a pastor, lives with wife, denies smoking, EtOH or
drug abuse.
Family History:
Mother: breast ca, DM, HTN lived to 90s
Father: prostate ca, DM, HTN
no family hx of hematologic malginancy
Physical Exam:
ADMISSION EXAM
Vitals: 100.6, 100, 110/58, 21, 99% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, 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-distended, bowel sounds present,
splenomegaly, but no hepatomegaly, nontender on palpation
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.
Pertinent Results:
ADMISSION LABS
[**2132-9-9**] 02:35PM BLOOD WBC-1.8* RBC-3.92* Hgb-10.6* Hct-33.4*
MCV-85 MCH-
27.0 MCHC-31.7 RDW-18.1* Plt Ct-154
[**2132-9-9**] 02:35PM BLOOD PT-12.3 PTT-37.7* INR(PT)-1.1
[**2132-9-9**] 02:35PM BLOOD Glucose-62* UreaN-22* Creat-0.9 Na-128*
K-6.2* Cl-
101 HCO3-23 AnGap-10
[**2132-9-9**] 02:35PM BLOOD Albumin-3.1* Calcium-8.2* Phos-3.4 Mg-2.4
DISCHARGE LABS
LABS PENDING
PERTINENT MICRO
PERTINENT IMAGING
RUQ U/S ([**9-9**]): no evidence of stones or ductal dilation
CT ABD/Pelv ([**2132-9-10**]):
CT OF THE CHEST WITH INTRAVENOUS CONTRAST: Numerous enlarged
lymph nodes are seen in the left axillary and subpectoral
region, with the largest node
measuring 34 x 24 mm (3:24). Small right axillary lymph nodes
measuring less than a centimeter do not meet criteria for
significant adenopathy. Additional prominent scattered lymph
nodes are seen in the mediastinum in the prevascular,
pretracheal regions, with the largest in the right paratracheal
region measuring 10 mm (3:23). The imaged portion of the
thyroid gland is normal. The airways are patent to subsegmental
levels bilaterally. The lungs are clear, without suspicious
pulmonary nodules or masses. Small pleural calcifications are
seen anteriorly in the left lung (3:25). Small bilateral simple
pleural effusions are seen. There is no pericardial effusion.
The heart is normal in size. Moderate-to-severe coronary
arterial calcifications are noted. Mild atherosclerotic
calcification is seen in the thoracic aorta. The pulmonary
arteries are unremarkable.
CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: No focal liver
lesions are
identified. There is no intra- or extra-hepatic biliary
dilatation. Mild
gallbladder wall edema in the setting of a decompressed
gallbladder likely
relates to third spacing. The adrenal glands are normal. The
pancreas is
normal in appearance. The spleen is enlarged measuring 15.8 cm.
Both kidneys enhance and excrete contrast symmetrically without
hydronephrosis or renal masses. A 6.5 cm simple renal cortical
cyst is seen in the interpolar region of the left kidney.
Additional smaller renal cysts are seen in both kidneys.
Small scattered retroperitoneal lymph nodes are seen, with the
largest node in the left paraaortic region measuring 10 mm
(3:72). There is a small amount of perihepatic ascites and fat
stranding in the right paracolic gutter. The stomach, small and
large bowel loops are normal. The abdominal aorta has moderate
atherosclerotic calcification, without aneurysmal dilation.
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder
is
decompressed with mild bladder wall thickening, which may relate
to prior
radiation treatment or outlet obstruction. Multiple
brachytherapy seeds are seen within the prostate. The rectum
and sigmoid colon are normal. A small amount of simple ascites
is seen within the pelvis. No significant pelvic adenopathy is
seen. A small fat-containing left inguinal hernia is present.
BONES AND SOFT TISSUES: No bone lesions suspicious for
infection or
malignancy are detected. Moderate degenerative changes are seen
in the facet joints of L4-L5 and L5-S1 levels.
IMPRESSION:
1. Numerous axillary lymphadenopathy (largest in left axilla
measuring 3.4 x 2.4cm) and splenomegaly. These findings are
concerning for lymphoproliferative disorder. Borderline
mediastinal lymph nodes.
2. Bilateral small simple pleural effusions and a small amount
of abdominal ascites.
Brief Hospital Course:
MICU COURSE
# T Cell Lymphoma / Lymphadenopathy: Patient has history of
axillary adenopathy which had been biopsied in [**2128**], with
results consistent with CMV-lymphadenitis, negative for
[**Doctor Last Name **]-[**Doctor Last Name 93840**] cells, negative flow cytometry. As per the
outpatient Atrius records, patient was evaluated for
lymphadenopathy recently by Oncologist, who was planning to
arrange for a PET-CT. He was seen by the inpatient Atrius
Oncology service, who recommended a lymph node biopsy. He
underwent full excisional lymph node biopsy on [**9-12**] by general
surgery. Results of the pathology were c/w T cell lymphoma.
Patient developed liver and kidney failure, thought likely to be
secondary to infiltrative disease. Patient underwent one
treatment with etoposide, with little improvement. Patient was
found to have worsening mental status. CT scan was performed
which did not show evidence of bleed or malignancy. Potential
hepatorenal syndrome was considered, but urine sodium > 10 was
not consistent with HRS. Renal was consulted, who recommended
attempting volume resuscitation for likely ATN. This was
attempted but with little success, with patient still nearly
anuric. Conversation was held with family, and patient was made
CMO. Ativan, morphine, and scopolamine were started. He passed
away early morning of [**2132-9-25**] with family at the bedside.
Family consented to autopsy with nocturnist who pronounced his
death.
# Hypotension: This was responsive to fluid boluses in the ED.
Patient was started on Vanc/Cefipime for concern for febrile
neutropenia/sepsis. Patient was given maintenance fluids on the
floor and his pressures remained between 90s-110s systolic,
without the need for pressors.
# Fevers: Differential included sepsis vs. disseminated CMV
infection vs. lymphoma. Patient had a transaminitis with
obstructive hyperbilirubinemia but RUQ u/s did not show concern
for cholecystis or biliary obstruction. Patient had history of
fevers secondary to CMV, for which he was taking valgancyclovir.
He had recently stopped before this admission due to side
effects. He was cultured and covered for febrile neutropenia in
the ED with Vanc and Cefepime because his white count came back
at 1.8 with 28% bands. Patient had a temp to 100.6 on transfer
to the floor. On D2 of his MICU stay, he spiked temps to 102.
Blood cultures remained negative. He had an extensive ID
workup, including CMV viral load, HepB/C AG, Hep B/C viral load,
cryptococcal antigen, HIV viral load, RPR, as well as
cryptococcal antigen, which all came back negative. His blood
cultures remained negative. He was started on Acyclovir ppx.
given his low white count and positive EBV titers. After
diagnosis of T cell lymphoma, these constitutional symptoms were
thought to be secondary to his underlying malignancy as opposed
to active infection.
# Obstructive jaundice: He had elevated liver enzymes with an
elevated direct biliribin, consistent with an obstructive
process. RUQ ultrasound failed to reveal biliary duct dilation
or stones. CT abdomen/pelv with contrast failed to show focal
liver disease or intra or extra hepatic biliary dilation.
Hepatitis studies as well as [**Doctor First Name **] and AMA were negative. The
cause was thought to be due liver infiltration by malignancy.
# CMV retinitis: The patient was placed on valgancylovir
initially for concern for CMV reactivation. Outside records
were obtained, which showed that he was diagnosed with CMV
retinitis in [**2132-4-10**] after experiencing worsening vision
in his left eye. He was followed by [**Hospital 13128**], who
prescribed systemic valgancyclovir with resolution of his ocular
symptoms. His valgancyclovir was halted for a few weeks prior
to admission for concern for marrow suppression. His
valgancyclovir was discontinued on D3 of admission after an
ophthalmology evaluation revealed no retinitis and his CMV load
was negative.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Furosemide 20 mg PO DAILY
2. tadalafil *NF* 20 mg Oral qwk
3. NIFEdipine CR 30 mg PO DAILY
4. ValGANCIclovir 900 mg PO Q24H
5. 70/30 30 Units Breakfast
70/30 20 Units Bedtime
6. Tamsulosin 0.4 mg PO HS
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze, SOB
8. Aspirin 325 mg PO DAILY
Discharge Medications:
Patient expired [**2132-9-25**]
Discharge Disposition:
Expired
Discharge Diagnosis:
T cell lymphoma
Discharge Condition:
Expired in hospital
|
[
"584.5",
"995.94",
"780.61",
"401.9",
"276.7",
"288.00",
"276.2",
"275.41",
"V10.46",
"284.19",
"202.10",
"276.1",
"272.0",
"250.00",
"570",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.11",
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] |
icd9pcs
|
[
[
[]
]
] |
11637, 11646
|
7173, 11134
|
292, 298
|
11705, 11727
|
3639, 7150
|
2831, 2941
|
11581, 11614
|
11667, 11684
|
11160, 11558
|
2956, 3620
|
2250, 2610
|
231, 254
|
326, 2231
|
2632, 2724
|
2740, 2815
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,475
| 102,664
|
14581+14582
|
Discharge summary
|
report+report
|
Admission Date: [**2157-7-22**] Discharge Date: [**2157-8-8**]
Date of Birth: [**2082-2-27**] Sex: F
Service: VASCULAR
CHIEF COMPLAINT: Ruptured abdominal aortic aneurysm.
HISTORY OF THE PRESENT ILLNESS: This is a 75-year-old female
who was evaluated in an [**Location (un) 8641**], [**Hospital 3844**] Hospital for
acute onset of back pain. CT was obtained, which showed a
ruptured aneurysm. The patient has had a known aneurysm for
greater than two years, but has not had surgery due to high
surgical risk. She was transferred here for emergent
surgery.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS:
1. Isordil.
2. Zocor.
3. Nitroglycerin.
4. Diltiazem.
PAST MEDICAL HISTORY:
1. Myocardial infarction times four; last MI, [**2155**].
2. Gastroesophageal reflux disease.
3. Arthritis.
PAST SURGICAL HISTORY:
1. Appendectomy, remote.
2. Cataract surgery.
HABITS: The patient is a smoker of greater than 55 packs per
year. She denies alcohol use.
PHYSICAL EXAMINATION: Examination revealed the blood
pressure of 130/70; pulse 85; respirations 10. This is an
elderly female, who was awake, unable to communicate because
of pain. HEART: Regular rate and rhythm. LUNGS: Clear to
auscultation. ABDOMEN: Unremarkable. EXTREMITIES:
Examination shows warm extremities, palpable femoral pulses
bilaterally.
HOSPITAL COURSE: The patient was taken to the operating room
and under abdominal aortic repair with exploration of the
right femoral artery. She then was transferred to the SICU
for continued monitoring and care. The Department of
Cardiology was requested to see the patient because of a low
cardiac index in a patient with known coronary artery
disease. Intraoperative transesophageal echocardiogram
showed an ejection fraction of 44%.
Recommendations were to initiate ACE inhibitor for post-load
reduction. Captopril 0.25 mg for a goal dosing of 25 to 50
t.i.d.. Continue to monitor cardiac output index PA and
wedge pressures. Ultimately will need a beta blocker as
well. Continue nitroglycerin for afterload.
On postoperative day #1, there were no overnight events. The
patient remained intubated. She follows commands. She
remained tachycardiac with a V rate of 100. Lungs were clear
to auscultation. Abdominal examination was unremarkable.
Extremities were warm. She was continued on perioperative
Kefzol. The postoperative hematocrit was 24.7. The BUN and
creatinine were 10 and 0.6. Potassium was 3.6. Lopressor
was begun. She was weaned to be extubated. She remained
NPO. She was transfused two units of packed red blood cells.
On postoperative day #2, the patient continued to have
tachycardia, reported secondary to Lopressor. She was
attempted to be weaned to extubate. Post transfusion
hematocrit was 31.8. BUN and creatinine remained stable at
9 and 0.5, potassium 4.6.
On postoperative day #3, the patient remained in the SICU.
She required Lasix times two doses for diuresis and
nitroglycerin 7 mcg per kilogram per minute for afterload
reduction. She did show tiring postextubation with
respiratory effort. Blood gases was 7.4, 749, 134, 34 + 11.
CPAP was at 40%. Hematocrit remained stable at 31.6.
Electrolytes were unremarkable. She had coarse breath sounds
bilaterally. Abdominal incisions were clean, dry, and intact
with mild abdominal distention. Extremities were warm,
showing palpable DP and PT bilaterally.
On postoperative day #4, the patient was weaned off
nitroglycerin. She continued to require diuresis and she was
off BiPAP. Gases were 7.4, 47, 173, 33, 98%. Hematocrit was
33.3. BUN and creatinine remained stable. Calcium,
magnesium, and phosphatase were stable. The patient
continued to show decreased breath sounds at the bases
bilaterally. There were no bowel sounds ausculted or flatus
passed. Neurologically, she remained intact. Diuresis was
continued. She remained in the SICU.
On postoperative day #5, the patient was transferred to the
VICU.
On postoperative day #6, there were no overnight events. She
remained hemodynamically stable. Hematocrit and electrolytes
were unremarkable. Abdominal examination was unremarkable.
NG was discontinued and clear liquids were begun. She was
"delined" and transferred to the regular nursing floor. The
Department of Physical Therapy was requested to see the
patient to assess for discharge planning. On postoperative
day #6 she had an episode of left-sided chest discomfort
without associated symptoms. EKG was obtained, which was
unchanged from his preoperative EKG. She was given morphine
for pain and monitored.
On postoperative day #7, the patient remained afebrile, but
the patient had a leukocytosis from 9.2 to 15.3. Lung
examination was unremarkable. Incisions were clean, dry, and
intact. Foley was discontinued and central line was
discontinued. A peripheral line was placed.
On postoperative day #8 she ran a low grade 99. White count
showed a downward trend of 14.2. She continued on a diet as
tolerated. Urinalysis was negative. Chest x-ray was
unremarkable. She required an increase in her Lopressor
dosing to 100 b.i.d. She remained in the VICU. White count
on postoperative day #9 showed an increase to 19.6. Blood
cultures were obtained. The CBL cultures were negative. She
was transferred to the regular nursing floor on postoperative
day #10. Sputum was obtained and results were negative. The
Department of Physical Therapy continued to follow the
patient and recommended [**Hospital 3058**] rehabilitation. The
patient wanted to go home. This was discussed with
Dr. [**Last Name (STitle) 1476**] and he felt rehabilitation would be more
appropriate.
All blood and urine cultures obtained were no growth. The
remaining hospitalization was unremarkable. The patient was
discharged in stable condition. Skin clips of the abdominal
and femoral wounds were removed prior to discharge. The
patient is to followup with Dr. [**Last Name (STitle) 1476**] in one to two weeks'
time.
DISCHARGE MEDICATIONS:
1. Levofloxacin 500 mg q.24h. times seven days.
2. Metoprolol 125 mg b.i.d., hold for systolic blood
pressure less than 90, heart rate less than 60.
3. Lasix 20 mg q.d.
4. Nitroglycerin sublingual 0.3 mg p.r.n. for chest pain,
may be repeated times two q.10 minutes until pain free.
5. Imdur 30 mg q.d., hold for systolic blood pressure less
than 90.
6. Cilastatin 80 mg q.d.
7. Amitriptyline 10 mg h.s.
8. Pantoprazole 40 mg q.d.
9. Percocet tablets one to two q.4h.p.r.n. pain.
10. Heparin 5000 units subcutaneously q.12h.
11. Nicotine patch 21 mg q.d.
12. Aspirin 81 mg q.d.
DISCHARGE DIAGNOSES:
1. Rupture abdominal aortic aneurysm with femoral artery
embolism, status post triple A repair and right femoral
embolectomy.
2. Decreased cardiac index treated.
3. Postoperative fever secondary to atelectasis, treated.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2157-8-3**] 10:41
T: [**2157-8-3**] 11:31
JOB#: [**Job Number 9634**]
1
1
1
R
Admission Date: [**2157-7-22**] Discharge Date: [**2157-8-8**]
Date of Birth: [**2082-2-27**] Sex: F
Service:
ADDENDUM: The patient continued to work with physical
therapy. She was ambulating with a walker without
assistance. She was discharged to home in stable condition
on [**2157-8-8**]. She will follow up with Dr. [**Last Name (STitle) 1476**] as
directed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2157-8-8**] 09:57
T: [**2157-8-8**] 10:09
JOB#: [**Job Number 43008**]
|
[
"427.89",
"518.0",
"414.01",
"276.4",
"441.3",
"444.89",
"285.9",
"496",
"997.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.68",
"38.44",
"38.08",
"93.90",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6665, 7842
|
6053, 6644
|
1390, 6030
|
867, 1010
|
1033, 1372
|
158, 710
|
732, 844
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,764
| 113,159
|
42113+58500
|
Discharge summary
|
report+addendum
|
Admission Date: [**2187-12-7**] Discharge Date: [**2187-12-19**]
Date of Birth: [**2136-1-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Bactrim / Gentamicin
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
[**2187-12-14**]
1. Aortic valve replacement with a St. [**Male First Name (un) 923**] Epic tissue
valve, reference #[**Serial Number 91351**].
2. Mitral valve a repair with closure of anterior leaflet
perforation and closure of partial anterior, mitral
leaflet cleft with 28-mm [**Company 1543**] CG Future
annuloplasty ring, model #63HR.
History of Present Illness:
51 year old female seen in [**Hospital **] clinic on [**12-7**] in follow up for
Enterococcal endocarditis and referred to ED for further
evaluation due to altered balance, vision changes, nausea,
anterior chest discomfort, orthopnea, and DOE,
worsening over the past week. She is 6 weeks into IV PCN/gent
complicated by recent AKIN due to gentamycin. In ED she had non
contrast head CT was negative for acute findings and Chest CT
questioned spleenic infarcts however ultrasound ruled out acute
splenic infarcts. She had TTE that showed new involvement for
mitral valve, she was continued on IV PCN, but then discontinued
by infectious disease then resumed next day, however TEE
revealed moderate-sized vegetation on the aortic valve. Severe
(4+) aortic regurgitation is seen with reversal of flow in the
aortic arch. The mitral valve is abnormal. There is small
vegetation abscess on the anterior leaflet of the mitral valve
with perforation.
Severe (4+) mitral regurgitation is seen. Now referred for
surgical evaluation
Cardiac Catheterization: none
CT scan chest [**2187-12-7**] [**Hospital1 18**]
1. No evidence of pulmonary septic emboli. Evaluation for
pulmonary embolism is not possible given lack of IV contrast.
2. 3-mm pulmonary nodule in the right upper lobe and a 2-mm
pleural-based nodule in the left lower lobe are present.
3. Splenic hypodensity better seen on prior contrast enhanced
abdominopelvic CT consistent with infarct.
Cardiac Echocardiogram: TEE [**2187-12-10**] preliminary report [**Hospital1 18**]
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3).
Moderate-sized vegetation on aortic valve. Severe (4+) AR.
MITRAL VALVE: Abnormal mitral valve. Small vegetation on mitral
valve. Abscess cavity adjacent to mitral valve. Severe (4+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
No mass or vegetation on tricuspid valve.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No vegetation/mass on pulmonic valve.
PERICARDIUM: No pericardial effusion.
Conclusions No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. No atrial septal defect
is seen by 2D or color Doppler. Overall left ventricular
systolic
function is normal (LVEF>55%). Right ventricular chamber size
and
free wall motion are normal. There are simple atheroma in the
descending thoracic aorta to 42 cm from the incisors. The aortic
valve leaflets (3) are mildly thickened. There is a
moderate-sized vegetation on the aortic valve. Severe (4+)
aortic
regurgitation is seen with reversal of flow in the aortic arch.
The mitral valve is abnormal. There is small vegetationabscess
on
the anterior leaflet of the mitral valve with perforation.
Severe
(4+) mitral regurgitation is seen. No vegetation/mass is seen on
the pulmonic valve. There is no pericardial effusion
Past Medical History:
Enterococcal endocarditis aortic valve dx [**10/2187**]
fibromyalgia
hepatitis c s/p 1 yr interferon ([**12/2177**]/[**2178**])
GERD
? Sciatica
Past Surgical History
s/p appendectomy
s/p cholecystectomy
s/p tubal ligation
Social History:
Race:Caucasian
Last Dental Exam: edentulous
Lives with: alone (boyfriend there off and on)
Contact: [**Name (NI) 717**] [**Last Name (NamePattern1) 91352**]
Phone # home [**Telephone/Fax (1) 91353**] cell [**Telephone/Fax (1) 91354**]
Occupation: not currently working
Cigarettes: Smoked no [] yes [x] last cigarette [**12-5**] Hx: 1-2
packs per day since age 15 - ~~50-72pack year history
ETOH:drank heavily as teenager quit at age 21
Illicit drug use cocaine and YHC as teenager and young adult
none
recently
Family History:
Mother breast ca - deceased 62
Father lung and heart disease deceased 79
Physical Exam:
Pulse: 100 Resp: 18 O2 sat: 96% RA
B/P 138/64
General: Sitting in bed slightly winded with talking, breathing
easy after resting
Skin: Dry [x]red non raised rash under bilateral breast R>L
Midline to right abdominal surgical scar healed
HEENT: right eye with slight divergence, no variance left,
pupils
equal and reactive to light, decreased visual acuity right eye
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur diasytolic [**4-8**] and systolic
[**5-9**]
Abdomen: Soft [x] non-distended [x] tender left upper quadrant
with light palpation bowel sounds + [x]
Extremities: Warm [x], well-perfused [x] Edema trace bilateral
LE Varicosities: None [x]
Neuro: Alert, oriented x3 forgetful in relation to medical
treatment over last two months, R=L strength 5/5
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 Bruit vs murmur
Pertinent Results:
[**2187-12-18**] 05:44AM BLOOD Hct-28.0*
[**2187-12-17**] 05:45AM BLOOD WBC-8.4 RBC-3.48* Hgb-9.8* Hct-29.4*
MCV-84 MCH-28.2 MCHC-33.4 RDW-15.1 Plt Ct-153
[**2187-12-18**] 05:44AM BLOOD PT-13.3 INR(PT)-1.1
[**2187-12-17**] 05:45AM BLOOD Plt Ct-153
[**2187-12-17**] 05:45AM BLOOD PT-13.6* INR(PT)-1.2*
[**2187-12-14**] 12:52PM BLOOD PT-14.0* PTT-37.2* INR(PT)-1.2*
[**2187-12-18**] 05:44AM BLOOD UreaN-19 Creat-1.0 Na-136 K-4.3 Cl-100
[**2187-12-17**] 05:45AM BLOOD Glucose-141* UreaN-19 Creat-1.1 Na-135
K-4.3 Cl-98 HCO3-26 AnGap-15
[**2187-12-16**] 02:06AM BLOOD Glucose-120* UreaN-16 Creat-1.1 Na-137
K-3.9 Cl-101 HCO3-25 AnGap-15
Brief Hospital Course:
51 yo female with a history of hepC with a nearly 2 month
history of enterococcal endocarditis who presented with
worsening dyspnea and TTE showed abscess and perforation of
anterior mitral valve leaflet. Patient also has 4+ MR [**First Name (Titles) **] [**Last Name (Titles) **]+
although she remained hemodynamically stable. She was considered
to have failed therapy with penicillin and gentamicin and it was
thought that she would need ampicillin/ceftriaxone for 4-6 weeks
per the infectious disease service. On [**2187-12-14**] she underwent an
aortic valve replacement with a St. [**Male First Name (un) 923**] Epic tissue valve and
mitral valve a repair with closure of anterior leaflet
perforation and closure of partial anterior, mitral leaflet
cleft with 28-mm [**Company 1543**] CG Future annuloplasty ring. See
operative note for full details. She was transferred to the
CVICU in stable condition and weaned off all vasoactive
medications on post operative night. She was extubated post
operative night without incident and started on inhalers and
Flovent for a significant tobacco history. She was transfused 2
units of blood on postoperative night for a low mixed venous and
a hematocrit of 24.4. She had a good cardiac output the
following day and her PA catheter was removed. Her chest tubes
and pacing wires were removed per cardiac surgery protocol. On
POD2 she went into a slow atrial flutter in the 50's. Coumadin
was started when she remained in afib/flutter. Infectious
disease service followed the patient pre and post operatively
and recommended ceftriaxone IV until OR cultures finalized. She
was transferred to the step down unit on POD2 in stable
condition. Physical therapy worked with her for strength and
mobility. She was gently diuresed toward preoperative weight
and her beta blockers were adjusted for good heart rate and
blood pressure control. Of note the patient does need repeat CT
of chest in 12 months to follow-up pulmonary nodules seen on a
preop Chest CT. She also needs ophthalmology follow up in 1
month (appointment already scheduled) for follow-up of left
retinal irregularity seen on bedside exam (benign nevus vs optic
melanoma) and psych follow-up to address patient's anxiety. On
POD5 she was ambulating with assistance, her incisions were
healing well and she was tolerating a full oral diet. Coumadin
is to continue for INR goal of 2.0-3.0 for atrial fibrillation
and follow up Coumadin dosing should be set with PCP upon
discharge from rehab. Her OR valve tissue Cultures returned
negative and per ID, no further antibiotics or ID follow up is
needed. On POD5 she was transferred to [**Location (un) **] rehab in
Plimoth in stable condition. All follow up appointments were
arranged.
Medications on Admission:
penicillin G sodium 5 million unit Solution for Injection
3 millions every four (4) hours
lisinopril 2.5 mg Tab
1 Tablet(s) by mouth once a day
amitriptyline 50 mg Tab
1 Tablet(s) by mouth HS (at bedtime)
oxycodone-acetaminophen 2.5 mg-325 mg Tab
1 Tablet(s) by mouth every 4-6 hours as needed for pain
Discharge Medications:
1. amitriptyline 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
8. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Dose based on INR
Goal 2.0-2.5.
9. clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
10. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
11. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**2-4**]
Puffs Inhalation Q6H (every 6 hours).
12. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
15. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO twice a day for 10 days.
16. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days.
17. Outpatient Lab Work
check INR on [**2187-12-20**] then mon/wed/fri until stable
Goal INR 2.0-2.5 for afib
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Location (un) 3320**]
Discharge Diagnosis:
Endocarditis of aortic and mitral valve with severe aortic
regurgitation and severe mitral regurgitation.
Post-op afib
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
Edema 1+
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 Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**1-17**] at 1:00pm
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2 weeks
Opthalmology: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4853**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2188-1-8**] 2:30
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) **] in [**5-8**] weeks [**Telephone/Fax (1) 91355**]
**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 Atrial fibrillation
Goal INR 2.0-3.0
First draw [**2187-12-20**]
Coumadin follow up to be arranged by rehab with PCP upon
discharge
Completed by:[**2187-12-19**] Name: [**Known lastname **],[**Known firstname 1647**] Unit No: [**Numeric Identifier 14389**]
Admission Date: [**2187-12-7**] Discharge Date: [**2187-12-19**]
Date of Birth: [**2136-1-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Bactrim / Gentamicin
Attending:[**First Name3 (LF) 135**]
Addendum:
Mrs. [**Known lastname **] had decompensated CHF secondary to worsening
Mitral regurgitation as a result of the mitral valve perforation
pre-operatively.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Location (un) 1541**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2188-1-4**]
|
[
"427.31",
"305.1",
"997.1",
"427.32",
"421.0",
"424.1",
"729.1",
"362.9",
"278.00",
"584.9",
"530.81",
"070.70",
"424.0",
"E930.8",
"V58.61",
"456.1",
"041.04",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"45.13",
"88.72",
"39.61",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
14175, 14413
|
6546, 9301
|
297, 655
|
11630, 11797
|
5889, 6523
|
12721, 14152
|
4769, 4844
|
9654, 11362
|
11488, 11609
|
9327, 9631
|
11821, 12698
|
4859, 5870
|
249, 259
|
683, 3978
|
4000, 4224
|
4240, 4753
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,947
| 198,512
|
33905+57878
|
Discharge summary
|
report+addendum
|
Admission Date: [**2194-2-27**] Discharge Date: [**2194-3-8**]
Date of Birth: [**2119-5-10**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Latex / Neomycin / nickel
sulfate / metabisulfites
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
asymptomatic aortic aneurysm
Major Surgical or Invasive Procedure:
[**2194-2-27**] L thoracotomy/ repair thoracoabdominal aortic aneurysm
(32 mm x 8mm Gelweave graft)
[**2194-2-27**] re-exploration for hemothorax
History of Present Illness:
74 year old female who has been
followed with serial CT scans x many years for a known
descending
thoracic aneurysm. Most recent scan shows progression of aortic
size and surgery was recommmended. She is not a candidate for
endo-stent grafting.
Past Medical History:
Hypertension
Thoracoabdominal aortic aneurysm
Glaucoma
Vaginal prolapse
Stress incontinence
Gastroesophageal reflux disease
Hypothyroidism
Eczema
Bullous Pemphigoid (currently on Prednisone)
Past Surgical History:
s/p hysterectomy, bladder suspension and rectocele in [**2187**], and
also another bladder suspension in [**2189**]
s/p Appendectomy
s/p Tonsillectomy
Social History:
Lives with: Husband in [**Name2 (NI) 7658**], MA
Occupation: Retired
Tobacco: She quit smoking approximately 30 to 40 years ago.
ETOH: Rare use
Family History:
father with CABG in his 70's
Physical Exam:
Height: 62" Weight: 165 lb
General: Well-developed female in no acute distress
Skin: Dry [X] intact [X] Healing lesions throughout
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema: -
Varicosities: b/l
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
TTE [**2194-2-28**] Conclusions:
There is mild symmetric left ventricular hypertrophy. Overall
left ventricular systolic function is normal (LVEF>75%). with
normal free wall contractility. The aortic valve leaflets (3)
are mildly thickened. No masses or vegetations are seen on the
aortic valve. Mild (1+) aortic regurgitation is seen. No mitral
regurgitation is seen. There is no pericardial effusion.
PRELIMINARY REPORT developed by a Cardiology Fellow. Not
reviewed/approved by the Attending Echo Physician. [**Last Name (NamePattern4) **]. [**Last Name (STitle) 26687**]
was notified in person of the results .
Interpretation assigned to [**First Name8 (NamePattern2) 35980**] [**Name8 (MD) 35981**], MD, Interpreting
physician
[**2194-3-2**]:
BRAIN MRI:
There are multiple areas of restricted diffusion seen
predominantly in the
left cerebral hemisphere in the subcortical region, but also in
the right
basal ganglia region indicative of acute infarcts, likely
embolic. There is
mild-to-moderate brain atrophy and small vessel disease seen. No
evidence of
midline shift or hydrocephalus identified.
IMPRESSION: Multiple small acute infarcts in the basal ganglia
and
subcortical region of the left cerebral hemisphere as well as in
the right
basal ganglia region. No mass effect or hydrocephalus. Small
acute infarct
is also seen in the right cerebellum.
MRA HEAD:
The head MRA demonstrates no evidence of vascular occlusion of
the major
arterial structures of the anterior and posterior circulation.
IMPRESSION: No significant abnormalities on MRA of the head.
[**2194-3-8**] 04:49AM BLOOD WBC-11.5* RBC-3.17* Hgb-10.0* Hct-29.5*
MCV-93 MCH-31.5 MCHC-33.9 RDW-16.6* Plt Ct-242
[**2194-3-8**] 04:49AM BLOOD Glucose-123* UreaN-38* Creat-0.9 Na-145
K-3.9 Cl-107 HCO3-35* AnGap-7*
Brief Hospital Course:
Ms. [**Known lastname 78339**] was admitted on [**2-27**] and underwent open repair of
thoracoabdominal aortic aneurysm from left subclavian to celiac
(known descending aortic aneurysm)with Dr. [**Last Name (STitle) 914**] and Dr.
[**Last Name (STitle) **]. She underwent DHCA of 27mins. She transferred to the
CVICU in fair condition on levophed and propofol with a lumbar
drain in place. She returned to the operating room for bleeding
and control was achieved. See intraoperative note for further
details. She arrived to the unit the second time on
Neosynepherine and remained on Amiodarone for NSVT. She became
hypotensive but a bedside TTE was unremarkable. She was awoken
for neuro evaluation and was noted not to be moving her lower
extremities. Seizure activity was noted on POD #2 and neurology
was consulted. A CT of the head showed L thalamic acute stroke
while her exam revealed RLE paresis. An MRI of the brain noted
multiple small acute infarcts as well as a small R cerebellar
infarct and T11 infarct. She was started on Keppra. She was
bronched on POD#2 for LLL collapse and hypoxemia. Propofol was
eventually discontinued and she extubated without difficulty on
POD#4 Pressor support was slowly weaned off. She was started on
emperic vancomycin and Zosyn for leukocytosis. She also became
thrombocytopenic but was HIT negative and her plts eventually
recovered. Her lumbar drain was eventually removed without
difficulty. She continued to have episodes of NSVT and she
continued on amiodarone taper. She continued to make improvement
neurologically. She failed her speech and swallow exam and was
started on tube feeds. She also had continued hoarse voice. On
POD#7 she transferred to the floor. She was seen by ORL and was
found to have hypomobility of left vocal cord and may benefit
from injection if it does not improve. Should this be the case,
she should follow-up with Dr. [**Last Name (STitle) 1837**] from ORL. She
continued to progress and was advanced to pureed solids and
nectar thick fluids and pills crushed in apple sauce after
passing a speech and swallow exam. She continued with tube
feeds at night of Two Cal HN Full strength with 7gm/day of
beneprotein at a rate of 30 ml/hr via her dobhoff tube until her
nutritional needs are adequately met orally. Her oral intake
will likely be sufficient over the next couple of days to
warrant cessation of tube feeds. The neurology service saw her
a few days before discharge and felt that she is making
neurological recovery and should continue to do so. They
recommended continuing Keppra, maintaining a MAP of around 100,
and following up with Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] in [**4-6**] weeks. Her
former chest tube site drains copious serosanguinous fluid and
requires frequent gauze dressing changes to keep the site dry.
Although macerated from fluid, the site does not look infected.
By post-operative day nine she was ready for discharge to
[**Hospital3 7665**]. All follow-up appointments were advised.
Medications on Admission:
CLOBETASOL - (Prescribed by Other Provider) - 0.05 % Cream -
ointment twice a day
ESTRADIOL [VAGIFEM] - (Prescribed by Other Provider) - 25 mcg
Tablet - 2x/wk
FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1
(One) Tablet(s) by mouth once a day
IRBESARTAN [AVAPRO] - (Prescribed by Other Provider) - 150 mg
Tablet - 1 Tablet(s) by mouth once a day
LATANOPROST [XALATAN] - (Prescribed by Other Provider) - 0.005 %
Drops - 1 (One) once a day
LEVOTHYROXINE [SYNTHROID] - (Prescribed by Other Provider) - 100
mcg Tablet - 1 (One) Tablet(s) by mouth once a day
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 (One) Capsule(s) by mouth once a day
TIMOLOL [BETIMOL] - (Prescribed by Other Provider) - 0.25 %
Drops - 1 (One) once a day
VERAPAMIL - (Prescribed by Other Provider) - 180 mg Cap,24 hr
Sust Release Pellets - 1 (One) Cap(s) by mouth once a day
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Chewable
- 1 (One) Tablet(s) by mouth once a day
MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1
Tablet(s) by mouth once a day
VIT C-VIT E-COPPER-ZNOX-LUTEIN [PRESERVISION] - (Prescribed by
Other Provider; OTC) - 226 mg-200 unit-[**Unit Number **] mg-0.8 mg-34.8 mg
Capsule - 1 (One) Capsule(s) by mouth twice a day
Minocylcine 100mg [**Hospital1 **]
Acyclovir 400mg [**Hospital1 **]
Hdroxyzine 10mg q6 prn
Hydrocortisone cream prn
Ketoconazole cream prn
Prednisone 10mg daily
Discharge Medications:
1. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day:
take 200mg [**Hospital1 **] for one week, then decrease to 200mg daily
ongoing.
6. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
8. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
11. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain/fever.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. therapeutic multivitamin Liquid Sig: Five (5) ML PO
DAILY (Daily).
16. Novolog 100 unit/mL Solution Sig: sliding scale units
Subcutaneous four times a day: Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
novalog novalog novalog novalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
mg/dL Units Units Units Units
mg/dL Units Units Units Units
mg/dL Units Units Units Units
mg/dL Units Units Units Units
mg/dL Units Units Units Units
.
17. nystatin 100,000 unit/mL Suspension Sig: Three (3) mL PO
three times a day for 5 days: thrush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
thoracoabdominal aortic aneurysm s/p repair and s/p re-explor.
for bleeding
postop embolic CVA
postop seizure
Hypertension
Glaucoma
Vaginal prolapse
Stress incontinence
Gastroesophageal reflux disease
Hypothyroidism
Eczema
Bullous Pemphigoid (currently on Prednisone)
Discharge Condition:
Alert and oriented x3 nonfocal
Max assist, lift to chair, weak lower extremities 2/5 strength
Incisional pain managed with oral analgesics
Incisions:
thoracoabdominal incision - healing well, no erythema or
drainage
former chest tube site draining serosanguinous fluid requiring
frequent dressing changes to keep the site dry. site is
macerated but without sign of infection.
Edema 1+ lower extremity
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 6 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] [**2194-4-7**] at 2:45pm on [**Hospital Ward Name **] [**Hospital Unit Name **]
Cardiology: Dr. [**Last Name (STitle) 78340**] [**2194-4-1**] at 3:15p
Vascular: Dr. [**Last Name (STitle) 3407**] [**2194-3-18**] at 1:00p
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 26775**] ([**Telephone/Fax (1) 78341**] in [**5-8**] 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:[**2194-3-8**] Name: [**Known lastname 12625**],[**Known firstname 1940**] Unit No: [**Numeric Identifier 12626**]
Admission Date: [**2194-2-27**] Discharge Date: [**2194-3-8**]
Date of Birth: [**2119-5-10**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Latex / Neomycin / nickel
sulfate / metabisulfites
Attending:[**First Name3 (LF) 1543**]
Addendum:
Based on her discharge summary and weight, Ms. [**Known lastname **] was
started on lasix and potassium on the day of discharge. She
should continue this for five days or according to her exam and
weight.
Discharge Medications:
1. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day:
take 200mg [**Hospital1 **] for one week, then decrease to 200mg daily
ongoing.
6. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
8. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
11. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain/fever.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. therapeutic multivitamin Liquid Sig: Five (5) ML PO
DAILY (Daily).
16. Novolog 100 unit/mL Solution Sig: sliding scale units
Subcutaneous four times a day: Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
novalog novalog novalog novalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
mg/dL Units Units Units Units
mg/dL Units Units Units Units
mg/dL Units Units Units Units
mg/dL Units Units Units Units
mg/dL Units Units Units Units
.
17. nystatin 100,000 unit/mL Suspension Sig: Three (3) mL PO
three times a day for 5 days: thrush.
18. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
19. potassium chloride 20 mEq Packet Sig: One (1) PO once a day
for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1933**]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2194-3-8**]
|
[
"401.9",
"441.7",
"511.89",
"287.5",
"780.39",
"V58.65",
"244.9",
"276.0",
"E878.8",
"434.91",
"518.51",
"365.9",
"288.60",
"998.11",
"512.1",
"784.42",
"478.5",
"694.5",
"344.1",
"427.1",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.6",
"38.93",
"33.24",
"38.45",
"39.61",
"34.03",
"88.72",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
15042, 15247
|
3871, 6903
|
378, 526
|
10520, 10923
|
2054, 3848
|
11846, 13129
|
1368, 1398
|
13152, 15019
|
10229, 10499
|
6929, 8395
|
10947, 11823
|
1037, 1190
|
1413, 2035
|
310, 340
|
554, 801
|
823, 1014
|
1206, 1352
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,150
| 153,019
|
52175
|
Discharge summary
|
report
|
Admission Date: [**2170-7-13**] Discharge Date: [**2170-7-17**]
Date of Birth: [**2092-2-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Carbapenem / A.C.E Inhibitors /
Angiotensin Receptor Antagonist
Attending:[**First Name3 (LF) 14145**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Echocardiogram
History of Present Illness:
76 y/o male with a history of DM2, pericarditis (known since
[**2170-5-16**], CAD presenting from cardiologist visit with pleuritic
chest pain worse when lying down, SOB. O2 sat 92% (nml 96%)
worsening over two days. Complaints of pleuritic chest pain and
shortness of breath beginning one week prior led to echo [**7-9**] by
Dr. [**Last Name (STitle) **] which demonstrated an EF of 40%, trace regurg,
thickened mitral valve, increasing pericardial effusion
circumferential, no evidence of tamponade. Office visit this AM
due to increasing sob leading to inability to sleep, chest pain.
Echo demonstrating 3 cm anterior effusion with RA inversion and
no signs of tamponade. Pt sent to ED.
In ED, vitals 97.1, Hr 58, BP 150/76, RR 20. Hydral was given.K
repleted 40 mg. Nurse found patient stupurous, FBG noted to be
23. Given 3 amps of D50, rose to normal. Pt continued to be
sleepy but gradually increasing in alertness. Head CT non
contrast demonstrating lacunar infarcts in the past.
Admitted to CCU for hemodynamic monitoring, setting of
pericardial effusion, obtundation, possible hx of CHF. Blood
pressure elevated to systolic 200.
Past Medical History:
1. CAD status post MI in [**2166**] (intraoperative MI during blood
loss from nephrectomy), s/p LAD stents in [**11/2167**] and OM1
stent in [**12/2167**], c/b in-stent restenosis of OM1 s/p ballon
angio in 01/[**2169**]. Also LCX stent.
2. CHF- Echo [**12-25**]-[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated. LVSF depressed (EF 35%).
Regional wall motion abnormalities include inferolateral and
lateral akinesis. 1+ MR ; mod PA HTN; small-mod pericardial
effusion.
3. DM 2- c/w peripheral neuropathy and nephropathy, no recent
HbA1C on file.
4. CRI- baseline 1.5-1.8
5. Hypertension
6. Hypercholesterolemia
7. History of renal cell carcinoma s/p nephrectomy in [**2-/2166**]
8. History of prostate cancer treated with XRT
9. Type 1 RTA
10. History of multiple falls, status post mid shaft and
surgical neck humerus fracture in [**7-/2169**]
11.Hypoaldosteronism
12. Hx of hyperkalemia
13. Anemia- Crit baseline ~30
Social History:
Shares an apartment with his ex-wife. Ex-[**Name2 (NI) 1818**], quit smoking
55 years ago. No EtOH. Uses a scooter most of the time, able to
walk also with a walker. A retired attorney who has argued
before the supreme court.
Family History:
NC
Physical Exam:
VS: T: 95.9, bp 183/83 range 83-156/64-83, hr 61 (61-70), rr 12,
spo2 99% RA
Gen: obese, elderly male, snoring in bed, only arousable with
shouts
HEENT: anicteric sclera, op clear with mmm
Neck: JVP difficult to assess secondary to body habitus
CV: rrr, s1s2, no m/r/g
Lungs: fair air movement, Crackles at bases
Abd: obese, soft, nt, nabs, colostomy in place, surgical scars
present.
Back: no cva/vert tenderness, no sacral edema
Ext: Warm/dry. 1+ pitting edema in extremities bilaterally
Neuro: Appears stuporous, sleepy, snoring heavily. Answers when
spoken to loudly or to heavy touch.
Pertinent Results:
STUDIES:
Echo [**2170-7-9**]
infero posterior thinned scarred and akinetic LV, EF 40%.
Thickened mitral valve with trace regurgitation. Persistent
circumferential pericardial effusion slightly increased since
[**2170-5-25**], no evidence of tamponade.
.
Head CT [**2170-7-13**]
Stable appearance of the brain from [**2169-11-21**], without
intracranial hemorrhage or mass effect. Chronic lacunar infarcts
within both basal ganglia, unchanged.
.
CXR [**2170-7-13**]: A/P. No blunting of costophrenic angles. Moderate
cardiomegaly. No evidence of florid pulmonary edema.
.
[**7-14**] TTE
Conclusions:
The left atrium is mildly dilated. There is moderate regional
left ventricular systolic dysfunction with akinesis of the
inferior and inferolateral wall. 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 left ventricular
inflow pattern suggests impaired relaxation. There is mild
pulmonary artery systolic hypertension. There is a moderate
sized pericardial effusion (1.5-2.0 cm). There are no
echocardiographic signs of tamponade.
Compared with the report of the prior study (images unavailable
for review) of [**2170-1-8**], the effusion may be slightly bigger
but there is no signs of tamponade.
.
[**7-16**]- TTE
Conclusions:
The left ventricular cavity is moderately dilated. LV systolic
function
appears depressed with lateral wall hypokinesis. The right
ventricular free wall is hypertrophied. Right ventricular
chamber size is normal. Right ventricular systolic function is
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. The mitral valve leaflets are
mildly thickened. There is a small to moderate sized pericardial
effusion (small anteriorly; moderate inferolaterally). There is
brief right atrial diastolic collapse.
Compared with the prior study (images reviewed) of [**2170-7-14**],
the effusion appears similar in size.
Brief Hospital Course:
A/P: 78 yo M with h/o CAD s/p CABG, stents, CHF EF 40% presented
to PCP with shortness of breath pleuritic chest pain, referred
to [**Hospital1 18**] ED. Known 3 cm pericardial effusion, echo in ED with no
evidence of tamponade. patient became unarousable in ED with
blood sugar 28, given 3 AMPS D50 and admitted to the CCU.
.
# Pericardial effusion: has known h/o pericarditis with
worsening chest pain and SOB. Pulsus currently approx 10 cm.
Echo shows evidence of RA collapse. Monitored with serial pulsus
checks. Increased to 14 several hours into admission and then
regressed to 10. Considered related to infectious, viral or
autoimmune causes. Repeated echo in preparation of possible
pericardiocentesis given extent of effusion and concern for
tamponade. TTE [**7-14**] with no evidence of significant worsening
effusion of tamponade. 1.5-2 cm pericardial effusion. Continued
to monitor. Treated pain with cochicine [**Hospital1 **], per PCP pt did not
achieve any relief from NSAIDS. Rheumatology consult to
determine treatment options for symptomatic pericardial effusion
unable to be managed surgically. Obtained RF, histone, [**Doctor First Name **] and
UA for possible drug induced lupus or other cause of
pericarditis. Also considered hydral as possible cause. Patient
was discharged in stable condition with follow up with Dr.[**Last Name (STitle) **].
.
# CAD: s/p CABG and stents: ECG unchanged. No current s/sx
ischemia . Continued ASA, [**Last Name (un) **], BB, statin, zetia. Started
norvasc 5 mg and increased hydralazine to 50 TID to stabilize BP
regimen, discharged on [**Hospital1 **] dose. Did not feel as though hydral
likely cause of pericarditis and subsequent effusion.
.
# Pump: EF 40%. Clinically appeared relatively euvolemic, though
difficult to ascertain. CXR with no remarkable pulm edema. BP
markedly elevated, likely in setting of med non-compliance.
Acutely controlled BP with nitro gtt on admission. Restart po BP
meds - carvedilol, hydral, losartan, with subsequent holding
hydral and also held imdur while on nitro gtt.
.
# Rhythm: NSR to brady currently. Monitored on tele. Carvedilol
with holding parameters.
.
# altered mental status: likely [**2-22**] hypoglycemia in setting of
pt takes large dose of lantus usually, decreased po intake on
day of admission. Has signs of prior lacunar infarcts on head
CT. Likely pt is slow to improve mental status from
hypoglycemia. Head CT did not show acute bleed. Followed FS q2
hrs treated FS>200 with insulin. Held lantus. LFT's with no
evidence of hepatic encephalopathy. Pt became alert and
oriented, talkative within one day and was stable to discharge.
.
# DM: hypoglycemia as above. Held Lantus, and neurontin for
diabetic neuropathy.
.
# mild hypoxia - has h/o COPD. Weaned off O2 as the patient
tolerated. Nebulizer treatments and cxr with no evidece of
pulmonary edema or bleed.
.
# h/o depression: continued paxil.
.
# h/o prostate cancer: continued flomax.
.
# h/o hypoaldosteronismm: continue florinef.
.
# FEN: NG tube placed on admission for medications as patient
was not alert enough to take PO. DC's two days into admission.
Medications on Admission:
MEDICATIONS:
Albuterol inhaler prn
insulin- glargine 100 ml, 65 units qhs
regular insulin sliding scale
Paxil 30 mg qd
Neurontin 1200 mg tid or qid
Coreg 25 mg [**Hospital1 **]
Zetia 10 mg qd
Lipitor 40 mg qd
ASA 325 mg qd
Calcitriol 0.25mg [**Hospital1 **]
lasix 20 mg alternatin with 40 mg
Florinef0.1 mg [**Hospital1 **]
Imdur 30 mg qd
aspirin 81 mg qd
combivent inhaler prn
loperamide 2 mg qd
Hydralazine 50 mg [**Hospital1 **]
Cozaar 25 mg qd
Flomax 0.4 mg [**Hospital1 **]
Afrin nasal spray prn
Colchicine 0.6 mg qd
.
Allergies:
KCL, ACE I, [**Last Name (un) 11823**]- severe hyperkalemia requiring dialysis
Penicillin
Cephalosporins
Crestor- myalgias
Discharge Medications:
1. Paroxetine HCl 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO once a day.
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
9. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*
10. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO QOD for 2
weeks.
Disp:*7 Tablet(s)* Refills:*0*
11. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
13. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*3*
14. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours.
Disp:*90 Tablet(s)* Refills:*2*
15. Insulin
Please continue to take 50Units of Lantus at bedtime
16. Combivent 103-18 mcg/Actuation Aerosol Sig: One (1)
Inhalation [**Hospital1 **]:prn.
17. Imdur 30 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
18. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Pericarditis with pericardial effusion
2. Hypertension
3. Renal Insufficiency
4. Hypoglycemia
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 3gm sodium diet.
.
Please call your PCP or return to the ED if you develop chest
pain, nausea, fevers, worsening shortness of breath,
lightheadedness, palpitations, or any other symptoms of concern.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**Telephone/Fax (1) 5768**], Thursday [**2170-7-19**] at 1pm
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20430**], MD Date/Time:[**2170-7-26**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20430**], MD Date/Time:[**2170-8-9**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20430**], MD Date/Time:[**2170-8-23**] 2:00
|
[
"401.9",
"357.2",
"423.9",
"V10.52",
"250.60",
"250.40",
"583.81",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10941, 10947
|
5523, 7688
|
360, 377
|
11088, 11097
|
3403, 5500
|
11428, 11916
|
2774, 2778
|
9362, 10918
|
10968, 11067
|
8680, 9339
|
11121, 11405
|
2793, 3384
|
317, 322
|
405, 1549
|
7703, 8654
|
1571, 2512
|
2528, 2758
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,554
| 117,759
|
26224
|
Discharge summary
|
report
|
Admission Date: [**2195-7-3**] Discharge Date: [**2195-7-29**]
Date of Birth: [**2123-12-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Diuril
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
71yoW s/p AVR(#19 [**Company 1543**] Mosaic)CABGx2(LIMA-LAD,SVG-RCA)[**7-16**]
Right internal jugular line and PA catheter
Bilater thoracentesis
History of Present Illness:
71 y/o female with CAD, AS, and PVD who presented to [**Hospital 1474**]
hospital on [**2195-7-2**] with dyspnea for one month, worse over the
preceeding week with cough but no clear fevers. Vitals were
98.7, 124/69, 91, and 94% on 2L/M O2 on presentation. CXR showed
cardiomegaly with mild [**Date Range 1106**] congestion. Labs showed a WBC
count of 19.2 with 89% neutrophils. HCT was 24.6. ABG was
7.41/52/63. She was tried on BIPAP unsuccessfully and then
intubated for respiratory distress. She became transiently
hypotensive, requiring dopamine drip. She became tachycardic,
and so was changed to levophed. Initial labs showed BNP of 880,
BUN of 28, Cr of 1.2, CK 100 to 84 to 540, troponin 0.01 to 0.4
to 14.2. EKG had ST depressions in I, II, V4-V5 which were more
pronounced with tachycardia
Past Medical History:
Hypertension
CAD s/p RCA stenting [**2193**] (Cypher stent x 2 to ostial and mid
RCA, two bare metal stents to distal RCA)
Bilateral carotid artery disease
Aortic stenosis [**Location (un) 109**] 1.1cm and mean gradient 37
LE claudication
Possible COPD
Obstructive sleep apnea (not on CPAP)- uses 2 liters O2 at night
Diabetes
Hyperlipidemia
Left LE ORIF c/b infection
Glaucoma
GERD
s/p cataract surgery of right eye with lens replacement
Percutaneous coronary intervention, in [**2193**] anatomy as follows:
Cypher stent x 2 to ostial and mid RCA, two bare metal stents to
distal RCA
Social History:
Husband died in [**2192-3-17**] of cancer. She lives alone and has
three children who are very helpful. Her son is [**Name (NI) 4468**] [**Name (NI) **] and
her daughter [**Name (NI) **] [**Name (NI) **]. [**Doctor First Name 4468**] can be reached at
[**Telephone/Fax (1) 64736**]. [**Doctor First Name **] can be reached by cell phone at
[**Telephone/Fax (1) 64737**]. Patient has smoked >50 years. She used to smoke
two and a half to three packs a day. Currently smoking half a
pack a day. Min EtoH. Used to work as a bookeeper.
Family History:
(+) FHx CAD. Mother had CAD. Father had MI and died at 52.
Physical Exam:
PHYSICAL EXAMINATION:
.
T 99.3 BP 105/50 HR 100 Vent TV500 Rate14 PEEP5 FiO250% Sat 100%
General: Intubated, able to follow simple commands, appears
comfortable. Pale skin throughout.
HEENT: Pupils equal and reactive. Pale conjunctiva.
NECK: Unable to determine JVP. Late peaking pulses.
LUNGS: Mild Wheezes bilaterally. No crackles.
HEART: Regular rhythm. S1 and S2 with harsh late peaking
systolic creshendo/decreshendo murmur.
ABD: Obese, soft, NT, ND, normal active bowel sounds.
EXT: Pitting edema to
SKIN: Generally warm with cool feet. Weak femoral, popliteal,
and DP/TP pulses.
.
Pertinent Results:
[**2195-7-6**] Cardiac Cath:
COMMENTS:
1. Coronary angiography in this right-dominant system
demonstrated
2-vessel disease. The LMCA had 50% stenosis at its origin with
noted
dampening of pressure. The LAD had moderate diffuse disease.
The LCx
was a non-dominant vessel without critical lesions. The RCA was
a
dominant vessel with previous stent origin 90% stenosis.
2. Resting hemodynamics revealed elevated left-sided filling
pressures
with LVEDP of 40. There was moderate pulmonary arterial
systolic
hypertension with PASP of 58. The cardiac output was preserved
at 5.71
L/min.
3. There was severe aortic stenosis with a peak to peak
gradient of 60
mmHg, mean gradient of 41 mmHg and aortic valve area of 0.8 cm2.
4. The aortic root and arch were noted to have significant
calcifications.
.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Severe aortic stenosis.
3. Elevated left-sided filling pressures and moderate pulmonary
artery
systolic hypertension.
.
[**2195-7-4**] Echo:
Conclusions:
The estimated right atrial pressure is 11-15mmHg. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. There is mild to moderate global left
ventricular hypokinesis (LVEF = 40 %). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. There
is severe aortic valve stenosis (area <0.8cm2). Mild (1+)
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. There is no pericardial effusion.
.
[**2195-7-9**] Chest CT:
IMPRESSION:
1. Bilateral moderate to large dependent simple pleural
effusions.
2. Bilateral dependent pulmonary opacities, which may be due to
a combination of atelectasis and provided history of pneumonia.
A 1.5 cm diameter rounded lucency in superior segment left lower
lobe may represent underlying pneumatocele or bulla, but a focus
of necrotizing pneumonia is difficult to exclude given adjacent
pleural effusion and absence of intravenous contrast. If
warranted clinically, a followup contrast enhanced chest CT
could be considered, ideally following thoracentesis, for more
complete evaluation of this region.
3. Emphysema.
4. Coronary artery and aortic valvular calcifications.
[**2195-7-29**] 02:50AM BLOOD WBC-12.4* RBC-3.48* Hgb-10.1* Hct-31.2*
MCV-90 MCH-29.2 MCHC-32.5 RDW-15.9* Plt Ct-410
[**2195-7-28**] 02:22AM BLOOD WBC-11.8* RBC-3.61* Hgb-10.3* Hct-32.5*
MCV-90 MCH-28.6 MCHC-31.8 RDW-16.1* Plt Ct-412
[**2195-7-27**] 02:15AM BLOOD WBC-8.9 RBC-3.51* Hgb-10.2* Hct-31.2*
MCV-89 MCH-29.1 MCHC-32.7 RDW-16.1* Plt Ct-292
[**2195-7-29**] 04:43AM BLOOD PTT-81.5*
[**2195-7-29**] 02:50AM BLOOD Plt Ct-410
[**2195-7-29**] 02:50AM BLOOD PT-12.9 PTT-101.3* INR(PT)-1.1
[**2195-7-29**] 02:50AM BLOOD Glucose-66* UreaN-24* Creat-1.1 Na-141
Cl-96 HCO3-38*
Brief Hospital Course:
Ms. [**Known lastname 4223**] was admitted to the CCU for invasive monitoring and
mechanical ventilation. She was started on levofloxacin,
vancomycin and zosyn for CAP. She was transfused for a
hematacrit of 22. She was seen by renal for likely atn and
contrast nephropathy from cath. She was started on tube feeds.
Cardiac cath on 8.20 showed 50% LM, moderate diffuse LAD
disease, 90% RCA. She was seen by cardiac surgery for AVR/CABG,
and awaited diuresis, plavix washout and possible extubation
prior to surgery. Cautious diuresis was attempted given her
severe AS. On [**7-9**] she underwent thoracentesis. Pressure support
trial was unsuccessful as was steroid taper and she remained
intubated. On [**7-16**] she ws taken to the operating room where she
underwent a CABG x 2 and AVR (porcine). She was transferred to
the ICU in critical but stable condition on epi, neo, propofol
and insulin. She remained intubated. She ws startd on amiodarone
for post op atrial fibrillation. She was seen by general
surgery for abdominal pain, increased pressor requirement and
increased LFTs. She did not require surgery, and her LFTs
improved. She continued on tube feeds postoperatively.
Aggressive diuresis continued. She was weaned from her
vasoactive drips. She was seen by thoracic surgery for trach and
PEG, which was performed on [**2195-7-24**]. The ventilator was weaned
and she was screened for rehab. She was ready for discharge to
rehab on [**2195-7-29**].
Medications on Admission:
asa, plavix, atenolol, vytorin, spiriva, metformin 500'',
glyburide 5', timolol, avndia, aciphex, MVI
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
6. Albuterol 90 mcg/Actuation Aerosol Sig: 4-6 Puffs Inhalation
Q4H (every 4 hours).
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 4-6 Puffs
Inhalation Q4H (every 4 hours).
8. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
9. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day) as needed.
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed.
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
16. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
17. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Prevacid 30 mg Susp,Delayed Release for Recon Sig: One (1)
PO once a day.
19. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
20. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
AS
CAD
PMH: DM, Dyslipidemia, HTN, PVD s/p Right Carotid stent s/p
stenting of aortic bifurcation, Hemorrhoids, GERD, Anemia, COPD
Discharge Condition:
Stable.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Followup Instructions:
Dr. [**Last Name (STitle) **] after discharge from rehab.
Dr. [**Last Name (STitle) 17887**] after discharge from rehab.
Dr. [**Last Name (STitle) **] after discharge from rehab.
Already scheduled appointments:
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2195-9-29**]
10:00
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2195-9-29**]
11:00
Completed by:[**2195-7-29**]
|
[
"530.81",
"428.0",
"486",
"424.1",
"584.9",
"578.1",
"496",
"365.9",
"272.4",
"327.23",
"250.00",
"427.31",
"414.01",
"443.9",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"33.22",
"36.11",
"99.15",
"43.11",
"36.15",
"35.21",
"39.61",
"34.91",
"31.1",
"37.22",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
9491, 9563
|
6196, 7661
|
292, 440
|
9739, 9749
|
3130, 3934
|
9915, 10367
|
2446, 2506
|
7813, 9468
|
9584, 9718
|
7687, 7790
|
3951, 6173
|
9773, 9892
|
2521, 2521
|
2543, 3111
|
233, 254
|
468, 1270
|
1292, 1880
|
1896, 2430
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,391
| 168,593
|
4228
|
Discharge summary
|
report
|
Admission Date: [**2185-9-5**] Discharge Date: [**2185-9-7**]
Date of Birth: [**2107-11-7**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: Patient is a 78-year-old white
male with a history of known coronary artery disease status
post myocardial infarction in [**2178**], status post PTCA of the
left anterior descending artery in [**2178**], who subsequently
developed VT with episodes of syncope and had AICD placed in
[**2178**], also with history of hypertension,
hypercholesterolemia, diabetes type 2 insulin requiring, who
underwent EP ablation of VT focus today, [**2185-9-5**].
The patient reports having had no chest pain, shortness of
breath, dyspnea on exertion, orthopnea, PND, and was doing
well until several months prior to admission. He was told by
his cardiologist that his ICD device was having to overdrive
pace his ventricle for episodes for ventricular tachycardia.
The patient was unaware of the ventricular tachycardia and
was asymptomatic during episodes. Then the patient's ICD
device delivered a shock on [**2185-8-12**]. The patient
recalls being asymptomatic prior to defibrillation. He was
advised by his cardiologist to have an electrophysiological
study with mapping and ablation of his ventricular
tachycardia focus.
The patient underwent mapping and ablation on [**2185-9-5**].
Subsequently, status post ablation, the patient developed a
profuse bleeding and large hematoma formation at his right
groin catheterization site. At this time, the patient
reported only mild nausea, mild groin and leg pain. His
femoral catheterization sheath was removed, and direct
pressure was applied to the bleeding site for over two hours.
Throughout this time, his blood pressure remained stable in
the 140s/50s with heart rate in the 60s. A STAT hematocrit
laboratory value was sent with result of 26.4. It is unclear
what is the patient's baseline hematocrit.
Vascular Surgery was consulted, and they advised that the
patient be typed and crossed for 4 units of blood, and
transfused 2 units. In the interim, the patient was sent for
an ultrasound which demonstrated no evidence of
pseudoaneurysm formation at the site of the femoral hematoma.
He was volume resuscitated with 3 liters of IV fluid. The
bleeding stopped and pressure dressing was applied.
The patient was transferred to the Coronary Care Unit for
further monitoring. On arrival to the Coronary Care Unit, he
was pain free. He denied any chest pain, shortness of
breath, dizziness, back pain, fevers, chills. He did have
one episode of emesis upon arrival to the unit, but denied
any recurrent nausea. Repeat hematocrit was sent with a
value of 37.5. Therefore, the patient was not initially
transfused after arrival to the CCU.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post myocardial infarction
in [**2178**]. PTCA of the LAD in [**2178**] complicated by right
pseudoaneurysm formation in the femoral artery. Stress
echocardiogram in [**2181**] showed no evidence of ischemia.
2. Ventricular tachycardia status post ICD placement in [**2178**].
Prior to ICD placement, patient had symptoms of syncope.
Batteries in ICD device were placed in [**2182-10-11**].
3. Asthma.
4. Diabetes type 2, insulin requiring.
5. Hypertension.
6. Obesity.
7. Status post cerebrovascular accident in [**2178**].
8. Status post cholecystectomy.
9. Hypercholesterolemia.
ALLERGIES: The patient reports allergies to Keflex resulting
in rash, beta blockers resulting in aggravation of his
asthma, Avandia resulting in rash and edema, aldactone
resulting in hyperkalemia.
MEDICATIONS PRIOR TO ADMISSION:
1. Verapamil SR 240 mg po q day.
2. Monopril 20 mg po bid.
3. Aspirin 325 mg po q day.
4. Lipitor 20 mg po q day.
5. Azmacort four puffs prn.
6. Isordil 20 mg po bid.
7. Folate 3 mg po bid.
8. Humalog insulin 75/25, pen with 36 units q am, 26 units q
pm.
9. Multivitamins.
10. Vitamins B12 and B6.
SOCIAL HISTORY: The patient is married with children in the
area. He worked as a sheet metal manufacturer. He is now
retired. He reports greater than 40 pack year smoking
history having quit over 35 years ago. He denies any abuse
of alcohol, no recreational drug use.
FAMILY HISTORY: Patient has father with history of diabetes,
deceased from myocardial infarction at age 78.
REVIEW OF SYSTEMS: Patient denied any chest pain, shortness
of breath, abdominal pain, stool changes, orthopnea, PND,
headache, lightheadedness, syncope.
PHYSICAL EXAMINATION UPON ADMISSION: Vital signs showed a
temperature of 98.8, blood pressure 126/52, heart rate 80,
respiratory rate 21, oxygen saturation 99% on 2 liters nasal
cannula. General appearance: Well-developed, obese white
male, pleasant, in no acute distress, lying supine on nasal
cannula O2. HEENT: Normocephalic, atraumatic. Pupils are
equal, round, and reactive to light and accommodation.
Sclerae are anicteric. Oropharynx clear. Oral mucosa moist.
Neck is supple, no masses or lymphadenopathy, no carotid
bruits auscultated. Lungs: Clear to auscultation
anterolaterally. Cardiovascular: Regular, rate, and rhythm,
S1, S2 heart sounds auscultated. No murmurs, rubs, or
gallops. Abdomen: Soft, obese, nontender, and nondistended,
positive bowel sounds noted. Groin: Left femoral
catheterization site with Tegaderm dressing clean, dry, and
intact, no blood oozing, no bruit auscultated. Right groin
site with 15 cm x 6 cm ecchymotic hematoma, dark black-blue
skin discoloration. No bruit auscultated, nontender to
palpation. Extremities: Warm and dry, with right foot
slightly cooler than left. Dorsalis pedis and posterior
tibial pulses 1+ palpated bilaterally. Bilateral leg edema
1+.
PERTINENT LABORATORIES, X-RAYS, AND OTHER STUDIES: Complete
blood count on admission showed white blood cells of 8.3,
hemoglobin of 8.5, hematocrit 26.4, platelet count 186.
Repeat hematocrit drawn after arrival to the Coronary Care
Unit was 37.5. Coagulation profile showed a PT of 14.0, INR
1.3. Serum chemistries demonstrated a sodium of 144,
potassium 3.5, chloride 115, bicarbonate 21, BUN 20,
creatinine 1.1, glucose 164.
ULTRASOUND: No pseudoaneurysm formation.
ELECTROCARDIOGRAM: Before ablation showed normal sinus
rhythm at 84 beats per minute. Right bundle branch block
morphology, left axis deviation, T-wave inversions in leads
III, aVF. Electrocardiogram after ablation showed normal
sinus rhythm at 72 beats per minute. Right bundle branch
block morphology. Left axis deviation. T-wave inversions in
leads III, aVF.
SUMMARY OF HOSPITAL COURSE:
1. Coronary artery disease: Patient is status post
myocardial infarction in [**2178**], status post PTCA of the left
anterior descending artery in [**2178**]. He was continued on
medical management with aspirin 325 po q day, Isordil 20 mg
po bid, Lipitor. His Lipitor dose was increased to 40 mg po
q day and was to be modified after a check of his lipid
profile. Originally, the patient's ACE inhibitor was held
secondary to his falling hematocrit, the question of any
blood pressure lability.
Patient was not started on a beta blocker secondary to his
history of reactive airway disease. However, it is felt that
the patient should clarify with his PCP the role of beta
blockade and could perhaps be started on a beta blocker in
the future. As the patient was status post ablation for
ventricular tachycardia, he is monitored on telemetry for
arrhythmias. Additionally, he had an ICD in place, which was
functional.
Overnight he had occasional episodes of ectopy with PVCs in
singlets and couplets. He did not have any runs of
ventricular tachycardia. On hospital day #2, his verapamil
240 mg po q day and ACE inhibitor were reinstated. He
remained hemodynamically stable with stable blood pressures
and heart rates.
On hospital day #2, an echocardiogram was done to assess the
patient's left ventricular function and assess for any
valvular abnormalities. Echocardiogram demonstrated an
ejection fraction of 40%, mild left atrial dilatation. Mild
regional left ventricular systolic dysfunction with focal
severe hypo/akinesis of the basal half of the inferolateral
wall and basal inferior wall. The aortic valves are mildly
thickened. He had trace aortic regurgitation. Trivial
mitral regurgitation. The echocardiogram was unable to
assess pulmonary artery systolic pressure.
At the time of discharge, the patient was hemodynamically
stable. He was chest pain free. He did not have any
evidence of ectopy on telemetry monitoring. He was
discharged home on a regimen of aspirin, ACE inhibitor, and
Lipitor. Additionally, his verapamil 240 mg po q day was
added for antiarrhythmic properties.
2. Right groin hematoma: Patient underwent ultrasound which
demonstrated no evidence of pseudoaneurysm formation.
Additionally, Vascular Surgery was following the patient and
recommended serial hematocrit checks q4h with a goal to keep
his hematocrit greater than 30 in light of his coronary
artery disease history. He was typed and crossed for four
units of packed red blood cells and was said to be transfused
2 units of packed red blood cells upon arrival to the
Coronary Care Unit.
However, prior to transfusion, a repeat hematocrit was sent,
which demonstrated a value of 37.3. Therefore, the decision
was made to hold off on transfusion and simply monitor the
patient with serial hematocrits. In addition, he was volume
resuscitated with a total of 3 liters of IV fluid.
Throughout the hospital course, his hematocrit slowly trended
down to a value of 27.4. On the evening of hospital day #2,
the patient was transfused 1 unit of packed red blood cells.
He tolerated this well, and at the time of discharge, his
hematocrit was stable at a value of 30.3.
3. Diabetes mellitus type 2: Patient was maintained on his
outpatient dose of Humalog 25/75 with 36 units q am, 26 units
q pm. Additionally, he was monitored with qid fingerstick
blood glucose testing and covered with a regular
insulin-sliding scale. Hemoglobin A1C laboratory was sent,
but was pending at the time of discharge.
4. Asthma: Patient was prescribed an albuterol MDI inhaler
for use on an as needed basis for shortness of breath or
wheezing. He experienced no evidence of dyspnea, shortness
of breath, wheezing, bronchospasm during this admission.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: Patient was discharged home with services.
DISCHARGE DIAGNOSES:
1. Status post ablation of ventricular tachycardia foci.
2. Right groin hematoma.
3. Coronary artery disease status post myocardial infarction,
status post coronary artery bypass graft.
4. Diabetes type 2.
5. Asthma.
DISCHARGE MEDICATIONS:
1. Percocet 1-2 tablets po q4-6h as needed for pain.
2. Lipitor 20 mg one po q day.
3. Folate 3 mg po bid.
4. Aspirin 325 mg one po q day.
5. Isosorbide dinitrate 20 mg one po bid.
6. Verapamil 240 mg one po q24h.
7. Monopril 20 mg one po bid.
8. Humalog 75/25 36 units q am, 26 units q pm.
FOLLOW-UP PLANS:
1. Patient was told to notify his primary care physician or
visit [**Name Initial (PRE) **] local Emergency Room if he experienced any chest
pain, shortness of breath, groin pain at his catheterization
site, back pain, nausea, vomiting, fainting, or
lightheadedness.
2. He was told to continue to take all of his home
medications as previously prescribed and directed. We had
not changed any of his medications nor had he had any
medications added to his regimen.
DISCHARGE INSTRUCTIONS:
1. It is recommended the patient follow up with his primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 18376**] at [**Telephone/Fax (1) 18377**] for a follow-up
appointment within the next 7-10 days.
2. Additionally, he was told to call his cardiologist, Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 5768**] for a follow-up appointment
within the next two weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Last Name (NamePattern1) 257**]
MEDQUIST36
D: [**2185-9-7**] 18:41
T: [**2185-9-16**] 12:37
JOB#: [**Job Number 18378**]
|
[
"250.00",
"414.01",
"427.1",
"V70.7",
"998.12",
"V53.32",
"493.90",
"V45.82",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.34",
"37.26",
"37.27"
] |
icd9pcs
|
[
[
[]
]
] |
4216, 4309
|
10435, 10653
|
10676, 10968
|
11477, 12197
|
6564, 10319
|
3626, 3925
|
10985, 11453
|
4329, 4488
|
159, 2753
|
4503, 6536
|
2775, 3594
|
3942, 4199
|
10344, 10414
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
344
| 176,203
|
24690
|
Discharge summary
|
report
|
Admission Date: [**2154-11-12**] Discharge Date: [**2154-11-16**]
Date of Birth: [**2096-9-5**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
thrombocytopenia, vaginal bleeding, pancreatitis, diabetes
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 58 year-old woman with a history of hypertension
transferred to [**Hospital1 18**] from [**Hospital3 **] with pancreatitis for
further management. Patient was admitted to [**Hospital1 46**] on
[**2154-11-10**] with one week of polydipsia and one day of increased
lethargy, confusion. On questioning now patient gives 2 week
history of decreased appetite, early satiety, intermittent RUQ
abdominal "discomfort" with eating. No history of gallstones.
Significant polyuria, polydipsia of 1 week duration, no constant
abdominal pain. No fevers, chills, wieght change or
nightsweats. Rare alcohol. Also reports poor PO intake--small
meals.
On admission to [**Hospital1 46**] she was found to have a blood glucose of
1590, ketones in urine without gap, amylase of 491 and lipase of
7561. Vital signs at that time were stable and in the normal
range--BP's 150's and HR 90's, afebrile. She was admitted to the
ICU, vigoroisly hydrated, started on insulin drip. CT
demonstrated acute pancreatitis, possible gallstones and a 19 x
17cm soft tissue density in the pelvis felt likely to be a
fibroid, although patient is s/p hysterectomy. Creatinine on
admission was 2 and increased to 5.3 with oliguria. Baseline
creatinine of 0.8. Amylase and lipase peaked on [**11-11**] at 1,027
and [**Numeric Identifier **] and on [**11-12**] trended down to 813 and 6228
respectively. Platelets on admission were 338,000 and fell to
55,000 on [**11-12**]. With normalization of blood glucose on [**11-11**],
serum sodiu to 157. Hydrated with D5water. MRCP done on [**11-11**]
but no results reported.
..
At this time patient also noticed vaginal bleeding--has not
menstruated for two years.
Past Medical History:
Past Medical History:hypertension
s/p hysterectomy by records but patient denies
Had 3 normal vaginal deliveries.
Social History:
Social History: No smoking, rare alcohol, no drug use. Lives
with her children.
Family History:
Family History: Mother died from breast cancer in 70's, father
died of MI at 46.
Physical Exam:
Physical Exam on Admission:
VS: Temp: 98 BP: 137 /47 HR:90 RR:20 99%rm
airO2sat
general: pleasant, comfortable, NAD, obese, oriented x3
(although does not know [**8-12**]--"in teens"
HEENT: PERLLA, EOMI, anicteric, no sinus tenderness, MMdry, op
without lesions, no supraclavicular or cervical lymphadenopathy,
no jvd, no carotid bruits, no thyromegaly or thyroid nodules,
lungs: CTA b/l with good air movement throughout
heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops
appreciated
abdomen: distended, +b/s, diffuse tenderness especially in area
of large abdominal mass from umbilicus to left upper quadrant to
epigastrum, no Grey-[**Doctor Last Name 27210**] or Cullens
extremities: no edema, non-tender, cold feet but warm lower
exremities
neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing
on finger to nose. 2+DTR's-patellar and biceps
skin: patient has blistering over both shoulder regions,
mottling on lower extremities below knee bilaterally, no
jaundice, splinters
..
Pertinent Results:
ADMISSION LABS
WBC-17.6* RBC-3.86* Hgb-12.5 Hct-37.5 MCV-97 MCH-32.5* MCHC-33.4
RDW-13.7 Plt Ct-46
Diff: Neuts-83.7* Lymphs-11.2* Monos-4.1 Eos-0.9 Baso-0.1
Coags: PT-14.7* PTT-24.9 INR(PT)-1.5
DIC labs: Fibrinogen-363 D-Dimer->[**Numeric Identifier 961**]*
Chemistries: Glucose-247* UreaN-71* Creat-3.5* Na-147* K-4.0
Cl-107 HCO3-25, Albumin-3.3* Calcium-7.8* Phos-1.7* Mg-1.5*
Liver functions: ALT-31 AST-56* LD(LDH)-661* AlkPhos-80
Amylase-132* TotBili-0.7, Lipase-157*
Cardiac enzymes: CK-MB-4 cTropnT-<0.01
Cholesterol: 123, tg-191-->119, hdl-25, ldl-74
Others:
Haptoglobin-379*
TSH-0.40
Urine electrolyte:CREAT-102 SODIUM-LESS THAN URIC ACID-A,
OSMOLAL-420
AU/A: SP [**Last Name (un) 155**]-1.016, BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG, RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2, URIC
ACID-OCC
Pelvic ultrasound:
An enlarged fibroid uterus measuring 19 x 12.1 x 15.4 cm is
present. Multiple large fibroids are seen, 1 located at the
fundus on the right measuring 6.3 x 6.4 x 7.6 cm. Another
located towards the left measures 5.7 x 5.8 x 5.9 cm. Other
fibroids are also present. Fibroids distort the endometrium, and
the endometrium cannot be assessed. Neither ovary is visible.
There are no adnexal masses.
EKG:Rate about 90, nsr, nl axis, borderline LVH and left atrial
abnormality, borderline prolonged QT of 472. U waves.
Skin biopsy:
Brief Hospital Course:
Pancreatitis: Diff dx: gallstones, alcohol, triglycerides,
hypercalcemia, infection, meds, vascular. Triglycerides were
elevated at OSH. Triglycerides and calcium within normal limits
at [**Hospital1 **]. No medication changes since [**Month (only) 404**]. Possible gallstones
seen at outside hospital CT. Gives no gallstone history but
possible biliary colic in 2 weeks preceding admission. Never
had elevation of bili or alk phos, only very minimal
transaminitis. Also, ? abd mass causing compression leading to
pancreatitis-- This is a very curious picture as amylase and
lipase extremely elevated at OSH but here relatively modestly
elevated--last lipase there of 6228 and here 157. She was
treated with IVFs and made NPO. Initially she was treated with
levofloxacin and flagyl, but these were discontinued after a
couple of days. Gastroenterology was consulted and they felt
that it was likely triglyceridemia that caused her pancreatitis.
Patient improved with aggressive hydration although noted to be
in DIC and to have severe pancreatitis by [**Last Name (un) 5063**] criteria.
Patient stabilized by [**6-16**] and planned transfer to floor.
Abdominal/Pelvic mass: Gynecology consulted. She had a pelvic
ultrasound that revealed fibroids. Plan was for outpatient
follow-up.
Endocrine: DKA vs. HONK at outside hospital with serum glucose
1500 and ketones but no anion gap. She was treated with an
insulin drip and then tarnsitioned to long-acting insulin.
[**Last Name (un) **] was consulted. Stable by [**6-16**].
Oliguric renal failure: Likely pre-renal due to improvement with
IVFs.
Hypernatremia: likely from extreme dehydration. Treated with
IVFs.
Thrombocytopenia/Platelet drop: HIT antibody negative. Likely
from DIC. Hematology consulted. Improving.
Mouth and vaginal bleeding: due to DIC/thrombocytopenia.
Improving by [**6-16**].
Skin papules: Possible xanthomas. Dermatology consulted and
lesion biopsed.
The patient's pancreatitis was improving and her diabetes was
under control by hospital day #4. Plan was to transfer out of
the intensive care unit but early on the morning of [**2154-11-16**] the
patient had a PEA arrest. The patient got up out of bed to go
to the bathroom with assistance of nursing and nusrsing saw the
patient gasp and then syncopize. Upon arrival the patient was
unconscious and PEA. Patient underwent attempts at
rescucitation for approximately 35 minutes which was
unsuccessful. Patient declared dead at 5:37AM. Autopsy
scheduled. No obvious cause of PEA arrest. Thrombolysis
attempted approximately 20 minutes into code given possibility
of PE.
Medications on Admission:
Medications outpatient:hydrochlorothiazide 25 mg daily,
lisinopril 10mg daily, atenolol 25 mg daily, norvasc 2.5 mg
daily, indapamide 2.5 mg daily, aspirin 81 mg daily
Medications on admit: ISS, metoprolol 2.5 mg IV q6h, morphine,
nystatin, protonix, levo 250 mg daily, flagyl 500 q8h
Allergies: NKDA
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
pancreatitis
DIC
Hyperglycemia
DKA
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"584.9",
"577.0",
"427.5",
"287.5",
"278.01",
"401.9",
"623.8",
"250.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"96.04",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
7994, 8003
|
4984, 7612
|
374, 380
|
8081, 8091
|
3545, 4018
|
8143, 8149
|
2367, 2434
|
7966, 7971
|
8024, 8060
|
7638, 7943
|
8115, 8120
|
2449, 2463
|
4035, 4961
|
276, 336
|
408, 2099
|
2477, 3526
|
2142, 2236
|
2268, 2335
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,214
| 122,082
|
45993
|
Discharge summary
|
report
|
Admission Date: [**2193-3-30**] Discharge Date: [**2193-4-11**]
Date of Birth: [**2116-6-3**] Sex: F
Service: General Surgery, Blue Team
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old
female residing in a nursing home who presented with eight
hours of right upper quadrant pain without radiation.
The patient described the pain as dull, occasionally
accompanied by left lower quadrant pain as well. Nausea and
vomiting times one of undigested food. No fevers or chills.
No similar previous episodes. She did not feel distention or
cramps. No chest pain. No difficulty breathing. No cough.
No hematemesis. No melena. She had a bowel movement on the
night prior to admission.
PAST MEDICAL HISTORY:
1. Type 2 diabetes mellitus.
2. Hypertension.
3. Coronary artery disease; status post stenting with an
ejection fraction of 65%.
4. Depression.
5. Anxiety.
6. Hypercholesterolemia.
7. Diverticulitis.
8. Gastroesophageal reflux disease.
9. Asthma.
10. History of kidney stones.
11. History of chronic obstructive pulmonary disease.
12. A questionable history of Crohn's disease in the past.
No flares for many years.
PAST SURGICAL HISTORY:
1. Ileocolectomy in [**2165**].
2. Total abdominal hysterectomy/bilateral
salpingo-oophorectomy.
3. Appendectomy.
MEDICATIONS ON ADMISSION:
1. Celexa 20 mg p.o. once per day.
2. Vicodin one to two tablets p.o. q.4-6h. as needed (for
pain).
3. Ambien 5 mg p.o. q.h.s. as needed.
4. Colace 100 mg p.o. twice per day.
5. Lopressor 50 mg p.o. twice per day.
6. Humalog/glargine insulin (please see attached sheet).
7. Imdur 60 mg p.o. once per day.
8. Lisinopril 20 mg p.o. once per day.
9. Simvastatin 40 mg p.o. once per day.
10. Combivent q.12h. as needed.
11. Norvasc 7.5 mg p.o. once per day.
ALLERGIES:
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed a pleasant and cooperative. In no acute distress.
Mucous membranes were moist. The lungs were clear to
auscultation bilaterally. Heart was regular in rate and
rhythm. No murmurs. The abdomen was soft and nondistended.
Bilateral upper quadrant tenderness. No rebound. No
guarding. A well-healed right perimedial scar. Extremities
were warm and well perfused. No edema. Rectal examination
was guaiac-positive. Hemorrhoids were noted.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed a
slight elevation ST segment in V1 and V2 and V3. Lower
narrow complex tachycardia in V4, V5, and V6.
An upright chest x-ray revealed no free air.
A computed tomography scan was suspicious for a small-bowel
obstruction.
A right upper quadrant ultrasound was negative for
cholecystitis and cholelithiasis.
HOSPITAL COURSE: The patient was admitted to the Surgical
Service for a questionable small-bowel obstruction.
Given the patient's history and electrocardiogram changes, a
Cardiology consultation was obtained who stated that the
patient was a reasonable risk for surgery. Her hard to
control blood pressure could be due to renovascular
hypertension. She was a reasonable risk for surgery. Per
Cardiology, her medications should be started after the
surgery when feasible.
The Renal Service was also consulted who stated history was
not very consistent with renovascular hypertension, although
it was very difficult to figure perioperatively. Their
recommendation was to proceed with surgery if necessary, and
if a further workup is needed it would be done on an
outpatient basis.
The patient was taken to the operating room on [**2193-3-31**]
where lysis of adhesions and internal hernia reduction was
performed. Please see the Operative Note for details. The
patient tolerated the procedure well and was transferred to
the Surgical Intensive Care Unit in stable condition.
On postoperative day one, the patient received a double dose
of levofloxacin and Flagyl perioperatively and was
successfully extubated. During the next few days in the
Intensive Care Unit, the patient remained stable. There was
some difficulty controlling her blood pressure which was in
the high 80s and was controlled with intravenous Lopressor.
The patient had some difficulty breathing, consistent with
her previous chronic obstructive pulmonary disease/asthma
exacerbations. The patient was complaining of abdominal
pain. No flatus.
On postoperative day five, the patient was afebrile. Her
vital signs were stable. Her blood pressure was between 140
and 150. The patient had an oxygen requirement. The patient
had bilateral wheezing and occasional attacks of shortness of
breath, which were controlled with albuterol nebulizers. No
flatus. The patient's urine output was good. It was decided
to start the patient of intravenous Lasix for pulmonary
edema. The patient responded to Lasix very well with
diuresis.
On postoperative day six, the patient was afebrile. Her
vital signs were stable. She was placed on twice per day
diuresis. Still no gas. Given it had almost been one week,
she was started on total parenteral nutrition. A
peripherally inserted central catheter line was also ordered
and was placed on postoperative day seven.
In the meantime, the patient actually started to pass gas.
She was slowly advanced from sips to soft solids on
postoperative day nine which she tolerated well. Her
respiratory status had improved. She did not have an oxygen
requirement anymore. Her lungs were clear to auscultation
bilaterally.
On postoperative day ten, the patient was afebrile. Her
vital signs were stable. She was ambulating with Physical
Therapy. She was passing gas. She was tolerating a soft
diabetic diet. Her lungs were clear to auscultation
bilaterally. Her abdomen was minimally tender and
nondistended. Her wound was clean, dry, and intact. No
edema. Total parenteral nutrition was discontinued. No
concerns. No active issues at this time.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: The patient was scheduled to be discharged
back to [**Hospital3 **] on postoperative day eleven.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to contact Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office
for a follow-up appointment in 7 to 10 days.
2. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (the patient's cardiologist) was to be
following her blood pressure and cardiac medications.
MEDICATIONS ON DISCHARGE:
1. Albuterol 1 to 2 puffs inhaled q.4-6h. as needed.
2. Neurontin 300 mg p.o. twice per day.
3. Ipratropium q.4-6h. as needed,
4. Plavix 75 mg p.o. once per day.
5. Protonix 40 mg p.o. once per day.
6. Lopressor 50 mg p.o. twice per day.
7. Vicodin one to two tablets p.o. q.4-6h. as needed.
8. Reglan 5 mg p.o. four times per day.
9. Norvasc 7.5 mg p.o. once per day.
10. Celexa 20 mg p.o. once per day.
11. Simvastatin 40 mg p.o. once per day.
12. Lisinopril 20 mg p.o. once per day.
13. Imdur 60 mg p.o. once per day.
14. Insulin (please see attached sheet).
DISCHARGE DIAGNOSES:
1. Internal hernia; status post reduction and lysis of
adhesions.
2. Chronic obstructive pulmonary disease; status post
exacerbations.
3. Pulmonary edema; resolved.
4. Hypertension.
5. Hypercholesterolemia.
6. Failure to thrive.
7. Anxiety.
8. Type 2 diabetes mellitus.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (STitle) 97915**]
MEDQUIST36
D: [**2193-4-10**] 14:03
T: [**2193-4-10**] 14:04
JOB#: [**Job Number **]
|
[
"491.21",
"428.0",
"414.01",
"250.00",
"560.1",
"560.81",
"593.9",
"560.2",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.08",
"99.15",
"38.93",
"54.59",
"46.81"
] |
icd9pcs
|
[
[
[]
]
] |
7051, 7599
|
6445, 7030
|
1340, 2708
|
2727, 5898
|
6097, 6418
|
1195, 1313
|
5913, 6064
|
183, 712
|
735, 1172
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,342
| 168,364
|
24499
|
Discharge summary
|
report
|
Admission Date: [**2178-8-24**] Discharge Date: [**2178-8-29**]
Date of Birth: [**2111-11-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2178-8-24**] Coronary Artery Bypass graft x 3 (LIMA-LAD, SVG-D1,
SVG-D2)
[**2178-8-24**] Removal of foreign body from right internal jugular vein
and primary repair
History of Present Illness:
This is a 67 year old male with multiple cardiac risk factors
who recently was transferred emergently to the [**Hospital1 18**] for cardiac
catheterization following a right total knee replacement on
[**2178-6-19**]. This revealed multivessel coronary artery disease and
surgical revascularization was recommended approximately [**5-12**]
weeks after recovery from TKR. He remains stable on medical
therapy with no further chest pain. He continues to experience
dyspnea on exertion. He denies orthopnea, PND, syncope,
palpitations, pedal edema and lightheadedness.
Past Medical History:
Coronary artery disease, s/p DES to LAD [**2171**]
Hypertension
Hyperlipidemia
Severe PVD
Carotid Disease, no history of stroke
Insulin-dependent diabetes (on insulin pump)
Alcohol dependence - quit [**2167**]
OSA with BIPAP at night
Depression
Retinopathy
Severe Autonomic Neuropathy with orthostatic hypotension
Left 1st and 3rd toe fractures
Abdominal Hernia
Past Surgical History:
- Right TKR [**2178-6-19**] at [**Hospital6 **] ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 61939**])
- Right superficial femoral-to-posterior tibial artery BPG [**2173**]
- Amputations of right great toe [**2172**] c/b gangrene/osteomyelitis
- Amputation of distal right thumb [**2131**]
- Left carpal tunnel surgery
- Right trigger finger release
- Tonsillectomy
Social History:
Race:Caucasian
Lives with: Wife and daughter
Occupation: Clerical administrator
Tobacco: Denies
ETOH: Hx of heavy ETOH use (6pack beer+ daily) - quit [**2167**]
Family History:
Uncertain (adopted)
Physical Exam:
Pulse: 77 Resp:17 O2sat:100% RA BP Right: 156/81 Left:
161/68
Height:5'[**77**]" Weight:174#
General: Middle aged male in no acute distress
Skin: Dry [x] intact [x] right knee incision healing well,
slight
erythema, nontender, no drainage noted
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur - none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema trace
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right:2+ Left:2+
DP Right:1+ Left:1+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right:2+ Left:2+
Carotid Bruit Right:none Left:present
Pertinent Results:
[**2178-8-24**] Echo: Prebypass: No atrial septal defect is seen by 2D
or color Doppler. The left ventricular cavity size is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened.
Moderate to severe (3+) mitral regurgitation is seen. Restricted
P2 portion of posterior leaflet. Dr. [**Last Name (STitle) **] was notified in
person of the results on [**2178-8-24**] at 930am. Post bypass:
Patient is A paced and receiving an infusion of phenylephrine
and epinephrine. LVEF= 50%. Moderate mitral regurgitation
persists. Aorta is intact post decannulation.
Brief Hospital Course:
Mr. [**Known lastname 6105**] was a same day admit after undergoing preoperative
work-up as an outpatient. On [**8-24**] he was brought directly to the
operating room where he underwent a coronary artery bypass
graft. Prior to surgery ultrasound guided access of the right
internal jugular vein had been achieved by the anesthesia staff
with placement of a cordis. Placement of a Swan-Ganz catheter
was met with difficulty and it realized that a portion of the
catheter was retained within the vein after the Swan-Ganz
catheter was removed. Vascular surgery was urgently consulted
and removed the foreign body from right internal jugular vein
along with primary repair of IJ. Please see both operative
reports for further details. Following surgery he was
transferred to the CVICU for invasive monitoring in stable
condition. Within 24 hours he was weaned from sedation, awoke
neurologically intact and extubated. He was transferred to the
step down floor, where his chest tubes and epicardial wires were
removed. He restarted his own insulin pump. Physical therapy
saw him in consultation and felt he would be safe to send home
when medically ready. By post-operative day five he was ready
for discharge to home. All follow-up appointments were advised.
Medications on Admission:
ASPIRIN 325 mg Tablet once a day
ALPRAZOLAM 1 mg qHS
ATENOLOL 25 mg daily
ATORVASTATIN [LIPITOR] 40 mg qHS
WELLBUTRIN 200mg daily
CLOPIDOGREL [PLAVIX] 75 mg daily
DESLORATADINE [CLARINEX] 5 mg qPM
FLUDROCORTISONE 0.05 mg QHS
GABAPENTIN 200 mg Capsule twice a day
INSULIN ASPART [NOVOLOG] - 100 unit/mL Cartridge - sliding scale
as directed 12a-3a 0.9units/hr, 3a-6a 1.1 units/hr, 6a-8am 1.5
units, 8am-9pm 1.9 units/hr, 9p-12a 1.1units/hr
LISINOPRIL 10 mg qAM and 5 mg qPM
VICODIN PRN
SERTRALINE - 25 mg daily
SILDENAFIL [VIAGRA] 100 mg Tablet PRN
AMBIEN 5-10 mg Tablet at bedtime PRN
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
3. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
4. Bupropion HCl 100 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO QAM (once a day (in the morning)).
5. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for sleep.
7. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO twice a day:
10mg am, 5mg pm.
Disp:*60 Tablet(s)* Refills:*2*
10. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q4H (every 4 hours) as needed for pain: do not exceed 4g APAP
per day.
Disp:*60 Tablet(s)* Refills:*0*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
12. 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*
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
14. Insulin
Insulin Pump as directed
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft
Past medical history:
s/p DES to LAD [**2171**]
Hypertension
Hyperlipidemia
Severe PVD
Carotid Disease, no history of stroke
Insulin-dependent diabetes (on insulin pump)
Alcohol dependence - quit [**2167**]
OSA with BIPAP at night
Depression
Retinopathy
Severe Autonomic Neuropathy with orthostatic hypotension
Left 1st and 3rd toe fractures
Abdominal Hernia
- Right TKR [**2178-6-19**] at [**Hospital6 **] ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 61939**])
- Right superficial femoral-to-posterior tibial artery BPG [**2173**]
- Amputations of right great toe [**2172**] c/b gangrene/osteomyelitis
- Amputation of distal right thumb [**2131**]
- Left carpal tunnel surgery
- Right trigger finger release
- Tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg /Left - healing well, no erythema or drainage.
Edema - +1 lower extremity edema bilat
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. [**Last Name (STitle) **] [**9-17**] at 1pm
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**9-30**] at 1pm
Please call to schedule appointments with your
Primary Care Dr. [**Known firstname **] [**Last Name (NamePattern1) **] in [**3-9**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2178-8-29**]
|
[
"362.10",
"458.0",
"411.1",
"V49.71",
"998.4",
"303.93",
"E871.7",
"327.23",
"416.8",
"V49.61",
"747.0",
"440.20",
"433.10",
"433.30",
"414.01",
"337.9",
"250.01",
"V43.65",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.94",
"36.15",
"38.93",
"39.61",
"36.12",
"39.32"
] |
icd9pcs
|
[
[
[]
]
] |
7283, 7317
|
3869, 5129
|
342, 512
|
8160, 8400
|
2906, 3846
|
9240, 9784
|
2092, 2113
|
5767, 7260
|
7338, 7395
|
5155, 5744
|
8424, 9217
|
1513, 1898
|
2128, 2887
|
283, 304
|
540, 1106
|
7417, 8139
|
1914, 2076
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,529
| 161,507
|
37401
|
Discharge summary
|
report
|
Admission Date: [**2121-11-20**] Discharge Date: [**2121-12-10**]
Date of Birth: [**2056-3-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal Pain, Nausea, Vomiting
Major Surgical or Invasive Procedure:
[**2121-12-1**] Percutaneous Tracheostomy
History of Present Illness:
Patient is a 65 year-old male with gallstone pancreatitis who
presents as a transfer from an OSH for possible ERCP and
cholecystectomy. The patient initially presented to [**Hospital 1474**]
Hospital ED on [**2121-11-15**] c/o abdominal pain x 3 days. CT
showed cholelithiasis without pericholecystic fluid; the patient
was afebrile and without leukocytosis. He was sent home and
scheduled for outpatient elective cholecystectomy. Then on
[**2121-11-18**], a day prior to the scheduled elective
cholecystectomy, the patient presented to the [**Hospital 1474**] Hospital
ED with nausea, vomiting, and epigastric pain radiating to his
back. CT was suggestive of acute pancreatitis. He was admitted
to the [**Hospital1 1474**] MICU, where he remained afebrile and initially
without leukocytosis. This morning the patient's WBC rose to
20.5 (from 10.9) and he was switched to Imipenem. He was
transferred to the [**Hospital1 18**] ICU on [**2121-11-20**].
Past Medical History:
Hypertension, DMII, Chronic renal insufficiency (1.4 Baseline)
Social History:
retired, no EtOH, no tobacco, no drugs
Physical Exam:
On Admission:
VS: T 100 HR 105 BP 132/88 RR 29 SpO2 97% 4L nasal cannula
PE:
General: combative, agitated
HEENT: mucous membranes dry; NG tube in place
Skin: B/L flank ecchymoses
CV: RRR, no r/m/g
Lungs: mild expiratory wheeze, no crackles
Abdomen: + bowel sounds, tender to palpation in epigastrium and
RUQ, no rebound, distended
Pertinent Results:
[**2121-11-20**] 08:35PM BLOOD WBC-22.2* RBC-5.15 Hgb-15.1 Hct-45.3
MCV-88 MCH-29.2 MCHC-33.2 RDW-14.5 Plt Ct-190
[**2121-11-20**] 08:35PM BLOOD PT-15.7* PTT-32.7 INR(PT)-1.4*
[**2121-11-20**] 08:35PM BLOOD Glucose-103 UreaN-39* Creat-2.1* Na-146*
K-3.6 Cl-118* HCO3-17* AnGap-15
[**2121-11-20**] 08:35PM BLOOD ALT-254* AST-57* CK(CPK)-138 AlkPhos-155*
Amylase-1082* TotBili-1.2 DirBili-0.8* IndBili-0.4
[**2121-11-20**] 08:35PM BLOOD Lipase-604*
[**2121-11-20**] 08:35PM BLOOD Albumin-2.8* Calcium-6.1* Phos-3.5 Mg-2.4
[**2121-12-9**] 02:15AM BLOOD calTIBC-127* Ferritn-551* TRF-98*
[**2121-12-10**] 02:20AM BLOOD WBC-7.2 RBC-2.96* Hgb-8.6* Hct-26.2*
MCV-88 MCH-29.1 MCHC-33.0 RDW-14.4 Plt Ct-396
[**2121-12-10**] 02:20AM BLOOD Glucose-114* UreaN-35* Creat-1.3* Na-142
K-3.9 Cl-111* HCO3-21* AnGap-14
[**2121-12-10**] 02:20AM BLOOD ALT-8 AST-17 AlkPhos-72 Amylase-45
TotBili-0.4
[**2121-12-10**] 02:20AM BLOOD Lipase-26
.
Per outside Hospital Report: CT [**11-19**] - Multiple gallstones, no
pericholecystic fluid, no free fluid
Radiology Report CT PELVIS W/CONTRAST Study Date of [**2121-11-30**]
2:42 PM
IMPRESSION:
1. Lack of enhancement in the pancreatic head and neck and
extensive peripancreatic fluid, in keeping with severe
pancreatitis. Interval worsening in comparison to prior CT
[**2121-11-19**].
2. The superior mesenteric vein and splenic vein are patent, but
exhibit
luminal narrowing. These vessels may therefore be compromised by
the peripancreatic inflammation.Subotimal arterial bolus makes
evaluation for arterial compromise difficult though none is
seen.
3. Complete atelectasis of the lower lobe of the left lung.
Consolidation in the basilar segments of the right lower lobe
consistent with atelectasis and possible superimposed pneumonia.
4. Moderate amount of ascites in the abdomen and pelvis.
5. Mild fullness of the collecting system of the right kidney
has developed
since the prior CT. There is no significant caliceal dilatation,
and the right ureter is not dilated.
.
Radiology Report BILAT LOWER EXT VEINS Study Date of [**2121-11-25**]
8:50 AM IMPRESSION:
1. No evidence of deep vein thrombosis in either leg. The tibial
veins could not be assessed as no son[**Name (NI) 493**] window was
accessible.
2. Small fluid collections seen in the right groin measuring
about 1.9 cm.
.
[**2121-12-10**] - CT ABD/Pelvis:
.
[**2121-11-21**] 12:16 pm BLOOD CULTURE Blood Culture, Routine (Final
[**2121-11-27**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final [**2121-11-22**]):
REPORTED BY PHONE TO [**Doctor First Name 84081**] [**Doctor Last Name 18977**] AT 13:58PM ON
[**2121-11-22**].
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Brief Hospital Course:
Pt was initially transferred to [**Hospital1 18**] [**2121-11-20**] for gallstone
pancreatitis, he was febrile, agitated and combative upon
arrival, his hospital course was complicated by respiratory
failure, multisystem organ failure and a prolonged ICU course.
He was discharged to ventilatory rehab on [**2121-12-10**] with a
tracheostomy. He recovered from his pancreatitis with supportive
care and agressive resussitation.
.
Neuro: Pt intubated and sedated with propofol shortly after
arrival/admission. He was empirically placed on CIWA scale and
given thiamine and folate for possible ETOH withdrawl. He was
eventually transitioned to fentanyl and versed drips. At time of
discharge pt is trached and ventilated but otherwise alert and
oriented, nodding appropriately, and not requring sedation. Pt
taking zyprexa PRN for agitation
.
Cardiovascular: Hypertensive during his hospital course
controleld with beta blockade which was tritated up as IV
lopressor while pt was NPO and hydralazine PRN.
.
Respiratory: Pt was intubated on [**12-1**] in the ICU for
respiratory failure, on [**12-1**] a bedside percutaneous
tracheostomy was placed as respiratory status was not improving
as quickly as desired. The patient was able to be weaned from
assist control with moderate ventilatory support to pressure
support at the time of discharge. Initially requiring a propofol
drip for tachypnea while on pressure support, by discharge pt
was tolerating pressure support with no sedation required.
.
GI/GU: Initially presenting with elevated transaminases,
bilirubin, amylase and lipase indicitive of obstruction and
likely gallstone pancreatitis, there were no obstruting stones
on imaging and LFTS, bilirubin, amylase and lipase all
normalized during his hospital course with supportive care. ERCP
was not preformed as LFTS and bilirubin were normalizing, as was
WBC.
.
Heme: HCT trended down during his hospital course secondary to
illness and dilution. There was no bleeding episodes during his
admission and no transfusion requirement. The pt did recieve
albumin during his ICU course for volume/colloid support
.
FEN: Very agressive fluid rehydration at time of admission given
pancreatitis, acute on chronic renal failure and tachycardia.
TPN was started for nutritional support on [**11-21**] as a prolonged
NPO course and bowel rest was anticipated. As his pain improved,
as did his nurological status - his Amylase and lipase
normalized and pt was transitioned to tube feeds via a dubbhoff
nasoenteric feeding catheter.
.
Endocrine: Regular Insulin Sliding Scale during hospital course.
He was transiently on an insulin drip whcih was transitioned to
RISS by the time of discharge.
.
Renal: Pt has a history or CRI (1.4) presented with Cr of 2.1
and muddy brown casts consistent with acute tubulat necosis.
Agressive fluid rehydration for both renal and pancreatic
issues. He was also on an HCO3 drip for his acidosis/ATN. Once
renal function normalized, he was diuresed with a lasix drip due
to massive total body water overload from his resussitation. His
creatine normalized to his baseline by time of discharge on [**12-10**].
.
ID: Initially presenting with a leukocytosis of 22.2, he trended
down and normalized to a WBC of 7.2 on the day of discharge. He
had positive blood cultures on [**11-21**] growing out coagulase
negative staff aureus. He did have persistent diarrhea during
his hospital course. Despite multiple negative c-diff assays,
the pt was placed on an empiric course of PO vanc and flagyl
extending for 5 days after [**12-10**]. Pt also was intermittenly
febrile during his hospital course with no clear source. Lower
extremity duplex exams were done to rule out DVT as source of
fever. Pt was pan-cultured several times with no positive blood
cultures ([**11-21**] Aline source thought to be contaminant as all
other cultures were negative)
Medications on Admission:
Meds: (upon transfer)
Labetalol 100 mg TID
Imipenen 250 mg IV Q6hr
Heparin 5000 TID
Protonix IV daily
RISS
Zofran 4mg IV Q8hr PRN nausea
Dilaudid 1mg IV Q2hr PRN pain
(home meds)
Labetalol 300mg PO BID
Lisinopril 20mg PO daily
Metformin 500mg PO BID
Lantus Insulin, dose unknown
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection TID (3 times a day).
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation Q4H (every 4 hours) as needed for wheezing.
4. Acetaminophen 160 mg/5 mL Solution Sig: 15-20 ml PO Q6H
(every 6 hours) as needed for fever.
5. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Four (4) ML
Mucous membrane [**Hospital1 **] (2 times a day).
6. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
10. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: [**1-14**]
units Subcutaneous four times a day: Sliding Scale Insulin.
11. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: Three (3)
Tablet, Rapid Dissolve PO TID (3 times a day) as needed for
agitation.
12. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 5 days.
13. Amylase-Lipase-Protease 30,000-8,000- 30,000 unit Tablet
Sig: 1-2 Tablets PO DAILY (Daily).
14. Hydralazine 20 mg/mL Solution Sig: Twenty (20) mg Injection
Q6H (every 6 hours) as needed for SBP>160.
15. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Gall Stone Pancreatitis
Respiratory Failure
Hypertension
Diabetes
Diarrhea
Discharge Condition:
Stable with ventilatory support
Discharge Instructions:
Call your physicain if you experience increasing abdominal pain,
chest pain, shortness of breath, jaundice, uncontrollable nausea
or vomiting, or any other symptoms which are concerning to you.
Followup Instructions:
Call the office of Dr.[**Last Name (STitle) **] to schedule a follow-up
appointment for 2 weeks. ([**Telephone/Fax (1) 2363**]
|
[
"511.9",
"008.45",
"250.02",
"038.9",
"574.20",
"585.9",
"518.0",
"995.92",
"403.10",
"482.83",
"276.0",
"577.0",
"576.1",
"291.81",
"427.0",
"584.5",
"518.81",
"276.3",
"789.59",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.6",
"96.04",
"96.72",
"99.15",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
10494, 10566
|
4700, 8573
|
348, 392
|
10685, 10719
|
1892, 4677
|
10961, 11091
|
8976, 10471
|
10587, 10664
|
8599, 8953
|
10743, 10938
|
1537, 1537
|
276, 310
|
420, 1380
|
1551, 1873
|
1402, 1466
|
1482, 1522
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,693
| 101,747
|
39329
|
Discharge summary
|
report
|
Admission Date: [**2148-8-6**] Discharge Date: [**2148-8-9**]
Date of Birth: [**2079-12-19**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 4691**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Laparoscopic cholecystectomy ([**2148-8-8**])
ERCP with sphincterotomy and balloon sweep ([**2148-8-6**])
History of Present Illness:
The patient is a 68-year-old male who is transferred to [**Hospital1 18**]
from [**Hospital **] Hospital with chief complaint of abdominal pain.
He was brought to [**Hospital **] Hospital by supervisors at his group
home. He reports dull pain in the midepigastrum At [**Hospital1 **] he
had a lipase of greater than 4000 and an US which demonstrated
gallstones and slude, with no evidence of cholecystitis.
Past Medical History:
Past Medical History:
1. h/o CHF, MR
2. DM2
3. GERD
4. h/o diverticulitis
5. [**Location (un) 805**] syndrome, Mental retardation
6. HTN
7. h/o SBO (last in [**10-22**])
8. Impulse control d/o
9. Depression
Past Surgical History:
s/p colectomy (reason unclear)
Social History:
Lives in a group home.
Family History:
Non-contributory.
Physical Exam:
99.3 F 86 113/63 16 97% RA Pain [**4-22**]
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: well healed midline incision, soft, mildly distended,
mildly
tender in midepigastrum, no RUQ pain, no [**Doctor Last Name **] sign, no rebound
or guarding, normoactive bowel sounds, no palpable masses
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
[**2148-8-6**] 12:20AM BLOOD WBC-15.7* RBC-3.71* Hgb-12.7* Hct-37.2*
MCV-100* MCH-34.4* MCHC-34.2 RDW-14.0 Plt Ct-168
[**2148-8-6**] 10:14AM BLOOD WBC-11.4* RBC-3.18* Hgb-11.6* Hct-32.5*
MCV-102* MCH-36.4* MCHC-35.6* RDW-14.0 Plt Ct-143*
[**2148-8-7**] 01:47AM BLOOD WBC-8.5 RBC-3.60* Hgb-11.8* Hct-36.8*
MCV-102* MCH-32.8* MCHC-32.0# RDW-13.7 Plt Ct-151
[**2148-8-8**] 05:30AM BLOOD WBC-5.7 RBC-3.60* Hgb-12.3* Hct-36.7*
MCV-102* MCH-34.1* MCHC-33.5 RDW-13.7 Plt Ct-160
[**2148-8-6**] 12:20AM BLOOD ALT-57* AST-77* AlkPhos-155* TotBili-0.9
[**2148-8-6**] 10:14AM BLOOD ALT-40 AST-45* AlkPhos-112 Amylase-724*
TotBili-0.7
[**2148-8-6**] 07:10PM BLOOD ALT-56* AST-91* AlkPhos-170* Amylase-562*
TotBili-2.1*
[**2148-8-7**] 01:47AM BLOOD ALT-93* AST-165* AlkPhos-247*
Amylase-356* TotBili-2.6* DirBili-2.4* IndBili-0.2
[**2148-8-7**] 01:47AM BLOOD ALT-93* AST-165* AlkPhos-247*
Amylase-356* TotBili-2.6* DirBili-2.4* IndBili-0.2
[**2148-8-8**] 05:30AM BLOOD ALT-68* AST-66* AlkPhos-272* Amylase-85
TotBili-1.1
[**2148-8-9**] 06:00AM BLOOD ALT-73* AST-57* AlkPhos-221* TotBili-0.9
[**2148-8-9**] 08:33AM BLOOD ALT-70* AST-54* AlkPhos-207* TotBili-0.8
[**2148-8-6**] 12:20AM BLOOD Lipase-1890*
[**2148-8-6**] 10:14AM BLOOD Lipase-793*
[**2148-8-6**] 07:10PM BLOOD Lipase-450*
[**2148-8-7**] 01:47AM BLOOD Lipase-244*
[**2148-8-8**] 05:30AM BLOOD Lipase-36
Brief Hospital Course:
The patient was initially admitted to the unit because of
concern for hypotenstion in the ED. His SBPs were never lower
than the 80's but a central line was placed prior to his leaving
the ED. His pressures responded to fluid resuscitation and he
never required pressors. The patient was taken to ERCP on the
day of admission, the results of which are listed below. He
tolerated the procedure well and was transferred to the floor.
His labs were checked the next day and his lipase was
decreasing. He was taken for laparoscopic cholecystectomy the
following day. His diet was then advanced as tolerated and his
pain was controlled with PO pain meds. He was ready for
discharge on HD4. His foley catheter was removed and the patient
voided.
RUQ/Liver US ([**2148-8-6**]) - Intra and extrahepatic biliary
dilation with intraductal sludge. Choledocholithiasis cannot be
excluded due to limitations of visualization.
ERCP or MRCP could be used for further evaluation. Gallbladder
distention with sludge and wall thickening. Imaging findings
suggest cholecystitis. Clinical correlation is recommended as
son[**Name (NI) 493**] [**Name2 (NI) 515**] sign was negative; HIDA could be performed
to better evaluate for cholecystitis if clinically appropriate.
Trace ascites.
CXR ([**2148-8-6**]) - Multifocal opacities, worrisome for infection.
Right internal jugular central line with tip at cavoatrial
junction. Pulmonary vascular congestion. Cardiomegaly, which may
be in part due to pericardial fluid.
ERCP ([**2148-8-6**]) - A moderate diffuse dilation was seen at the
main duct with the CBD measuring 13 mm. The intrahepatic ducts
were also dilated. The cystic duct filled with contrast.
Successful sphincterotomy. Biliary sludge was seen exiting the
ampulla along with very dark, almost black, bile. Otherwise
normal ercp to third part of the duodenum.
Medications on Admission:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Verapamil 120 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Align 4 mg Capsule Sig: One (1) Capsule PO once a day.
8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Buspirone 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a
day).
10. Tolterodine 2 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Discharge Medications:
1. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for pain.
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Verapamil 120 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*40 Capsule(s)* Refills:*0*
10. Align 4 mg Capsule Sig: One (1) Capsule PO once a day.
11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. Buspirone 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
13. Tolterodine 2 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Discharge Disposition:
Home
Discharge Diagnosis:
Sympomatic choledocholithiasis
Discharge Condition:
Mental Status: Clear and coherent (Baseline mental retardation)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see 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.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-22**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Please call the Acute Care Surgery clinic at [**Telephone/Fax (1) 600**] to
arrange for a follow-up appointment in [**1-17**] weeks. The clinic is
located on the [**Location (un) 10043**] of the [**Hospital **] Medical Building at [**Last Name (NamePattern1) 12939**].
|
[
"401.9",
"576.1",
"577.0",
"424.0",
"530.81",
"574.70",
"311",
"759.89",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"51.84",
"51.85",
"51.23"
] |
icd9pcs
|
[
[
[]
]
] |
7106, 7112
|
3076, 4938
|
327, 434
|
7187, 7187
|
1699, 3053
|
9357, 9630
|
1215, 1234
|
5880, 7083
|
7133, 7166
|
4964, 5857
|
7367, 8825
|
8841, 9334
|
1126, 1159
|
1249, 1680
|
273, 289
|
462, 873
|
7202, 7343
|
917, 1103
|
1175, 1199
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,714
| 153,278
|
25212+57439
|
Discharge summary
|
report+addendum
|
Admission Date: [**2128-10-12**] Discharge Date: [**2128-10-20**]
Date of Birth: [**2058-2-19**] Sex: M
Service: VSU
CHIEF COMPLAINT: Abdominal aortic aneurysm.
HISTORY OF PRESENT ILLNESS: The patient is known with
abdominal aortic aneurysm initially repaired in [**2119**], returns
now for re-do repair electively.
PAST MEDICAL HISTORY: Allergies: No known drug allergies.
Medications on admission included hydrochlorothiazide,
Lipitor and Nifedical 60 mg q.d. Illnesses include abdominal
aortic repair in [**2119**] which was found incidentally on
physical examination, hypertension, chronic obstructive
pulmonary disease.
HABITS: The patient is a former smoker. There is a history
of 50 pack years. Has not smoked for the past month. He
admits to alcohol use, two 12 ounce beers daily. He denies
drug habit.
PHYSICAL EXAMINATION: Vital signs: Blood pressure 142/94,
pulse 79, oxygen saturation 97% on room air. General
appearance: Alert and oriented male in no acute distress.
Head, eyes, ears, nose and throat examination is
unremarkable. There are no carotid bruits. Heart is a regular
rate and rhythm without murmur, gallop or rub. Lungs are
clear to auscultation bilaterally. Abdominal examination is
soft and nontender with percussible pulsatile mass in the
epigastric area. Pulse examination is palpable femorals
bilaterally. There is no pedal edema and pedal pulses are
palpable 2+ bilaterally. Neurological examination is grossly
intact.
HOSPITAL COURSE: The patient was admitted to the
preoperative holding area and he underwent an abdominal
aortic repair via a transthoracic abdominal approach with
beveled anastomosis and a left renal artery graft. Patient
tolerated the procedure well, required 6 units of packed red
blood cells intraoperatively and 1500 cc of Cell [**Doctor Last Name **].
Epidural catheter was placed in the operating room. Patient
was transferred intubated to the surgical intensive care unit
for continued monitoring and care for respiratory support and
vasopressor support. Patient's postoperative hematocrit was
34.1 up from 27. White count was 10.6, BUN 22, creatinine 1.9
which was up from the baseline of 1.1. Platelet count was
noted to be 33,000. A heparin dependent antibody panel was
negative. The patient remained in the intensive care unit
overnight. Patient was extubated on postoperative day 1. His
Neo-Synephrine drip was weaned. He remained hemodynamically
stable with a stable hematocrit of 33 and patient remained in
the intensive care unit. The patient's Swan catheter was
changed to a triple lumen without incident. Platelet count
showed an improved response over the next 24 hours to
102,000. Postoperative day 3 there were no overnight events.
He did require a diltiazem drip and an increase in his
Lopressor dosing for rate and blood pressure control.
Hematocrit on postoperative day 3 was 28, BUN 31, creatinine
2.7. Incisions were clean, dry and intact. Abdominal
examination was without flatus. Patient was begun on clear
sips and he was transferred to the surgical intensive care
unit for continued monitoring and care. Patient's nasogastric
tube and spinal catheter were discontinued prior to transfer.
Postoperative day 4 the patient continued to do well, there
were no overnight events and he was mobilizing fluid. His
postoperative hematocrit was 26.1. He was converted to a
Dilaudid PCA. His metoprolol dosing adjustment improved for
his rate control and systolic blood pressure. He continued on
clear liquids. He was transfused one unit of packed red
cells. He did develop postoperative atrial fibrillation on
postoperative day 3 which was controlled with diltiazem drip
converted to Lopressor p.o.
Postoperative day #5 the patient's analgesic control was
converted to Percocet. He continued on his Lopressor. His
creatinine continued to show improvement but no at baseline.
His diet was advanced as tolerated and he received another
unit of packed red cells for hematocrit of 27. The patient
remained in the vascular intensive care unit. On
postoperative day #6 the patient continued to do well. There
were no overnight events. He was rate controlled and blood
pressure was controlled. His central line was removed and a
PICC peripheral was placed. The chest tube was removed. The
post chest x-ray was without pneumothorax. The Foley was
discontinued. He had no difficulty post void. Physical
therapy was requested to see the patient in assessment for
discharge planning who felt that the patient should be able
to be discharged to home if he is here for another several
days. Postoperative day #7 patient continued to ambulate. His
wounds were clean, dry and intact. He continued to do well.
He was discharged to home in stable condition. He should
follow up with Dr. [**Last Name (STitle) 1391**] in 2 weeks time.
INSTRUCTIONS FOR DISCHARGE: The patient should call for an
appointment for follow up. No driving until seen in follow
up. No lifting anything greater than 2 pounds for 4 weeks. He
may shower. [**Month (only) 116**] ambulate essential distances. He should call
the office if he develops a temperature greater than 101.5 or
if the wounds become red, swell or drain.
DISCHARGE MEDICATIONS: The patient was placed on a nicotine
patch 14 mg per 24 hours. He should continue this upon
discharge. The patient was given a prescription with
instructions to not smoke while wearing the patch and to
follow up with his primary care physician for continued
smoking cessation and antihypertensive medication adjustments
and blood pressure monitoring. Acetaminophen 325 tablets 1 to
2 q 4 to 6 hours p.r.n., lorazepam 1 mg at h.s. Will give him
enough for 7 days until seen in follow up.
Oxycodone/acetaminophen 5/325 tablet 1 to 2 q 4 to 6 hours
p.r.n. as needed. Lopressor 25 mg tablets 1.5 mg tablets
b.i.d. Protonix 40 mg q.d. for 1 month. Other instructions:
Patient should take a stool softener which he can purchase
over the counter while he is taking narcotics to prevent
constipation.
DISCHARGE DIAGNOSES: Abdominal aortic aneurysm.
Postoperative blood loss anemia, transfused, corrected.
Postoperative atrial fibrillation, converted with __________.
Postoperative thrombocytopenia. HIT negative with resolution.
Postoperative renal insufficiency, improved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2128-10-19**] 12:37:08
T: [**2128-10-19**] 14:21:10
Job#: [**Job Number 63176**]
Name: [**Known lastname 11276**],[**Known firstname **] Unit No: [**Numeric Identifier 11277**]
Admission Date: [**2128-10-12**] Discharge Date: [**2128-10-20**]
Date of Birth: [**2058-2-19**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 231**]
Addendum:
[**2128-10-20**] Patient continued to have hypertention systolic 160's
restartred diltizem. Patient instructed to followup with PCP for
[**Name Initial (PRE) **]/p monitering and med adjustment with in the week of discharge.
Patient also instruced as to importaance of contaminate use of
nicotine patch and smoking and consequences of MI, or CVA.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2128-10-20**]
|
[
"285.1",
"287.5",
"305.1",
"496",
"427.31",
"401.9",
"593.9",
"441.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90",
"99.04",
"38.45",
"38.44",
"38.36",
"99.00",
"00.40",
"38.93",
"38.14"
] |
icd9pcs
|
[
[
[]
]
] |
7312, 7476
|
6026, 7289
|
5209, 6004
|
1498, 5185
|
863, 1480
|
156, 184
|
213, 341
|
364, 840
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,945
| 110,262
|
37545
|
Discharge summary
|
report
|
Admission Date: [**2157-12-15**] Discharge Date: [**2158-1-6**]
Date of Birth: [**2083-5-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Endotracheal Intubation
Central Venous Line Placement
[**Last Name (un) 1372**]-Intestinal Dobhoff Feeding Tube Placement
History of Present Illness:
Mr. [**Known lastname **] is a 74 year old gentleman with dementia, COPD,
HTN, CAD, PVD, seizure d/o, distant EtOH abuse admitted on
[**2157-12-15**] from nursing home after mechanical fall from his bed.
Per outside hospital records, he fell from bed, approximately 2
feet to the ground. He was found on the floor complaining of
left hip pain. He presented to the [**Location **] where a CT
abdomen/pelvis revealed a left acetabular and iliac crest
fracture with a retroperitoneal hematoma. He was given IV
fentanyl and dilaudid for pain and transferred to [**Hospital1 18**] for
further management.
In the ED his VS were HR 88 BP 136/73 RR18 SpO2 99. He had a
distended abdomen and was tender to palpation over his right
hip. He has one episode of coffee ground emesis. A CT abdoemn
pelvis showeda comminuted, intra-articular left acetabular
fracture with extension into left superior pubic ramus, ischium,
and inferior left iliac bone with surrounding large
retroperitoneal hematoma. HCt was 28 and he was given 2U of
PRBC. He was admitted to the trauma SICU for management of his
pelvic fracture and retroperitoneal bleed.
Past Medical History:
COPD
HTN
PVD, s/p fem-fem bypass
Seizure Disorder
Anemia
Dysphagia
s/p c1-c2 fusion
Social History:
Metoprolol 25mg [**Hospital1 **],
Lidoderm Patch 5% daily,
Tramadol 50mg tid,
Simvastatin 5mg ? qhs,
Terazosin 5mg qhs,
Aspirin 325mg daily,
Folic Acid 1mg daily,
MVI,
Celexa 30mg daily,
cilostazol 100mg [**Hospital1 **],
Prilosec 20mg [**Hospital1 **],
Colace 100mg [**Hospital1 **],
Advair Diskus 1 puff [**Hospital1 **],
Levetiracetam 500mg [**Hospital1 **],
Albuterol prn,
Vit B1 100mcg daily
Family History:
Unable to obtain
Physical Exam:
VITAL SIGNS: T= 99.5 BP= 164/77 HR= 114, RR 22, SATS= 98% on
face mask
GEN: frail elderly man, lying on bed, not in acute distress,
follows simple commends, moaning when repositioned
HEENT: PERRL, oral mucosa dry, NG in place on tube feeding
NECK: no LAD, no JVD
CV: RRR, tachy, no mumurs
RESP: poor inspirtary effort, no wheezes, no crackles
ABD: + BS, soft, +distended, non-tender, no masses, no guarding
or rebound
PULSES: 2+radial B, 2+ PT/DP B
GU: Foley catheter
EXT: no edema, no cyanosis, no clubbing
SKIN : no rash, no ulceration, no erythema in decubiti
NEURO: awake alert to person only, no tremor; no rigidity, gait=
not assessed
CAM: A/F: Y Inat: ? Disorg: ? Consc: N total:/4
Attention test: demented, unable to test at this time
Pertinent Results:
[**12-15**] CT c-spine: s/p post c1-c2 fusion. metallic nail through L
lat C2 extends w/tip in retropharnyngeal/prevertebral jxn soft
tissues ant to C1. mild anterolisthesis of C4 over C5. very min
retrolisthesis C5 over C6. mult-level [**Last Name (un) **] change. no acute fx
seen. pulmonary emphysema. coarse vertebral and carotid artery
calcs. 6mm R thyroid lobe hypodensity.
[**12-15**] CT torso: 1.6 x 1.2 cm focal hypodensity in ant
mediastinum (S2:im15). ?focal hematoma vs thymic cystic lesion.
No overlying sternal fx or aortic injury. dense aortic calcs.
LLL atelect/scarring. comminuted, intra-art L acetabular fx
involv ant &post columns and ext to L sup pubic ramus. adj mod
pelvic hematoma w/out active extrav. hematoma crosses midline,
extends superiorly ant to L psoas muscle and iliacus. mild loss
of ht of L2 & L3 vert bodies. Grade 1 spondylolisthesis L5/S1.
bladder diverticula .
[**12-15**] CT head: No acute ICH. opacification of inf L maxillary
sinus w/focal loss of ant inf L max sinus/ant L alveolar bone,
adj soft tissue swelling and foci of gas. ?infectious process
involving L alveolar process of maxilla, dental in nature vs
chronic sinusitis vs injury. recommend direct visualization.
[**12-17**] CXR: No consolidation
[**12-17**] CXR (pm): Increased lung volumes c/w emphysema.
Peribronchial cuffing and predominantly R-sided interstitial
opacities likely fluid overload. Subtle opacity @R apex
?superimposition of external
ventilator apparatus vs. consolidation.
[**1-1**] CXR:
The Dobbhoff tube tip is in the stomach. Cardiomediastinal
silhouette is
stable. There is no change in upper lobe interstitial opacities
in this
patient with hyperinflated lungs. The lower lungs are
unremarkable. There is no pleural effusion. There is no
pneumothorax.
[**2158-1-4**] ECG:
Normal sinus rhythm. Q waves in leads V1-V2 consistent with
prior anteroseptal myocardial infarction. Compared to the
previous tracing of [**2157-12-19**] there has been no diagnostic
interim change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
88 168 78 378/427 81 57 52
Admission Labs:
[**2157-12-15**] 06:00PM BLOOD WBC-6.6 RBC-3.25* Hgb-9.7* Hct-28.3*
MCV-87 MCH-29.8 MCHC-34.3 RDW-15.6* Plt Ct-269
[**2157-12-15**] 06:00PM BLOOD Neuts-88.2* Lymphs-6.2* Monos-4.9 Eos-0.6
Baso-0.1
[**2157-12-15**] 06:00PM BLOOD PT-12.8 PTT-26.9 INR(PT)-1.1
[**2157-12-15**] 06:00PM BLOOD Glucose-120* UreaN-18 Creat-0.8 Na-128*
K-4.2 Cl-97 HCO3-22 AnGap-13
[**2157-12-21**] 02:18PM BLOOD ALT-14 AST-16 CK(CPK)-50 AlkPhos-61
TotBili-0.6
[**2157-12-15**] 09:47PM BLOOD Calcium-8.3* Phos-4.9* Mg-1.9
[**2157-12-16**] 10:07PM BLOOD TSH-3.8
[**2157-12-16**] 07:59PM BLOOD Lactate-0.9
Discharge Labs:
[**2158-1-5**] 05:05AM BLOOD WBC-7.8 RBC-3.15* Hgb-9.3* Hct-28.3*
MCV-90 MCH-29.4 MCHC-32.7 RDW-14.6 Plt Ct-607*
[**2158-1-5**] 05:05AM BLOOD Glucose-110* UreaN-18 Creat-0.6 Na-139
K-3.2* Cl-105 HCO3-22 AnGap-15
[**2158-1-4**] 06:10AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.3
Brief Hospital Course:
#. Pelvic fracture. He was initially admitted to the trauma
surgery service. He was seen by orthopedic surgery and a pin
was placed through the distal femur and the leg was placed in
traction in anticipation of possible surgery. 3d reconstructive
CT imaging of the pelvis was performed. Ultimately, it was
decided to treat this fracture non operatively given his
baseline functional status and the severity of his fracture on
imaging. The pin was removed. Pain was controlled with IV
morphine and PO oxycodone.
# Retroperitoneal Bleed. On CT, retroperitoneal and pelvic
bleeding was discovered. Interventional radiology was consulted
and patient was monitored clinically. He remained
hemodynamically stable and his hematocrit remained stable and no
intervention was necessary. His hematocrit remained stable for
the remainder of his hospitalization.
# Hospital Acquired Pneumonia - On [**2149-12-21**], patient developed a
fever, hypoxia and an infiltrate was noted on CXR. He was
started on empiric therapy for hospital acquired pneumonia of
vancomycin, ciprofloxacin, and cefepime IV. A 7 day course was
completed with an improvement in his breathing, and a reduction
in his oxygen requirement. On the floor he was given standing
albuterol and Atrovent nebs, and was had regular chest PT with
respiratory therapy with a significant improvement in function.
# Tachycardia - Patient had tachycardia, alternating between
sinus tachycardia and multifocal atrial tachycardia in the range
of 110-140 early in his SICU course. Cardiology was consulted
and recommended up titration of his metoprolol. His metoprolol
was gradually up titrated to 200mg PO tid. As his clinical
picture improved, this dose was gradually reduced to 50mg PO
bid, with rates in the 80s-90s on discharge.
# Nutrition - Initial speech and swallow evaluation found that
it was unsafe for him to take anything PO due to aspiration
risk. A Dobbhoff feeding tube was placed for nutrition and given
tube feeds. He pulled the feeding tube once, and it needed to
be replaced. Repeat speech/swallow evaluation with video
swallow found him to be safe to eat pureed solids with nectar
thickened liquids. Feeding tube was removed and he was started
on the recommended diet on discharge.
#. Goals of care - The patient had severe dementia, and had no
health care proxy on admission. Guardianship was obtained
emergently given the patient initially tenuous clinical status.
[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 80570**] ([**PO Box 84306**], [**Location (un) 47**] [**Telephone/Fax (1) 84307**]) has agreed to be Mr. [**Known lastname **] guardian. On
discussion with Mr. [**Last Name (Titles) 80570**], [**First Name3 (LF) 282**] tube placement was declined
and it was decided to change Mr. [**Known lastname **] code status to
DNR/DNI.
Medications on Admission:
metoprolol 25mg PO bid
tramadol 50mg PO tid
simvastatin 5mg PO qhs
hytrin 5mg PO qhs
celexa 30mg PO daily
cilostazol 100mg PO bid
omeprazole 20mg PO bid
colace 100mg PO bid
advair 250/50
proair 90mcg IH q4prn
keppra 500mg PO bid
asa 325 po daily
folic acid 1mg po daily
multivitamin 1 tablet daily
vitamin b1 100mg po q daily
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet 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. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
4. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO TID (3 times a day) as needed for agitation.
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
8. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
9. Celexa 10 mg Tablet Sig: Three (3) Tablet PO once a day.
10. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
12. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
14. Simvastatin 5 mg Tablet Sig: One (1) Tablet PO once a day.
15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
17. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
18. Vitamin B-1 100 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
Resident Care Rehab & Nursing
Discharge Diagnosis:
Pelvic Fracture
Retroperitoneal Bleed
Multifocal Atrial Tachycardia
Pneumonia
COPD
Dementia
Discharge Condition:
Baseline dementia, not oriented to place or time. Ambulating
with assistance.
Discharge Instructions:
You were admitted for a fall. You were found to have a pelvic
fracture, and surgery was not needed. You developed a bleed
into your back and pelvis that resolved. You also developed a
high heart rate which was controlled with medications. You
developed a pneumonia which was treated with intravenous
antibiotics. Your pain was controlled with oxycodone.
Followup Instructions:
Please arrange a follow up appointment with your PCP.
|
[
"427.31",
"486",
"331.0",
"345.90",
"808.41",
"440.20",
"427.0",
"V45.4",
"401.1",
"518.81",
"440.4",
"E884.4",
"808.0",
"507.0",
"578.0",
"276.8",
"294.10",
"496",
"868.04"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"38.93",
"96.04",
"93.44",
"96.72",
"96.6",
"38.91",
"88.49"
] |
icd9pcs
|
[
[
[]
]
] |
10756, 10812
|
5925, 8796
|
320, 443
|
10948, 11028
|
2941, 3855
|
11435, 11492
|
2145, 2163
|
9172, 10733
|
10833, 10927
|
8822, 9149
|
11052, 11412
|
5632, 5902
|
2178, 2922
|
276, 282
|
471, 1608
|
3864, 5018
|
5035, 5615
|
1630, 1715
|
1731, 2129
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,072
| 170,972
|
14990
|
Discharge summary
|
report
|
Admission Date: [**2194-1-16**] Discharge Date: [**2194-1-18**]
Date of Birth: [**2146-10-9**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
This 47-year-old woman had experienced difficulty
with vision in the left eye in [**2183**], subsequent to which she was
discovered to have a large tuberculum sellae meningioma.
Major Surgical or Invasive Procedure:
Left Crani for tumor resection
History of Present Illness:
[**Known firstname **] [**Known lastname 43878**] was reviewed in the
[**Hospital **] clinic for an initial assessment and visual
field testing. This 47-year-old woman had experienced
difficulty
with vision in the left eye in [**2183**], subsequent to which she was
discovered to have a large tuberculum sellae meningioma. She
had
surgical excision in [**2184-8-1**] and her visual field
deficit,
which involved the inferior part of her visual field in the left
eye, resolved postoperatively. She has been monitored with
periodic MRIs and an MRI in [**2192**] showed interval growth of the
tuberculum sellae meningioma. Surgical excision is planned.
She
has not noticed any problems with her vision in either eye. She
does not complain of diplopia.
PAST MEDICAL HISTORY: Also notable for high blood pressure and
gastric ulcers.
MEDICATIONS: Currently, she is on lisinopril, omeprazole, and
Flonase. She also takes supplements.
ALLERGIES: She is allergic to penicillin.
FAMILY HISTORY: There is no family history of ocular disease.
SOCIAL HISTORY: The patient works as a writer/editor. She is a
nonsmoker.
REVIEW OF SYSTEMS: Unremarkable.
PHYSICAL EXAMINATION:
Today, corrected distance acuities were 20/20 in the right eye
and 20/20 -2 in the left eye. Color vision was [**7-9**] in both
eyes,
with no red desaturation. Confrontation fields were full. A
subtle left relative afferent pupillary defect was noted. The
eyes were orthotropic in primary position at distance, with full
motility. Intraocular pressures were 20 mmHg bilaterally. On
slit-lamp examination, the anterior segment was quiet. On
dilated fundus examination, she had small, crowded disks with
small cups bilaterally. Spontaneous venous pulsations were
present in both eyes. The left optic disk had mild pallor.
Retinal vessels, maculae, and the rest of fundus examination was
unremarkable.
Humphrey visual fields, central 30-2, were full in both eyes.
ASSESSMENT AND PLAN: This patient is status post excision of a
tuberculum sellae meningioma in [**2183**]. Her followup MRI has
shown
tumor recurrence and surgical excision is planned per patient.
The patient's visual acuity, color vision, and visual fields are
intact, though she has subtle relative afferent pupillary defect
and mild optic pallor in the left eye, both of which are
documented in Dr.[**Name (NI) 43879**] notes in [**2183**]. She will return for
postoperative visual fields.
Past Medical History:
HTN, Gastric ulcers.
Social History:
SOCIAL HISTORY: The patient works as a writer/editor. She is a
nonsmoker.
Family History:
NC
Physical Exam:
PHYSICAL EXAM UPON DISCHARGE-
non focal
no drainage from nose (even with challenging)
incision- staples intact, well healing
Pertinent Results:
MRI [**1-16**]:
IMPRESSION: Unchanged appearance of the recurrent meningioma
arising from the left tuberculum of the sella.
Skull Xray [**1-16**]: IMPRESSION: No visualized linear radiopaque
foreign body similar to the sponges noting limitation from
overlying metallic objects obscuring full visualization.
CT Head [**1-16**]: IMPRESSION:
1. No evidence of intracranial or extracranial radiopaque
foreign body.
2. Mild midline shift to the right of 4 mm and effacement of the
basilar
cisterns which could be related to postoperative state.
Subarachnoid blood
adjacent to the upper cervical spinal cord and within the right
sylvian
fissure.
MRI [**1-17**]:
IMPRESSION:
1. Subacute infarct in the left globus pallidus.
2. Post-surgical changes with a left frontal subdural hematoma
causing mild mass effect.
3. 4-mm enhancing soft tissue in the planum sphenoidale is
concerning for a small amount of residual tumor. Attention to
this region on followup imaging is recommended.
Brief Hospital Course:
47yo W with recurrent left tuberculum sella meningioma
electively presenting for redo resection. Initial resection in
[**2183**]. Operative course was uncomplicated, post operatively the
patient was transferred to the intensive care unit where she
remained stable overnight. Post op head CT was stable.
On [**1-17**] she was stable and cleared for transfer to the floor.
Post of MRI was with expected post operative changes. She
experienced some nausea and vomiting which was controlled with
antiemetics. After these 2 vomiting episodes she experienced a
question of epistaxsis vs heme drainage. After this stopped
there was a question of CSF drainage from the nose. This was not
confirmed, nor did it continue.
On [**1-18**] the patient was neurologically intact, nausea had
subsided and she was ambulating independently in the hallway.
There was no drainage from her nose even when challenged. She
was cleared for discharge home and she was in agreement with
this plan.
Medications on Admission:
flonase, lisinopril, omemprazole, MVI
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain or fever > 101.4.
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily) for 1 months.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
7. dexamethasone 2 mg Tablet Sig: taper Tablet PO taper for 1
weeks: 4mg PO Q8h on [**1-18**], then 3mg PO Q8h x2days, 2mg PO Q8h
x2days,1mg PO Q8h x2 days then d/c.
Disp:*qs Tablet(s)* Refills:*0*
8. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Left tuberculum sella meningioma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Your wound was closed with staples so you must wait until
after they are removed to wash your hair. You may shower before
this time using a shower cap to cover your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
?????? You need an appointment in the Brain [**Hospital 341**] Clinic in
approximately 2 weeks. The Brain [**Hospital 341**] Clinic is located on the
[**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their
phone number is [**Telephone/Fax (1) 1844**]. They should call you with your
appointment but please call if you do not hear from them, need
to change your appointment, or require additional directions. If
your appointment is greater than 10-14 days from the date of
your surgery, please make an appointment for a wound check and
removal of your staples at Dr.[**Name (NI) 9034**] office [**Telephone/Fax (1) 1669**].
?????? You should call your ophthomologist and make an appointment
for follow up evaluation approximately 4 weeks after your
surgery.
Completed by:[**2194-1-18**]
|
[
"787.01",
"401.9",
"225.2",
"530.81",
"533.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.51",
"02.12"
] |
icd9pcs
|
[
[
[]
]
] |
6302, 6308
|
4288, 5262
|
455, 487
|
6384, 6384
|
3284, 4265
|
8123, 9020
|
3119, 3123
|
5350, 6279
|
6329, 6363
|
5288, 5327
|
6534, 8100
|
3138, 3265
|
1695, 2965
|
1658, 1673
|
238, 417
|
515, 1270
|
6399, 6510
|
2987, 3009
|
3042, 3103
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,622
| 125,497
|
110
|
Discharge summary
|
report
|
Admission Date: [**2164-5-4**] Discharge Date: [**2164-5-18**]
Date of Birth: [**2115-11-19**] Sex: M
Service: SURGERY
Allergies:
Phenobarbital / Depakote / Zarontin / Gabapentin / Zonegran /
Tranxene Sd
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy.
2. Exploration of retroperitoneum.
3. Open cholecystectomy.
4. Venting decompressed colotomy.
5. J-tube placement.
History of Present Illness:
This 48-year-old [**First Name3 (LF) 1229**] has mental retardation and a seizure
syndrome. He presents to our emergency room acutely with reports
of [**1-15**] days of abdominal
pain as described by his caretakers, who find him grimacing in
an umbilical position. He had a change in bowel habits and
decreased PO intake for 2 weeks. He is largely unresponsive and
he responds only to keep the stimulation for pain. He has had
fevers for the last few days, up as high as 104 degrees. A
workup was performed for this, and initial imaging of the
abdomen showed multiple views consistent with a free air in the
abdomen. This with a lactic acidosis, distended abdomen and a
neutrophilia band shift, along with the after mentioned history
was very concerning for an acute process which
required an emergent operation. This was especially so given the
fact that we could not adequately communicate with this
[**Name2 (NI) 1229**] and did not know the full extent of his recognition of
pain due to his mental retardation.
Past Medical History:
[**Location (un) 849**] Gastaut Syndrome, neurologist Dr. [**Last Name (STitle) 851**]
Seizure disorder
Mental retardation
Osteoporosis
Peripheral neuropathy secondary to dilantin
h/o hyponatremia secondary to trileptal
GERD
Behavioral d/o
Social History:
Lives in group home. Non-verbal at baseline. Does not smoke or
drink EtOH
.
Patient lives in a group home. # [**Telephone/Fax (1) 852**]. Has a legal
guardian, Rev [**First Name8 (NamePattern2) **] [**Name (NI) 853**], c # [**Telephone/Fax (1) 854**], w # [**Telephone/Fax (1) 855**].
Family History:
Noncontributory
Physical Exam:
104, 100, 94/37
Gen: non responsive, NAD, no jaundice
CV: S1, S2, no MRG
Chest: CTA bilat, decreased at right base
Abd: soft, nondistended, no rebound or guarding.
Pertinent Results:
[**2164-5-4**] 07:05PM BLOOD WBC-10.0# RBC-4.49* Hgb-12.9* Hct-39.8*
MCV-89 MCH-28.8 MCHC-32.5 RDW-16.9* Plt Ct-296
[**2164-5-8**] 01:58AM BLOOD WBC-14.2* RBC-3.29* Hgb-9.7* Hct-29.3*
MCV-89 MCH-29.5 MCHC-33.1 RDW-17.0* Plt Ct-232
[**2164-5-8**] 09:40AM BLOOD Glucose-114* UreaN-8 Creat-0.5 Na-131*
K-3.6 Cl-95* HCO3-25 AnGap-15
[**2164-5-6**] 02:08AM BLOOD ALT-83* AST-125* LD(LDH)-222 AlkPhos-62
Amylase-19 TotBili-0.3
[**2164-5-8**] 09:40AM BLOOD Calcium-7.3* Phos-3.3# Mg-1.4*
[**2164-5-4**] 11:57PM BLOOD Triglyc-78
[**2164-5-8**] 01:58AM BLOOD Phenyto-17.1
.
CHEST (PORTABLE AP) [**2164-5-4**] 7:25 PM
PORTABLE UPRIGHT CHEST, ONE VIEW: Heart size is normal. There is
a mild hilar prominence, with patchy areas of airspace opacities
bilaterally. Given the history of prolonged seizure, these may
represent areas of aspiration. There is no pneumothorax. There
is no pleural effusion.
There is a massive amount of free intraperitoneal air, with free
air seen underneath both hemidiaphragms. Osseous structures are
unremarkable.
IMPRESSION:
1. Massive amount of pneumoperitoneum.
2. Multifocal patchy areas of airspace opacity, likely
represents aspiration, and possible superimposed neurogenic
pulmonary edema.
.
CHEST (PORTABLE AP) [**2164-5-5**] 4:07 PM
Comparison is made with prior study performed the same day
earlier in the morning.
Cardiomediastinal contour is unchanged. Diffuse airspace
opacities, worse on the right side, are unchanged. There are no
new lung abnormalities. As mentioned before, these are
suspicious for aspiration. There are no increasing pleural
effusions.
.
CHEST (PORTABLE AP) [**2164-5-8**] 8:07 AM
FINDINGS: In comparison with the study of [**5-5**], there has been
some decrease in the still substantial bilateral pulmonary
opacifications, suspicious for aspiration.
.
CHEST (PORTABLE AP) [**2164-5-9**] 1:14 AM
CHEST (PORTABLE AP)
Reason: new NGT
[**Hospital 93**] MEDICAL CONDITION:
48 year old man s/p ccy
REASON FOR THIS EXAMINATION:
new NGT
HISTORY: New nasogastric tube.
FINDINGS: In comparison with the study of [**5-8**], there has been
placement of a nasogastric tube that coils within the fundus of
the stomach. The diffuse bilateral pulmonary opacification shows
a slow steady decrease.
.
[**2164-5-15**] 06:00AM BLOOD WBC-13.1* RBC-3.44* Hgb-10.3* Hct-31.3*
MCV-91 MCH-29.9 MCHC-32.9 RDW-18.3* Plt Ct-940*
[**2164-5-18**] 09:25AM BLOOD WBC-16.0* RBC-2.91* Hgb-8.7* Hct-26.9*
MCV-93 MCH-29.8 MCHC-32.2 RDW-18.7* Plt Ct-960*
[**2164-5-14**] 05:55AM BLOOD Glucose-86 UreaN-6 Creat-0.5 Na-132*
K-4.0 Cl-101 HCO3-22 AnGap-13
[**2164-5-6**] 02:08AM BLOOD ALT-83* AST-125* LD(LDH)-222 AlkPhos-62
Amylase-19 TotBili-0.3
[**2164-5-18**] 09:25AM BLOOD Albumin-2.5*
[**2164-5-14**] 05:55AM BLOOD Calcium-7.4* Phos-3.1 Mg-2.1
[**2164-5-16**] 06:05AM BLOOD Vanco-20.5*
[**2164-5-13**] 12:25PM BLOOD Vanco-11.9
[**2164-5-18**] 04:54AM BLOOD Phenyto-7.2*
[**2164-5-16**] 06:10AM BLOOD Phenyto-13.7
[**2164-5-15**] 06:00AM BLOOD Phenyto-8.5*
[**2164-5-14**] 05:55AM BLOOD Phenyto-5.4*
[**2164-5-12**] 06:05AM BLOOD Phenyto-10.4
.
ECHO
Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%) No masses or thrombi are seen in the left
ventricle. Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. No masses or vegetations
are seen on the aortic valve. The mitral valve leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: No evidence of endocarditis or
clinically-significant regurgitant valvular disease. Normal
global and regional biventricular systolic function.
.
CT ABDOMEN W/CONTRAST [**2164-5-13**] 2:09 PM
IMPRESSION:
1. Diffuse bilateral airspace opacities consistent with
bilateral pneumonia with a more focal consolidation in the
superior right lower lobe and posterior right upper lobe. Small
bilateral pleural effusions.
2. Large hiatal hernia.
3. Marked fecal impaction of the colon to the level of the
rectosigmoid.
4. Post-surgical changes in the anterior abdomen. Moderate
amount of free fluid in the pelvis, likely post-surgical.
Brief Hospital Course:
This is a 48 year old male with MR [**First Name (Titles) **] [**Last Name (Titles) **] who presented
with abdominal pain, fever.
Initial CXR revealed free air in the abdomen. This with a lactic
acidosis, distended abdomen and a neutrophilia band shift. This
was very concerning for an acute process which required an
emergent operation.
He went to the OR on [**2164-5-5**] for:
1. Exploratory laparotomy.
2. Exploration of retroperitoneum.
3. Open cholecystectomy.
4. Venting decompressed colotomy.
5. J-tube placement.
His pain was controlled with IV Morphine.
He was NPO with IVF. We awaited return of bowel function.
Trophic tube feedings were started. Due to possible silent
aspirations, a NGT was placed. The NGT put out a 2L of drainage.
The tubefeedings were temporarily held. The NGT was self D/C'd
on [**2164-5-9**].
His tubefeedings were restarted and he was tolerating these.
A swallow evaluation was done and he was started on pureed
solids and thin liquids.
He should continue with tubefeedings, these are now cycled. Tube
feeds can be weaned as he tolerates better PO's.
Blood loss anemia: His HCT on [**2164-5-10**] was 20.9. He received 2
unit of blood and a repeat HCT was 27.
Micro: He had MRSA blood culture from [**5-7**]. He was treated with
Vancomycin for a MRSA PNA. Vanco needs to continue thru [**2164-5-23**].
His incision was C/D/I and staples removed prior to discharge.
Respiratory: He was on nasal cannula. O2 sats dipped to the
80's% with agitation. CXR revealed possible aspiration PNA and
RLL infiltrate.
Seizure: Neurology was consulted given his seizure disorder. He
was extubated on [**5-5**] and was noted to have one brief seizure
since extubation, becoming unresponsive, jerking tonic clonic
movement of his UE was noted.
At baseline, he has approximately [**1-16**] seizures per month,
lasting 1-3 minutes in duration, with a long post-ictal period.
At baseline, he is alert and oriented to self.
He was restarted on his home meds and ordered for standing
Ativan. His goal corrected Dilantin level was >15 given
stressors of acute illness, fever. We will taper Ativan slowly
and depending on clinical course and frequency of sz.
After initially keeping his Dilantin level >15, we then aimed
for Dilantin level [**9-26**]. He required occasional Dilantin
boluses and his level should be checked at rehab.
Medications on Admission:
Zoloft 50', dilantin 100", felbatol 1400/1200, trileptal 300"
and 600 afternoon, colace 100", miacalcin nasal spray, protonix
40', fosamax 70qwk, tums 1200', NaCl 0.5'
Discharge Medications:
1. Outpatient Lab Work
Albumin, Phenytoin (Dilantin) level 3x/week.
Please fax Dilantin levels to [**Telephone/Fax (1) 891**].
2. Phenytoin 125 mg/5 mL Suspension [**Telephone/Fax (1) **]: One [**Age over 90 1230**]y (150)
mg PO DAILY (Daily) as needed for qAM: Maintain corrected
Dilantin level [**9-26**].
3. Sertraline 50 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO QAM (once a
day (in the morning)).
4. Oxcarbazepine 300 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2
times a day).
5. Oxcarbazepine 600 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
6. Docusate Sodium 50 mg/5 mL Liquid [**Month/Year (2) **]: One Hundred (100) mg
PO BID (2 times a day).
7. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Month/Year (2) **]: 5-10 MLs
PO Q4H (every 4 hours) as needed.
8. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
9. Felbamate 400 mg Tablet [**Month/Year (2) **]: 3.5 Tablets PO BID (2 times a
day) as needed for seizure d/o.
10. Phenytoin 125 mg/5 mL Suspension [**Month/Year (2) **]: Two Hundred (200) mg
PO DAILY (Daily) as needed for qPM.
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Vancomycin 500 mg Recon Soln [**Last Name (STitle) **]: 1250 (1250) mg Intravenous
Q 8H (Every 8 Hours): Continue thru [**2164-5-23**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Chronic cholecystitis
obstipation
colonic distention
Pneumonia
Respiratory Distress
Blood Loss Anemia
MRSA - Blood culture
.
Mental Retardation
[**Hospital1 875**]
Discharge Condition:
Good
Discharge Instructions:
You were admitted with abdominal pain and went to the OR for an
Exploratory Laparotomy.
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 (>[**9-26**] 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:
Please follow-up with Dr. [**Last Name (STitle) **] on [**2164-6-8**] at 10:30am. Call
[**Telephone/Fax (1) 1231**] with questions or concerns
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN (Neurology) Phone:[**Telephone/Fax (1) 876**]
Date/Time:[**2164-6-11**] 9:45
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2164-6-27**]
9:10
Completed by:[**2164-5-18**]
|
[
"E936.1",
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"V09.0",
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"345.00",
"569.89",
"280.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.03",
"51.22",
"46.39",
"54.0",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10873, 10952
|
6843, 9198
|
347, 491
|
11160, 11167
|
2338, 4229
|
12846, 13297
|
2122, 2139
|
9416, 10850
|
4266, 4290
|
10973, 11139
|
9224, 9393
|
11191, 12823
|
2154, 2319
|
293, 309
|
4319, 6820
|
519, 1536
|
1558, 1800
|
1816, 2106
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,809
| 117,092
|
18563
|
Discharge summary
|
report
|
Admission Date: [**2173-6-23**] Discharge Date: [**2173-6-30**]
Date of Birth: [**2110-8-12**] Sex: M
Service: [**Last Name (un) 7081**]
HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old
male with a history of right lower lobe stage III, non-small-
cell lung cancer of the squamous type who has had two cycles
of induction chemotherapy initiated on [**2172-12-22**] and
radiation therapy times six weeks.
The patient was planning to have a surgical resection on
[**2173-4-26**] but developed a small bowel obstruction
requiring an emergent exploratory laparotomy. Two bowel
perforations were found, and postoperatively the patient was
sick and in the Intensive Care Unit with evidence of a septic
physiology. He was discharged to rehabilitation at that time
and was home for three weeks prior to his current admission.
He gained about five pounds per week over those weeks, and
his appetite was much improved. He has an occasional dry
cough and reports that he had pneumonia while in the
rehabilitation facility; however, his breathing is quite
good.
Repeat scans showed increased activity within the tumor and
within the right hilar and right paratracheal lymph nodes.
This was quite concerning given that the induction
chemoradiotherapy did not eradicate lymphatic involvement and
that it is progressing rapidly. The patient was thought to
have a poor prognosis despite the addition of surgical
therapy; but nonetheless, after discussions with Dr. [**Last Name (STitle) 952**]
and the patient's wife, the patient opted for further
surgery.
PAST MEDICAL HISTORY: Right lower lobe stage III non-small-
cell lung cancer of the squamous type; status post radiation
therapy and chemotherapy.
Hypertension.
History of a small-bowel obstruction.
PAST SURGICAL HISTORY: Exploratory laparotomy/lysis of
adhesions.
Anal sphincterotomy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Metoprolol 100 mg twice per day.
2. Lisinopril 2.5 mg once per day.
3. Protonix 40 mg once per day.
4. Percocet.
5. Megace.
PHYSICAL EXAMINATION ON PRESENTATION: In general, the
patient appeared well. Thinner than usual but walked without
difficulty. Vital signs revealed his temperature was 98.6,
his heart rate was 100, his blood pressure was 130/80, his
respiratory rate was 18, and 98 percent on room air. Weight
was 163 pounds. Head, eyes, ears, nose, and throat
examination revealed the extraocular movements were intact.
The sclerae were anicteric. The oropharynx was clear. The
neck was supple. No palpable cervical, supraclavicular, or
axillary lymph nodes. Chest revealed occasional expiratory
wheezes. Good air movement. Cardiovascular examination
revealed a rate and rhythm. The abdomen was soft and
nontender. A well-healed surgical scar. A small opening in
the inferior umbilical area. Extremities were thin. No
edema or asymmetric swelling.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 10.1, his hematocrit was 33.9, and his
platelets were 218. Sodium was 137, blood urea nitrogen was
11, and his creatinine was 1.1. His albumin was 3.7. His
calcium was 9.6.
SUMMARY OF HOSPITAL COURSE: On [**2173-6-23**] the patient
underwent a right pneumonectomy, a radical mediastinal lymph
node dissection with a muscle flap. The patient tolerated
the procedure well. The intraoperative course was
complicated by recurrent hypotension into the low 60s. The
patient had an intraoperative transesophageal echocardiogram
which showed multiple areas of hypokinesis with tricuspid
regurgitation, right ventricular dilatation, and an ejection
fraction of 40 percent. However, this was no change from
preoperatively. Please see the dictated operative note for
further details.
Postoperatively, the patient remained hypotensive with a
blood pressure of 94/62 on a Neo-Synephrine drip. The
patient remained intubated. The patient was ultimately
extubated on postoperative day three without incident.
Postoperatively, cardiac enzymes were drawn and the CK/MB
fraction was found to range from 3 to 5 postoperatively with
a troponin of 0.06.
Also, on postoperative day one, the patient's temperature
spiked to 102.6. The patient had blood, urine, and sputum
cultures sent. The blood and urine cultures ultimately came
back negative, but the sputum culture later grew out
methicillin-resistant Staphylococcus aureus. As a
consequence, the patient was placed on vancomycin and was
transitioned to linezolid on discharge for a total of a 10-
day course.
On postoperative day two, the patient's chest tube was
removed but he continued to require Neo-Synephrine to
maintain his blood pressure at 99/57. His pulse remained
high at 109, and his hematocrit slowly drifted down from a
preoperative value of 37.8 to 25.9 on postoperative day
three; at which point the patient received a transfusion of 1
unit of packed red blood cells. Following this transfusion,
the patient's hematocrit bumped to the 28 to 29 range where
it remained stable for the remainder of his hospital course.
By postoperative day three, the patient's epidural was taken
out and he was started on a morphine patient-controlled
analgesia. He was able to come off the Neo-Synephrine, and
his blood pressure was maintained at 137/70. Diuresis was
begun with Lasix, and the patient was receiving aggressive
chest physical therapy.
On postoperative day five, the patient was switched to oral
pain medications. Chest physical therapy was continued, and
the patient was begun on Lopressor for his tachycardia. The
patient remained afebrile throughout his hospital course
following his initial temperature spikes in the Intensive
Care Unit. The patient was transferred to the floor late on
postoperative day five.
On postoperative day six, the patient continued to require
aggressive chest physical therapy for his coarse breath
sounds and a productive cough. His metoprolol dose was
increased ultimately to 100 mg by mouth twice per day.
On postoperative day seven, the patient was discharged to a
rehabilitation facility with a 7-day course of linezolid and
recommendation that the patient receive aggressive chest
physical therapy and frequent walking. On the day of
discharge, the patient continued to have rhonchi on the left
with a productive cough; however, his oxygen saturations were
good at 97 percent on 2 liters with a respiratory rate of 20.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: To a rehabilitation facility.
DISCHARGE DIAGNOSES: Identical to the admission diagnoses
listed in the Past Medical History with the addition of the
following: Status post right pneumonectomy, radical
mediastinal lymph node dissection and muscle flap on [**2173-6-23**].
MEDICATIONS ON DISCHARGE:
1. Linezolid 600 mg by mouth twice per day (times seven
days).
2. Percocet 5/325-mg tablets one to two tablets by mouth q.4-
6h. as needed.
3. Colace 100 mg by mouth twice per day.
4. Protonix 40 mg by mouth once per day.
5. Furosemide 20 mg by mouth twice per day.
6. Ipratropium bromide 2 puffs inhaled four times per day.
7. Metoprolol 100 mg by mouth twice per day.
[**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], [**MD Number(1) 15911**]
Dictated By:[**Last Name (NamePattern1) 15517**]
MEDQUIST36
D: [**2173-6-30**] 12:04:34
T: [**2173-6-30**] 13:02:29
Job#: [**Job Number 50996**]
|
[
"276.5",
"162.5",
"458.29",
"276.3",
"196.0",
"041.11",
"V09.0",
"397.0",
"785.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"33.23",
"96.04",
"96.71",
"32.5",
"40.59",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
6478, 6509
|
6531, 6752
|
6778, 7428
|
1935, 3164
|
1805, 1909
|
3193, 6422
|
187, 1578
|
1601, 1781
|
6447, 6454
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,251
| 178,975
|
44347
|
Discharge summary
|
report
|
Admission Date: [**2142-7-25**] Discharge Date: [**2142-8-1**]
Date of Birth: [**2103-6-18**] Sex: F
Service:
Primary care physician: [**Name10 (NameIs) 7158**] [**Last Name (NamePattern4) 7159**], M.D.
CODE STATUS: Full code
CHIEF COMPLAINT: Fever
HISTORY OF PRESENT ILLNESS: A 39-year-old female with human
immunodeficiency virus, last CD4 count of 400 two months ago
in [**2142-5-12**] presents with four days of fever to 104??????,
chills, nausea and diarrhea, also with multiple other
complaints, intermittent abdominal pain, myalgias,
arthralgias and headache, but these are classified as chronic
according to the patient. The patient also says that her
diarrhea is chronic. The patient presented on [**2142-7-24**] to [**Hospital6 1708**] where an abdominal CT
was obtained which was negative and blood cultures were drawn
in the Emergency Department. The patient was then
discharged. Today, a report from [**Hospital6 15291**] is 1 of 4 blood cultures positive for gram positive
cocci.
In the Emergency Department here, two additional sets of
blood cultures were sent and the patient was started on
vancomycin and gentamicin. The patient also has end stage
renal disease on hemodialysis Mondays, Wednesdays and
Fridays. The patient had a fistulogram of the left upper
extremity AV graft with angioplasty six days ago. The
patient missed last hemodialysis prior to admission because
she felt too sick to leave home. Patient's nephrologist is
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
PAST MEDICAL HISTORY:
1. Human immunodeficiency virus positive, viral load less
than 50, CD4 408 in [**2142-5-12**].
2. End stage renal disease on hemodialysis Monday, Wednesday
and Friday. Etiology human immunodeficiency virus or
hypertensive nephropathy.
3. PPD positive, status post one year of INH, negative chest
x-ray
4. B12 deficiency
5. Chronic diarrhea of unknown etiology
6. Clostridium difficile positivity in [**2139**], but
subsequently Clostridium difficile negative
7. Depression
8. History pneumococcal sepsis in [**2134**]
9. Anemia secondary to hyperparathyroidism
10. Thrombocytopenia
11. Coronary catheter in [**2140**] which showed clean coronary
arteries
ALLERGIES:
1. AMPHOTERICIN LEADS TO SHAKING.
2. DILAUDID
3. PERCOCET
4. VIRACEPT
SOCIAL HISTORY: No history of alcohol, tobacco or drug use.
She is currently single, daughter entering college. No
travel history, no sick contacts, born in [**Country 2045**]. Presumed
contraction of human immunodeficiency virus through
heterosexual contact.
PHYSICAL EXAM:
VITAL SIGNS: Initially temperature of 104.0??????, blood pressure
124/70, pulse of 100, respirations of 20, 98% on room air.
Vital signs at time of examination after Tylenol and
antibiotics - temperature 100.0??????, blood pressure 110/68,
pulse 108, respiratory rate 16, saturating 98% on room air.
GENERAL: Alert, pleasant, appears uncomfortable, rigors
occasionally.
HEAD, EARS, EYES, NOSE AND THROAT: Normocephalic,
atraumatic. Pupils equal, round and reactive to light.
Mucous membranes dry. Extraocular movements intact.
NECK: Supple, no meningismus.
PULMONARY: Clear to auscultation bilaterally.
CARDIOVASCULAR: Tachycardic, positive flow murmur, normal
S1, S2.
ABDOMEN: Soft, mildly tender right lower quadrant and left
lower quadrant. No rebound or guarding. Positive bowel
sounds.
EXTREMITIES: 2+ peripheral pulses, no cyanosis, clubbing or
edema. Left upper extremity fistula with a bruit and thrill.
NEUROLOGIC: Alert and oriented x3. Strength ..........
sensation not tested.
INITIAL LABS: Sodium 134, potassium 5.1 moderately
hemolyzed, chloride 96, bicarbonate 14, BUN 81, creatinine
17.2, glucose 181, calcium 9.7. White count 3.4, 81%
neutrophils, 14% lymphocytes, 4% monocytes, hematocrit 31.0,
platelets 133. PT of 13.9, INR of 1.3.
IMAGING: Chest x-ray done in Emergency Department showed a
small left effusion, no consolidation, mild vascular
engorgement.
HOSPITAL COURSE: Seen after admission to [**Hospital3 **], the
patient complained of her typical migraine headache,
photophobia headache, nausea, developed [**9-20**] substernal
chest pain and complained of throbbing pain on the left upper
extremity AV graft. The patient also developed shaking
chills and desaturation on room air to 87%. The patient was
taken to emergent hemodialysis where a Quinton catheter was
placed. Arterial blood gas was performed showing a mixed
respiratory alkalosis and metabolic acidosis. The patient
was then transferred to the Medical Intensive Care Unit for
observation or further treatment.
The patient's blood cultures in the Emergency Department came
back [**3-15**] positive for coagulase positive Staphylococcus
aureus and the patient was continued on vancomycin and
gentamicin in the Medical Intensive Care Unit. The patient
was evaluated by surgery and had AV graft removal in the
Operating Room where a hematoma was seen and graft was sent
for culture. The patient also had a PPE performed which
showed severe mitral regurgitation, good left ventricular
ejection fraction and a small density on the mitral valve
that was suspicious for a vegetative lesion. The patient
remained hemodynamically stable in the Medical Intensive Care
Unit and was restarted on her HAART while continuing
vancomycin and gentamicin until [**2142-7-27**] at which
point she was transferred to the floor for further medical
treatment. What follows is her hospital course from [**7-27**] onward.
Cardiovascular: The patient's antihypertensive medications
were stopped initially, as the patient was hypotensive during
acute sepsis with blood pressures down to 120s/70s. After
receiving vancomycin and gentamicin, the patient's blood
pressures had been returning to normal hypertensive values.
The patient was initially restarted on enalapril 5 mg po bid
titrated up to 10 mg po bid. As blood pressures kept coming
up, the patient was restarted on labetalol 400 mg po bid.
The patient will be discharged on usual cardiac medications
at home. The patient was taken off telemetry after coming
back from the Medical Intensive Care Unit. She had been
complaining of chest pain during her acute septic episode,
but has not been complaining of chest pain ever since
transfer from the Medical Intensive Care Unit. Serial ECGs
had revealed no ST changes in the Medical Intensive Care Unit
and pericardiac catheter showed clean coronary arteries,
making ischemic cause of her chest pain highly unlikely. The
patient received TEE on the [**7-27**] which showed
severe mitral regurgitation from a prolapsed leaflet. No
vegetation seen. No pericardial effusion seen. Trace aortic
insufficiency. Ejection fraction normal. The patient had a
[**3-17**] holosystolic murmur radiating to the axilla which did not
change throughout hospital course.
2. Pulmonary: Soon after transfer to the Medical Intensive
Care Unit, the patient developed new wheezing and dry
crackles. The patient's O2 saturations were consistently
above 90 initially on 2 liters per nasal cannula, but
eventually weaned off of oxygen entirely with good O2
saturations. The patient's lung exam revealed crackles with
prolonged expiratory phase, however no wheezing. The patient
had a peak flow at bed side which showed peak flows between
300 and 400 which vary depending on patient effort. The
patient had serial chest x-rays. On [**7-24**], chest x-ray
showed no evidence of pneumonia, linear atelectasis of the
left base. Chest x-ray on the 14th showed no acute
cardiopulmonary disease. Chest x-ray on the 16th showed no
evidence of congestive heart failure or pneumonia, unchanged
from prior study. Chest x-ray on the 17th showed no acute
cardiopulmonary disease, continued prominent vasculature
consistent with mild congestive heart failure, but TCP could
not be ruled. The patient's dry crackles, prolonged
expiratory phase, gradually improved throughout hospital
course. The patient was started on Robitussin DM for cough,
has sputum collected for gram stain and culture and had
gentle chest PT instituted with good response.
3. Renal: The patient has end stage renal disease requiring
hemodialysis Monday, Wednesday, Friday. Hemodialysis regimen
was continued in hospital. The patient's phosphate levels
were found to be high and the patient was started on limited
hydroxide suspension 30 ml po tid with meals and Renagel 2400
mg po tid. The patient's phosphate level dropped and limited
hydroxide suspension was discontinued. The patient at no
time developed symptoms of uremia throughout hospital course.
It was believed that her crackles on lung exam and
obstructive pattern may have been due to fluid overload and
dialysis may have helped with improvement of her lung exam
throughout hospital course.
4. Endocrine: The patient has secondary hyperparathyroidism
and was in the work up process to have an neck exploration at
surgery for parathyroid gland removal. The patient was
scheduled to have thyroid ultrasound on day of discharge.
Neck surgery should be postponed until antibiotic course of
six weeks has finished.
5. Heme: The patient's anemia is presumably secondary to
low erythropoietin level secondary to end stage renal
disease. The patient was started on Epogen therapy in
hospital 3500 units subcutaneous Monday, Wednesday and
Friday.
6. Infectious disease: Patient with coagulase positive
Staphylococcus aureus sepsis with infected AV graft as the
presumed source. The patient ruled out for endocarditis by
TEE. The patient was initially started on vancomycin and
gentamicin therapy. Once sensitivities were received, the
patient's gentamicin was discontinued. The vancomycin level
was checked daily and was dosed to keep vancomycin level
above 15 mcg per ml. Only set of positive blood cultures are
from the day of admission. Surveillance blood cultures daily
afterwards have been negative thus far. Tissue culture of
the AV graft showed sparse coagulase positive Staphylococcus
aureus growth. Stool cultures have thus far been, however on
ova or parasites, few polymorphonuclear sites, no
cyclosporin, no gastroesophageal reflux disease and no
cryptosporidia, no Escherichia coli [**Numeric Identifier 95089**], nasogastric
Clostridium difficile toxin, Campylobacter, Vibrio, Yersinia
cultures are still negative thus far.
7. Gastrointestinal: The patient continued to have chronic
diarrhea in the hospital. Clostridium difficile studies were
negative. The patient complained of red blood on toilet
paper x2, but patient was significantly guaiac negative.
Hematocrit was stable throughout hospital course. Episode
also complained of nausea which was controlled with Zofran
and Ativan.
8. Prophylaxis: The patient was placed on proton pump
inhibitor and was wearing Pneumo boots that hospital course.
9. Acces: AV graft was removed by surgery. The patient had
Quinton catheters placed x2 for hemodialysis. Quinton
catheter was eventually taken out once. PermCath was placed
by interventional radiology without complication.
DISCHARGE CONDITION: Good
DISCHARGE STATUS: To home with outpatient primary care
physician follow up, further hemodialysis, [**Location (un) 4265**] ..........
with vancomycin dosing, hemodialysis for next six weeks.
OUTPATIENT FOLLOW UP: Nephrology, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
attending
DISCHARGE MEDICATIONS:
1. Aciclovir 200 mg po qd
2. Celexa 60 mg po qd
3. Clonidine patch 0.1 mg per hour q Saturday
4. Nephrocaps 1 qd
5. Ultram 50 to 100 mg po prn q 4 to 6 hours, no more than
400 mg in 24 hours
6. Omeprazole 20m g qd
17. Abacavir 300 mg po bid
18. Meperidine 25 mg tid to qid po prn
19. Efavirenz 600 mg po hs
20. Didanosine 125 mg po qd
21. Calcium acetate 1 tablet po tid
22. Vitamin B12 IM q month
23. Hytrin 5 mg po bid
24. Enalapril 10 mg po bid
25. Labetalol 800 mg po bid
26. Epoetin alpha 3500 units subcutaneous Monday, Wednesday,
Friday
27. Vancomycin 500 mg to 1 gm intravenous with hemodialysis
FUTURE TREATMENTS: Hemodialysis q Monday, Wednesday, Friday,
vancomycin dosing at dialysis for next six weeks.
DISCHARGE DIAGNOSES:
1. Gram positive sepsis
2. Human immunodeficiency virus
3. End stage renal disease
4. Anemia
5. Depression
6. Secondary hyperparathyroidism
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 568**], M.D. [**MD Number(1) 3808**]
Dictated By:[**Doctor First Name 6677**]
MEDQUIST36
D: [**2142-8-1**] 10:26
T: [**2142-8-1**] 10:33
JOB#: [**Job Number 95090**]
|
[
"424.0",
"038.19",
"428.0",
"252.0",
"585",
"996.73",
"996.62",
"V08",
"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.43",
"88.72",
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11124, 11334
|
12208, 12654
|
11463, 12187
|
4027, 11102
|
2610, 4009
|
11346, 11440
|
268, 275
|
304, 1557
|
1579, 2331
|
2348, 2595
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,567
| 169,531
|
3871
|
Discharge summary
|
report
|
Admission Date: [**2205-5-26**] Discharge Date: [**2205-6-4**]
Date of Birth: [**2143-6-19**] Sex: F
Service: MEDICINE
Allergies:
Tetracyclines
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
61 yo F with a history of CAD and COPD with multiple prior
intubations for COPD flares admitted with respiratory failure
requiring intubation.
The patient's visiting nurse called her PCP [**Last Name (NamePattern4) **] [**2205-5-24**] with
reports of increasing cough and dyspnea for several days. Note
was made of yellow-green sputum. She was afebrile, bp 160/100
with diffuse inspiratory and expiratory wheezes. She had
moderate labored breathing. The patient refused to come to the
ED at that time. She was started on pulse dose prednisone 50mg
Daily and azithromycin.
On presentation to the ED, the patient was using accessory
muscles for breathing, speaking in [**11-28**] word sentences. ED vitals
HR 140-150, BP 152/84, RR 36-40 86% NRB improved after combivent
neb to 100% NRB. She was febrile to 101. The patient received
levofloxacin 750mg IV, ceftriaxone 2g, methylprednisolone 125mg
IV, acetaminophen and pantoprazole as well as 2.5L NS. The
patient was noted on OG lavage in the ED to have some
coffee-ground return and brown guaiac-positive stool.
Past Medical History:
- COPD, last PFTs [**8-4**] with FVC 1.72, FEV1 0.82, FEV1/FVC 66%
(61% and 40% predicted respectively); intubated several times in
the past. on 2L home O2.
- IgA deficiency, was on IV gamma globulin with Dr. [**Last Name (STitle) 2148**].
- CAD s/p MIs in [**2186**] (flu symptoms), [**2192**] (jaw pain), NSTEMI in
[**2197**] (chest pain with left arm discomfort). Cath in [**2197**] with
PTCA/stent to LCx. Cath in [**4-/2202**] with stent placement to RCA
and LCx.
- Hypertension
- Hyperlipidemia
- Gastritis, on PPI
- Osteoporosis, with history of multiple compression and rib
fractures from coughing
- History of thrush/[**Female First Name (un) **] esophagitis [**12-29**] steroid therapy
- Depression
- Tremor
Social History:
She lives with her daughter, [**Name (NI) 6177**], son-in-law and 3
grand-children. She is a widow. She is an ex-smoker, with
about a 30-pack-year smoking history, quit in [**2200**]. No EtOH.
Uses a cane and walker to ambulate.
Family History:
Mother with DM, father with pancreatic cancer.
Physical Exam:
Admission physical exam:
Gen: Intubated and sedated.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: Rhoncorous upper airway breath sounds heard bilaterally.
Abd: Mildly distended. Soft, nontender.
Ext: No edema.
Neuro: Unresponsive. Pinpoint pupils, minimally reactive.
Pertinent Results:
Na 142, K 4.2, Cl 93, BUN/Cr 24/0.9, glucose 106, WBC 26.4, Hct
43.0, platelets 511, INR 1.0, [**Doctor First Name **] 88.
.
Lactate 1.6
.
7.25/81/48 -> 7.23/80/141 AC Vt 400, FiO2 60 -> 7.29/64/121 AC
Vt 400, FiO2 50
.
UA [**1-30**] RBC, [**1-30**] WBC, Tr Leuk, Neg Nit, 30 Prot
.
EKG: Rhythm strip from the field reveals normal sinus rhtyhm at
a rate of approximately 140. Sinus tachycardia at 116. Normal
axis and intervals. Large voltage across the precordium. Likely
left atrial enlargement. Upsloping <1mm ST elevations in V3-6.
No acute ST or T wave changes. No prior available for
comparison.
.
Micro:
Blood culture ([**2205-5-26**]): NGTD
Urine culture ([**2205-5-26**]; [**2205-5-27**]): NGTD
Sputum culture ([**2205-5-26**]): STREPTOCOCCUS PNEUMONIAE
CEFTRIAXONE----------- 1 S
ERYTHROMYCIN---------- =>1 R
LEVOFLOXACIN---------- <=0.5 S
TETRACYCLINE---------- =>16 R
TRIMETHOPRIM/SULFA---- 8 R
VANCOMYCIN------------ <=1 S
.
Imaging:
CXR ([**2205-5-26**]):
1. Lines and tubes are in adequate position.
2. Ill-defined bibasilar opacities, nonspecific, yet may
represent a
component of aspiration.
3. Heart size upper limits of normal without acute pulmonary
edema.
.
[**2205-5-27**] TTE:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 10-20mmHg. There is mild regional left ventricular systolic
dysfunction with hypokinesis/akinesis of the basal to mid
inferolateral wall. [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] The right ventricular cavity is mildly dilated
with normal free wall contractility. The number of aortic valve
leaflets cannot be determined. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion. There is an anterior space which most
likely represents a fat pad.
IMPRESSION: Mild focal left ventricular systolic dysfunction.
Mildly dilated right ventricle with preserved systolic function.
At least moderate mitral regurgitation. Moderate pulmonary
artery systolic hypertension.
Brief Hospital Course:
HYPERCARBIC RESPIRATORY FAILURE, ACUTE COPD EXACERBATION:
Ms. [**Known lastname 17327**] is a 61 yo female with a history of multiple prior
intubations for COPD. On arrival to the ED on [**2205-5-26**], she was
febrile, tachycardic, tachypneic and satting only in the
mid-80's on a non-rebreather. She was in respiratory distress
using accessory muscles and speaking in short sentences. ABG
showed a respiratory acidosis, and she was intubated in the ED.
Chest x-ray showed bibasilar opacities and she was started
empirically on levofloxacin and ceftriaxone. She was also given
solumedrol and nebulizers for a COPD exacerbation. She was
admitted to the ICU for further care and continued on
levofloxacin for a CAP. On [**2205-5-27**], her steroids were changed
to prednisone 30 mg QD and she was continued on a taper (she was
discharged on prednisone 10 mg QD). On [**2205-5-30**] she was
extubated; she required intermittent BIPAP over the following 36
hours for hypercarbia, but was eventually able to be weaned to
2L NC after administration of IV lasix.
GASTRITIS:
Ms. [**Known lastname 17327**] was noted on OG lavage in the ED to have some
coffee-ground return and brown guaiac-positive stool. She has a
known history of gastritis. She was continued on a PPI and Hct
remained stable throughout.
CHRONIC DIASTOLIC HEART FAILURE, MITRAL REGURGITATION:
An echocardiogram was obtained this admission which showed an EF
of 55% and moderate MR. She was started diltiazem and
lisinopril for afterload reduction.
Medications on Admission:
Senna 8.6 mg Twice daily as needed
Simvastatin 20 mg Daily
Clopidogrel 75 mg Daily
Fentanyl 25 mcg/hr Patch every 72 hours
Montelukast 10 mg Daily
Hexavitamin
Paroxetine HCl 10 mg Daily
Fluticasone 50 mcg Two Sprays Nasal DAILY
Calcium Carbonate 500 mg 3 TIMES A DAY WITH MEALS
Cholecalciferol (Vitamin D3) 400 unit Twice daily
Pantoprazole 40 mg Daily
Docusate Sodium 100 mg twice daily
Oxycodone-Acetaminophen 5-325 mg every 4 hours as needed
Olanzapine 5 mg 2 times a day
Levalbuterol HCl 0.63 mg/3 mL 1ml Inh q2h
Lidocaine 5 %(700 mg/patch) Adhesive Patch Daily
Prednisone 10 mg Daily
Tiotropium Bromide 18 mcg Capsule Daily
Insulin Lispro sliding scale
Discharge Medications:
1. Simvastatin 10 mg Tablet [**Known lastname **]: Two (2) Tablet PO DAILY
(Daily).
2. Clopidogrel 75 mg Tablet [**Known lastname **]: One (1) Tablet PO DAILY
(Daily).
3. Montelukast 10 mg Tablet [**Known lastname **]: One (1) Tablet PO DAILY
(Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable [**Known lastname **]: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Known lastname **]: One (1)
Tablet PO TWICE DAILY ().
6. Olanzapine 5 mg Tablet [**Known lastname **]: One (1) Tablet PO BID (2 times a
day).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Fluticasone 110 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
9. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
12. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
13. Lisinopril 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
14. Prednisone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
15. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed for SOA.
16. Oxycodone-Acetaminophen 5-325 mg Tablet [**Hospital1 **]: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
17. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Two (2)
Puff Inhalation QID (4 times a day).
18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) neb Inhalation Q4H (every 4 hours) as
needed for SOB/wheezing.
19. Diltiazem HCl 240 mg Capsule, Sust. Release 24 hr [**Hospital1 **]: One
(1) Capsule, Sust. Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**]
Discharge Diagnosis:
Primary Diagnoses:
(1) Acute COPD exacerbation
(2) Pneumonia
(3) Heart failure - chronic diastolic
Secondary Diagnoses:
(1) Gastritis
(2) Depression
(3) Osteoporosis
Discharge Condition:
Stable-- on 2L NC; mental status good -- seems to be back to
baseline.
Discharge Instructions:
You were admitted with a COPD exacerbation requiring intubation.
You were also treated for a pneumonia.
Please call your doctor if you develop a fever or feel short of
breath. If you cannot reach your doctor or if you feel severely
short of breath, please return to the emergency department for
further evaluation.
Followup Instructions:
You will be followed by the physicians at your rehab facility
while you are there.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2205-6-4**]
|
[
"263.9",
"560.1",
"733.00",
"518.84",
"285.9",
"428.0",
"412",
"486",
"491.21",
"311",
"414.01",
"V15.82",
"401.9",
"781.0",
"V45.82",
"535.50",
"272.4",
"424.0",
"428.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9501, 9547
|
5112, 6636
|
301, 313
|
9758, 9831
|
2765, 5089
|
10197, 10446
|
2414, 2462
|
7344, 9478
|
9568, 9668
|
6662, 7321
|
9855, 10174
|
2503, 2746
|
9689, 9737
|
241, 263
|
341, 1407
|
1429, 2149
|
2165, 2398
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,391
| 180,776
|
17610
|
Discharge summary
|
report
|
Admission Date: [**2108-5-18**] Discharge Date: [**2108-5-31**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 85 year old
female who was found down unresponsive by her family. She
was brought to the Emergency Room at an outside hospital. An
electrocardiogram at the outside hospital showed atrial
fibrillation and a head computerized tomography scan showed a
questionable intracerebral bleed. She was transferred to
[**Hospital6 256**] for further evaluation.
Upon arrival in the Emergency Room here she was found to be
drowsy but arousable. She had left-sided neglect. She
underwent an magnetic resonance imaging scan which showed a
right-sided cerebrovascular accident. The patient was
admitted to the Neurology Stroke Service for further
treatment.
PAST MEDICAL HISTORY: Significant for a coronary artery
bypass graft and a bioprosthetic aortic valve. She also has
a history of atrial fibrillation.
MEDICATIONS ON ADMISSION: Her medications included Coumadin
which was stopped one week ago, Lasix and potassium.
SOCIAL HISTORY: She was independent and was living with her
son.
HOSPITAL COURSE: The patient was managed by the Neurology
service for the majority of her hospital course. She was
showing marginal changes in her neurological status. She was
able to respond mildly to her family. A lengthy discussion
was made with the family regarding her disposition. The
family made it clear very early on that the patient was very
independent and had made it abundantly clear to the family
that she never wanted any heroic measures done. She never
wanted to be put on a feeding tube or live in a nursing home.
As this was early into her cerebrovascular accident course
her exact prognosis was difficult to exactly ascertain. In
order to provide adequate nutrition, multiple swallow studies
were obtained on the patient which she failed. She was noted
to aspirate and would not be able to coordinate a swallowing
reflex. Thus, in order to remove the nasogastric tube from
the patient, the patient was sent to Interventional Radiology
for placement of a percutaneous gastrojejunostomy tube. Upon
attempted placement of this gastrojejunostomy tube, there was
an unfortunate complication and there was a perforation of
the duodenum. This perforation was recognized by the
Interventional Radiology Team almost immediately and surgery
was immediately consulted. The patient was promptly taken to
the Operating Room for exploratory laparotomy. A large sized
perforation of the duodenum was primarily repaired and also
the gastric puncture site was also closed. The patient was
brought to the Intensive Care Unit in critical condition.
She remained on the ventilator. Her blood pressure was
requiring multiple pressor supports including Levophed and
Neo-Synephrine. The patient required much volume
resuscitation on the day of surgery and on postoperative day
#1. Her blood pressures mildly responded, however, still
requiring blood pressure support. Her cardiac enzymes were
ruling out for myocardial infarction. On the evening of
postoperative day #1, the patient underwent placement of
pulmonary artery catheter which was complicated by pulmonary
artery perforation and as blood was noted to well up in the
endotracheal tube. The pulmonary artery catheter was pulled
back to central venous pressure. Cardiothoracic surgery
consult was obtained. The patient required one unit of blood
transfusion, however, did remarkably well for this
complication, and was doing well on the ventilator on the
morning of postoperative day #2. However, her overall state
remained the same if not a little bit worse. She was still
requiring Levophed and Neo-Synephrine for blood pressure
support and was still unresponsive and was still dependent on
the ventilator. On the morning of postoperative day #1 the
patient's family expressively wished to terminate care and
withdraw all measures and allow their mother to pass away
comfortably. Upon further discussion they agreed to allow
approximately 24 more hours to see if she would turn around
the corner. They also talked to the Intensive Care Unit
attending, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on the evening of postoperative
day #1 and agreed to let her go through the night to see what
she looked like in the morning. On the morning of
postoperative day #2, upon the patient's family's arrival it
was obviously aware that she had not made any progress and
was, in fact, a little bit worse. They proceeded to explain
to the primary surgical team that the patient had made it
explicitly clear three years prior that she never wanted any
of these kinds of measures done, she never wanted to have a
breathing tube, she never wanted to have a feeding tube and
she never wanted to be in a nursing home or in a
rehabilitation facility. The situation was discussed at
length by the surgical resident and Intensive Care Unit
attending. The family was notified that it is still possible
over a long Intensive Care Unit course to get their mother
back to the status that she was at prior to the complication,
however, due to the stroke she will probably never be
completely independent as she had wished. The patient's
family was in clear understanding of this scenario and
adamantly wished to continue with withdrawal care as they
thought that this would be the patient's wish. Upon
notification of Dr. [**Last Name (STitle) 519**] who was covering for Dr. [**Last Name (STitle) **], the
Intensive Care Unit attending Dr. [**Last Name (STitle) **] and the surgical
resident, everyone was in compliance, the family was well
informed and withdrawal of care ensued. The patient expired
at 12:50 PM on [**2108-5-31**]. The family was notified. The
medical examiner was also notified, and declined the case as
they said it did not have to be reported as the incident was
48 hours prior. Thus the patient expired at 12:50 PM on [**2108-5-31**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Name8 (MD) 3181**]
MEDQUIST36
D: [**2108-5-31**] 14:23
T: [**2108-5-31**] 15:56
JOB#: [**Job Number 49061**]
|
[
"567.2",
"414.00",
"998.2",
"V45.81",
"427.31",
"428.0",
"434.11",
"507.0",
"V42.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"46.39",
"46.75",
"96.71",
"96.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
960, 1048
|
1133, 6219
|
113, 780
|
803, 933
|
1065, 1115
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,745
| 149,458
|
52112
|
Discharge summary
|
report
|
Admission Date: [**2142-8-21**] Discharge Date: [**2142-8-26**]
Date of Birth: [**2092-6-1**] Sex: F
Service: ACOVE
HISTORY OF PRESENT ILLNESS: The patient is a 50 year old
female with a past medical history significant for
endocarditis status post aortic valve replacement on
Coumadin, stroke, coronary artery disease, peripheral
vascular disease, hypertension, and several past and recent
upper gastrointestinal bleeds of unknown source (most recent
[**2142-6-18**], when she refused nasogastric lavage and upper
endoscopy). She presents to the Emergency Room with
recurrent upper gastrointestinal bleed following several days
of fatigue, orthostatic symptoms and black, tarry stools. In
the Emergency Department, the patient was found to have a
hematocrit of 16.8 with an INR of 3.7. She refused
nasogastric lavage and was transferred to the Intensive Care
Unit for transfusion and monitoring.
The patient denies history of nonsteroidal anti-inflammatory
use, steroids and aspirin, as well as frequent episodes of
vomiting.
PAST MEDICAL HISTORY:
1. Recurrent upper gastrointestinal bleed of unknown source.
Endoscopy in [**2138**] demonstrated no varices but was positive
for esophageal diverticula. The patient refused further
work-up.
2. History of recurrent endocarditis status post aortic
valve replacement (St. [**Male First Name (un) 1525**]).
3. Left parietal stroke complicated by seizure.
4. Hypertension.
5. Gastroesophageal reflux disease.
6. Hepatitis C (no cirrhosis).
7. Peripheral vascular disease status post right lower
extremity bypass graft.
MEDICATIONS ON ADMISSION:
1. Coumadin 2.5 mg p.o. q. day.
2. Prilosec 20 mg p.o. q. day.
3. Protonix 40 mg p.o. q. day.
4. Diflucan 200 mg p.o. twice a day.
5. Lasix 40 mg p.o. q. day.
6. Iron 325 mg p.o. q. day.
7. Enalapril 5 mg p.o. q. day.
8. Methadone 55 mg p.o. q. day.
9. Percocet one to two p.o. p.r.n.
10. Colace 100 mg p.o. q. day.
ALLERGIES: Penicillin with a reaction of hives.
SOCIAL HISTORY: The patient lives with her mother. She has
a one pack per week tobacco use times many years. History of
intravenous drug use with no drug use in the last eight years
on methadone maintenance and no alcohol use.
PHYSICAL EXAMINATION: On admission, temperature 98.6 F.;
heart rate 95; blood pressure 105/40; respiratory rate 12;
100% oxygenation on room air (no orthostatic blood pressure
change). In general, the patient is a middle aged black
female in no acute distress. HEENT examination:
Normocephalic, atraumatic. Pupils equally round and reactive
to light and accommodation. Extraocular movements are intact
bilaterally. Anicteric sclerae. Dry mucous membranes.
Clear oropharynx; edentulous. Neck examination is supple
with no lymphadenopathy and no jugular venous distention.
Pulmonary examination: Clear to auscultation bilaterally.
No wheezes, rales or rhonchi. Cardiovascular examination is
regular rate and rhythm, with a III/VI holosystolic murmur
throughout the precordium. No S3 or S4 appreciated.
Abdominal examination is soft, normoactive bowel sounds.
Nontender, nondistended. No masses appreciated, no
hepatosplenomegaly. Rectal examination with black guaiac
positive stool. Extremities with no edema with two plus
distal pulses throughout with a bandaged ulcer in the left
lower leg, with a nonhealing ulcer. Neurologic examination
is awake, alert and oriented times three. Cranial nerves II
through XII intact bilaterally. Five out of five motor
strength throughout with sensation intact throughout.
LABORATORY: Studies on admission were CBC with a white blood
cell count of 8.5, hematocrit 16.8 with an MCV of 94 and
platelets of 282 with a differential of 73% polys, 22% lymphs
and 4% monos. A Panel-7 with a sodium of 137, potassium 4.2,
chloride of 103, bicarbonate 25, BUN 21, creatinine 0.7 and
glucose of 97. PT 23, INR 3.7, PTT of 37.8.
EKG with normal sinus rhythm at 80; normal axis, normal
intervals. T wave inversion in leads I, AVL and leads 2
through lead 4, unchanged from previous electrocardiograms.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit where she received four units of packed red blood
cells, Vitamin K and fresh frozen plasma. Despite the bleed,
the patient was started on heparin for her mechanical aortic
valve given her previous history of stroke off of
anti-coagulation. The patient's hematocrit increased
appropriately and remained stable after 24 hours at 28.1.
She was subsequently transferred to the Floor.
On the Floor, the patient was observed for 48 hours on high
dose Protonix and heparin with no further episodes of
bleeding. After 48 hours, the patient was restarted on
Coumadin and maintained on heparin until her INR became
therapeutic at greater than 2.5. The patient's systolic
blood pressures continued to run relatively low without
symptoms and therefore, the patient's Lasix and Enalapril
were held. The patient continued on her outpatient regimen
of Methadone maintenance.
The patient continued to complain of pain in her left lower
extremity at the site of the nonhealing pressure ulcer.
Wound Management was maintained and the patient was scheduled
for follow-up with the vascular surgeon as an outpatient.
CONDITION AT DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. twice a day.
2. Methadone 55 mg p.o. q. day ([**Hospital 2514**] Clinic).
3. Coumadin 5 mg p.o. q. h.s. times one day, then resumption
of her outpatient dose of 2.5 mg p.o. q. h.s.
4. Diflucan 200 mg p.o. twice a day.
5. Tylenol 1000 mg p.o. three times a day p.r.n. pain.
(The patient's Lasix and Enalapril were held secondary to
persistently low blood pressures)
DISCHARGE INSTRUCTIONS:
1. The patient was scheduled for follow-up with her primary
care physician, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 107835**], on [**8-30**], at 01:40
p.m.
2. As well, she was instructed to follow-up with the
Vascular Surgeon, Dr. [**Last Name (STitle) **], who performed her left
lower extremity bypass graft, on Thursday, [**8-30**], at
02:15 p.m.
3. The patient was instructed to return to the Emergency
Room with any further recurrence of bleeding episodes.
4. The patient was set up with [**Hospital6 407**]
services to follow-up on the left lower extremity ulcer wound
management, with moist occlusive wound management with Tielle
dressing to be changed every seven days. The last
application of Tielle dressing was on [**2142-8-24**].
5. The patient was also instructed to follow-up with the
[**Hospital 197**] Clinic for INR check the day following discharge.
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed.
2. Non-healing left lower extremity ulcer.
3. Hypertension.
4. Hepatitis C.
5. Endocarditis status post aortic valve replacement.
6. Peripheral vascular disease.
7. Gastroesophageal reflux disease.
8. Seizures.
9. Stroke.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Name8 (MD) 4935**]
MEDQUIST36
D: [**2142-9-9**] 16:36
T: [**2142-9-14**] 16:07
JOB#: [**Job Number 107836**]
|
[
"070.54",
"414.01",
"780.39",
"578.1",
"454.0",
"285.1",
"V43.3",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6649, 7164
|
5312, 5707
|
1623, 2000
|
4098, 5264
|
5731, 6628
|
2254, 4080
|
5280, 5289
|
163, 1051
|
1073, 1597
|
2017, 2231
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,195
| 135,206
|
40869+58379
|
Discharge summary
|
report+addendum
|
Admission Date: [**2133-7-10**] Discharge Date: [**2133-7-21**]
Date of Birth: [**2074-10-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2133-7-14**] Urgent Coronary artery bypass graft x3 (Left internal
mammary artery to left anterior descending, saphenous vein graft
to obtuse marginal, saphenous vein graft to diagonal) Mitral
valve repair (28 mm ring)
History of Present Illness:
58 year old male with no medical care for 20+ years transferred
from outside hospital after he presented after an episode of
sudden onset shortness of breath while walking to get lunch.
The episode last about 30 seconds, shortness of breath resolved
with rest. Upon interview, he admitted to an episode of sudden
onset of burning chest pain 2-3 weeks prior, which he attributed
at the time to heartburn. Since that episode, he has been
feeling increasingly fatigued but was not short of breath until
the day of presentation. He was admitted and ruled in for non
ST elevation myocardial infarction with troponin 0.8,
echocardiogram that revealed EF 20% and mitral regurgitation,
and cardiac catheterization that revealed coronary artery
disease. He was then transferred for surgical evaluation and
continued cardiac management.
Past Medical History:
Dyslipidemia
Hypertension
smoker
Remote h/o bell's palsy
Social History:
Recently retired from VW of America, was on vacation in [**Hospital3 **]
when the symptoms came on. 2 daughters, both college-age
-Tobacco history: 1ppd for 40 years
-ETOH: 2-3 beers/night
-Illicit drugs: none
Family History:
Mom: heart failure
Physical Exam:
VS: T=98.4 BP=105/87 HR=90 RR=20 O2 sat=100% 2L NC
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 7 cm.
CARDIAC: tachcardic, regular rhythm, normal S1, S2. S3 heard at
apex. Holosystolic [**2-8**] murmur heard at apex
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 89266**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 89267**]
(Complete) Done [**2133-7-14**] at 9:33:58 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 18**] - Department of Cardiac S
[**Last Name (NamePattern1) 439**], 2A
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2074-10-14**]
Age (years): 58 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Abnormal ECG. Chest pain. Congestive heart failure.
Coronary artery disease. Dilated cardiomyopathy. Hypertension.
Left ventricular function. Mitral valve disease. Pericardial
effusion. Shortness of breath.
ICD-9 Codes: 425.4, 428.0, 402.90, 786.05, 424.0
Test Information
Date/Time: [**2133-7-14**] at 09:33 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW3-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Diastolic Dimension: *6.9 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 20% to 25% >= 55%
Findings
LEFT ATRIUM: Moderate LA enlargement. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA and extending into the RV. No ASD
by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV
cavity.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque. Normal ascending aorta
diameter. Normal aortic arch diameter. Normal descending aorta
diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets (3). No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Moderate to severe (3+) MR.
TRICUSPID VALVE: Mild to moderate [[**1-4**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Very small pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-CPB:1. The left atrium is moderately dilated. No thrombus is
seen in the left atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated.
4. Right ventricular chamber size and free wall motion are
normal.
5. The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque. There are
simple atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. Moderate to
severe (3+) mitral regurgitation is seen. There is bilateral
leaflet retraction. The annulus is enlarged and measues 4.2 cm.
8. There is a very small pericardial effusion.
9. There are large bilateral pleural effusions.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-CPB: On infusion of epi, norepi, milrinone. AV pacing.
Welll-seated annuloplasty ring in the mitral position. MR is now
trace. Minimal mitral stenosis with peak gradient of 6 and mean
of 2 mmHg at a cardiac output of 5.9 L/min. Overall LV function
is improved on inotropic support LVEF = 25%. TR is now trace.
Aortic contour is normal post decannulation. Bilateral pleural
effusions are now small.
[**2133-7-10**] 01:10PM PT-15.1* PTT-43.5* INR(PT)-1.3*
Brief Hospital Course:
Mr. [**Known lastname **] was transferred in from an outside hospital for
cardiac management and preoperative evaluation. He underwent
preoperative workup including pulmonary function test, dental,
echocardiogram, and plavix washout. He was continued on
aspirin, statin, and gently diuresed. On [**7-14**] he was brought to
the operating room for coronary artery bypass graft and mitral
valve repair. Of note on induction he had refractory
hypotension non responsive to vasoactive medication, see
anesthesia report. CROSS-CLAMP TIME:102 minutes.PUMP TIME: 120
minutes. Please refer to operative report for further surgical
details. He received cefazolin and vancomycin for perioperative
antibiotics and was transferred to the intensive care unit for
post operative management. He arrived to the unit on milrinone,
levophed, and epinepherine. Epinepherine was weaned overnight.
The milrinone was slowly weaned given his ejection fraction of
20%. He was slow to wake without tachypnea but by
post-operative day two he extubated successfully on precedex.
Diuresis was resumed. He went into afib on POD#1 and was started
on amiodarone. POD#3 he was successfully cardioverted and his
Levo was weaned off successfully afterwards. He was transitioned
to oral amiodarone and he was transferred to the step down unit.
Chest tubes and pacing wires were removed per protocol. Physical
Therapy was consulted for evaluation of strength and
mobility.The remainder of his postoperative course was
essentially uneventful. On POD#7 he was discharged to home with
VNA. All follow up appointments were advised.
Medications on Admission:
no medications prior to admission at outside hospital
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. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of Central/[**Hospital3 29991**]
Discharge Diagnosis:
Coronary artery disease s/p CABG
Mitral regurgitation s/p MV repair
Acute systolic heart failure
Non ST Elevation myocardial infarction (troponin 0.8 OSH)
Hypertension
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema *******
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
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 [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2133-8-12**] at 1:15
Cardiologist: [**First Name8 (NamePattern2) 4115**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 33732**] on [**8-10**] at 1:15pm.
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) **] [**4-7**] 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:[**2133-7-21**] Name: [**Known lastname 14084**],[**Known firstname **] Unit No: [**Numeric Identifier 14085**]
Admission Date: [**2133-7-10**] Discharge Date: [**2133-7-21**]
Date of Birth: [**2074-10-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 135**]
Addendum:
Upon day of discharge, Lopressor was discontinued and Coreg
initiated for his poor LVEF of 20% An ACE-I/[**Last Name (un) **] cannot be
started at this time due to blood pressure. He will need
reevaluation as an outpatient by his cardiologist.
Upon discharge dose adjustment of Carvedilol was made to
Carvedilol 3.125 mg by mouth twice daily
Discharge Disposition:
Home With Service
Facility:
VNA of Central/[**Hospital3 14086**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2133-7-21**]
|
[
"425.4",
"410.71",
"428.21",
"458.29",
"305.1",
"272.4",
"401.9",
"428.0",
"414.01",
"427.31",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"36.15",
"35.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
12342, 12566
|
7038, 8640
|
331, 555
|
9855, 10083
|
2589, 5417
|
11013, 12319
|
1741, 1762
|
8744, 9553
|
9664, 9834
|
8666, 8721
|
10107, 10990
|
5460, 7015
|
1777, 2570
|
272, 293
|
583, 1414
|
1436, 1495
|
1511, 1725
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,625
| 144,352
|
14354
|
Discharge summary
|
report
|
Admission Date: [**2114-2-27**] Discharge Date: [**2114-3-16**]
Date of Birth: [**2059-5-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Amiodarone / Quinidine
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
ICD firing on the day of admission, unable to tolerate quinidine
[**1-19**] diarrhea, nausea, decreased POs
Major Surgical or Invasive Procedure:
[**2114-3-1**] Cardiac cath
[**2114-3-6**] Mitral Valve Repair with 28mm CE Annuloplasty ring,
Placement of LV lead
History of Present Illness:
54 yo F w/ multiple medical problems. She has a h/o MI at age 35
with an Ef of 35%. Cath at that time was normal. She had an ICD
placed in [**2108**] for NSVT. She has had recent admissions for
inappropriate ICD firing due to PAF. She was changed from
Amiodarone to Quinidine d/t increase in NSVT, but has had GI
upset with poor PO intake. Had an echo on [**2-22**] which revealed an
decrease in here EF to 20% and 4+ MR. She came to the ED today
d/t ICD firing and reaction to Quinidine.
Past Medical History:
Congestive Heart Failure (EF 35%), h/o Myocardial Infarction
(age 35), Hyperlipidemia, Hypertension, Diabetes Mellitus,
Paroxysmal Atrial Fibrillation, Nonsustained Ventricular
Tachycardia w/ ICD placement [**2108**], s/p Spleenectomy d/t ITP, s/p
Hysterectomy, s/p Tosillectomy, Chronic renal insufficiency
Social History:
She is single and lives alone. She works as office manager for
construction company. doesn not smoke, social drinker.
Family History:
Father died of MI in his 70s and mother died of CRI in her 70s.
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: 97, 100/70, 75, 20, 95% on RA
Gen: well appearing lying in bed eating dinner in NAD
HEENT: PERRL, EOMI, pink conjunctiva. Oral mucosa moist and
clear.
NECK: supple. No JVD, carotid bruits auscultated. No
thyromegaly.
CHEST: CTAB. well healed ICD pocket in left pectoral region.
CVS: nl S1/S2. 1/6 SEM LLSB,
ABD: +BS. soft, NT/ND.
EXT: Warm, without edema, 2+ pulses b/l
NEURO: AO3, appropriate, answering questions appropriate,
following commands, sensation to light touch intact, strength
grossly symmetric
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2114-3-1**] Cardiac Cath: 1. Selective coronary angiography in this
right dominant system demonstrated no angiographically apparent
CAD. The LMCA, LAD, LCx and RCA were normal. 2. Left
ventriculography was deferred. 3. Resting hemodynamics
demonstrated elevated right and left sided filling pressures.
RVEDP was 25 mmHg and pulmonary capillary wedge pressure was 40
mmHg. There was severe pulmonary arterial hypertension with a
PA pressure of 82/40 mmHg. Central aortic pressure was
low-normal at 102/75 mmHg. Cardiac index was low at 1.4
l/min/m2.
[**2114-3-4**] LE U/S: No evidence of right lower extremity DVT.
[**2114-3-5**] Echo: The left ventricular cavity is severely dilated.
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%) although intrinsic
function is more depressed given severity of mitral
regurgitation. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Overall left
ventricular systolic function is normal (LVEF>55%). Tissue
synchronization maging demonstrates no significant left
ventricular dyssynchrony; however cannot exclude since images
were technically suboptimal. Right ventricular chamber size and
free wall motion are normal. The mitral valve leaflets are
mildly thickened. Moderate to severe (3+) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
There is moderate pulmonary artery systolic hypertension.
Significant pulmonic regurgitation is seen. There is no
pericardial effusion.
[**2114-3-12**] Echo: The left atrium is moderately dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is severely dilated. There is severe global left
ventricular hypokinesis. No masses or thrombi are seen in the
left ventricle. Right ventricular chamber size is normal with
mild global free wall hypokinesis. There is abnormal septal
motion/position. 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. A mitral valve annuloplasty ring is present. There is
no mitral stenosis. Mild (1+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. The end-diastolic
pulmonic regurgitation velocity is increased suggesting
pulmonary artery diastolic hypertension. There is no pericardial
effusion. Compared with the prior study (images reviewed) of
[**2114-3-5**], a mitral valve ring is now identified with marked
decrease in the severity of mitral regurgitation. The left
atrial and left ventricular cavity sizes are now smaller. The
severity of pulmonary artery systolic hypertension is also
reduced. Global left ventricular systolic function is now
depressed.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted under medicine/cardiology service for
evaluation of her ICD. She underwent a cardiac cath on [**3-1**]
which revealed clean coronaries with severe pulmonary
hypertension. An LV gram was deferred d/t her increased
Creatinine. She was started on heparin for anticoagulation for
her atrial fibrillation (Coumadin was stopped). She was seen be
EP service for ICD management, as was well as cardiac surgery
for mitral valve repair. She was medically managed over the next
several days and her creatine trended down. During this time she
underwent another echocardiogram which revealed a normal EF with
3+ MR. On [**3-6**] she was taken to the operating room and underwent
a mitral valve repair with LV lead placement (for biventricular
pacing). Please see operative report for surgical details.
Following surgery he was transferred to the CSRU for invasive
monitoring in stable condition. Later on op day she was weaned
from sedation, awoke neurologically intact and extubated. She
initially required some inotropes which were slowly weaned off.
EP service continued to follow patient and interrogate her ICD,
post-operatively she was in atrial fibrillation. Chest tubes
were removed on post-op day two. Beta blockers and diuretics
were started per protocol. She was gently diuresed towards her
pre-op weight and Lopressor was titrated for maximal
hemodynamics. On post-op day four chest tubes were removed and
Coumadin was started (already started on Heparin). An ACE
inhibitor was added and she was transferred to the telemetry
floor on post-op day seven. She continued to work with the
physical therapy service daily. She was gently diuresed towards
her preoperative weight. Ms. [**Known lastname **] continued to make steady
progress and was discharged home on [**2114-3-16**]. She will follow-up
with the electrophysiology service, Dr. [**Last Name (STitle) **], her cardiologist
and her primary care physician as an outpatient.
Medications on Admission:
1. Furosemide 40 mg PO TID
2. Aspirin 81 mg PO daily
3. Famotidine 20 mg PO DAILY
4. Spironolactone 25 mg PO DAILY
5. Omega-3 Fatty Acids 550 mg Capsule One Capsule PO QID
6. Pravastatin 20 mg PO DAILY
7. Calcium Carbonate 500 mg Tablet PO BID
8. Docusate Sodium 100 mg PO BID
9. Warfarin 1 mg PO QTUTHSASU
10. Warfarin 2 mg PO QMOWEFR
11. Metoprolol Succinate 200 mg PO qAM and 100mg PO qPM.
12. Quinidine Gluconate 324 mg PO Q8H (started [**2114-2-22**])
13. Lorazepam 0.5 mg PO q6h prn
14. digoxin 0.125mg/day
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
3. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. 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*
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
Disp:*120 Tablet, Chewable(s)* Refills:*1*
6. Captopril 12.5 mg Tablet Sig: 0.25 Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
9. Coumadin 1 mg Tablet Sig: One (1) Tablet PO see directions
below: Take 1mg TTSS and 2mg MWF.
Disp:*60 Tablet(s)* Refills:*0*
10. Outpatient [**Name (NI) **] Work
PT/INR on Saturday [**2114-3-17**]. Please call results to Dr. [**Last Name (STitle) 3035**]
([**Telephone/Fax (1) 16005**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Mitral Regurgitation s/p Mitral Valve Repair
Congestive Heart Failure (EF 35%)
PMH: h/o Myocardial Infarction (age 35), Hyperlipidemia,
Hypertension, Diabetes Mellitus, Paroxysmal Atrial Fibrillation,
Nonsustained Ventricular Tachycardia w/ ICD placement [**2108**], s/p
Spleenectomy d/t ITP, s/p Hysterectomy, s/p Tosillectomy,
Chronic renal insufficiency
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No heavy lifting or driving until follow up with surgeon.
Followup Instructions:
Please see Dr. [**Last Name (STitle) **] in 4 weeks
Please see Dr. [**Last Name (STitle) **] in [**1-20**] weeks
Please see Dr. [**Last Name (STitle) 24522**] in [**12-19**] weeks
Please see Dr. [**Last Name (STitle) 2357**] in [**12-19**] weeks.
Please ask your PCP to check [**Name Initial (PRE) **] white blood cell count about [**12-19**]
weeks after discharge given its elevation during your admission.
If it continues to be elevated, a hematology work-up is
recommended.
Please take a PT/INR on Saturday [**2114-3-17**] with results to Dr.
[**Last Name (STitle) **].
Completed by:[**2114-3-22**]
|
[
"274.0",
"272.4",
"428.41",
"401.9",
"425.4",
"427.31",
"V53.32",
"585.9",
"250.00",
"424.0",
"287.31",
"412",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.74",
"37.21",
"88.72",
"39.61",
"35.12",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
9052, 9107
|
5238, 7207
|
396, 513
|
9508, 9514
|
2322, 5215
|
9799, 10404
|
1513, 1659
|
7770, 9029
|
9128, 9487
|
7233, 7747
|
9538, 9776
|
1674, 2303
|
249, 358
|
541, 1031
|
1053, 1362
|
1378, 1497
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,889
| 100,068
|
52838
|
Discharge summary
|
report
|
Admission Date: [**2192-1-5**] Discharge Date: [**2192-1-20**]
Date of Birth: [**2117-9-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Hydralazine / Opioid Analgesics / Compazine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain / epigastric pain
Major Surgical or Invasive Procedure:
Coronary artery bypass grafts x 4 (LIMA-LAD,SV-DG,SV-OM,SV-PDA)
[**1-13**]
left heart catheterization, coronary angiography
History of Present Illness:
The patient is a 74 year-old female who has a significant PMH
for recent NSTEMI ([**2191-11-5**]), CAD, hyperlipidemia,
hypertension, DM-2, and ESRD on hemodialysis who presented after
several hours of epigastric pain which evolved into predominant
complaint of [**2193-8-13**] chest pressure. She had a similar
presentation on [**2191-11-22**] and was diagnosed with an NSTEMI after
positive cardiac enzymes noted with new LBBB on EKG. She
underwent cardiac catheterization at that time which showed LAD
lesion of 90% and totally occluded mid LAD lesion, RCA lesion of
90%, and circumflex showed minimal disease. Unfortunately, she
had unsuccessful PCI, and CT Surgery consulted to arrange for
future CABG plan.
Past Medical History:
-Hypothyroidism (thyroidectomy in [**2173**] for benign growth)
-Diabetes type II for >10yrs
-End-Stage Renal Disease: on hemodialysis left forearm AV graft
in [**2187**], now using Tunelled HD Line
-CVA [**2186**]: left caudate infarct; several mini-strokes before
that
-Gait disorder/shaky and unsteady when she walks
-Splenectomy in [**2145**] (trauma related)
-SVC stenosis
-Cataract surgery (bilateral)
-Hypertension
-Hyperlipidemia
-Coronary Artery Disease (recent cath [**11/2191**] showing 90%
proximal LAD totally occluded mid LAD and 90% RCA and minimal
disease of the circumflex)
Social History:
Patient lives alone at home but daughter [**Name (NI) **]([**Telephone/Fax (1) 108910**])
is extensively involved in her care. She has 7 other children.
She uses a walker at baseline, but has been wheelchair bound for
about 1 year per daughter because patient is afraid of
falling. She denies current or past tobacco, alcohol or illicit
drug use.
Family History:
Mother: died 5 year ago (cause unknown to pt)
Father: died when pt was 17 (cause unknown to pt)
Children have no major medical problems
Physical Exam:
Admission
VS -T 98.6F, BP 153/100, HR 80s, RR 20, 96% 3L oxygen
Gen: appears fatigued, middle aged female in NAD, Oriented x3.
Affect somewhat flattened.
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 7-8cm. Left EJ in place (clean/intact)
and left IJ HD catheter in place with non-erythematous
surrounding skin.
CV: S1/S2 appreciated, RRR, II-III/VI systolic murmur noted @
LUSB, No murmurs, rubs, gallops. No thrills, lifts. No S3/S4.
Chest: No chest wall deformities or scoliosis, but + Mild
kyphosis. Respirations unlabored, no accessory muscle use.
Decreased aeration at bases bilaterally (R>L). No wheezes or
rhonchi.
Abd: Soft, mild upper epigastric tenderness, moderate
distension. No HSM or tenderness at RUQ. Due to distension,
unable to ausculate well for abdominial bruits -but all 4
quadrants with +normoactive BS.
Ext: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] cool, 1+ DP and PT pulses on left and 2+ DP and 1+
PT pulse on right. No femoral bruits/femoral pulses 2+
bilaterally.
Skin: LE calves with scaling of skin, no sores/lesions/rashes.
Pulses:Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
.
Discharge
VS T 98.4 BP 144/71 HR 80 SR RR 20 O2sat 97%-2LNP
Gen NAD, sitting in chair
Neuro A&O x3, nonfocal exam
Pulm CTA bilat
CV RRR, sternum stable, incision CDI
Abdm soft, NT/+BS
Ext Warm, trace pedal edema bilat.
Skin staples L groin down thigh. Left subclav HD catheter
Pertinent Results:
ADMISSION LABS:
[**2192-1-5**] 03:57PM PT-41.6* PTT-37.8* INR(PT)-4.6*
[**2192-1-5**] 03:03PM GLUCOSE-381* NA+-138 K+-4.4 CL--91* TCO2-27
[**2192-1-5**] 03:03PM HGB-14.3 calcHCT-43
[**2192-1-5**] 02:45PM GLUCOSE-385* UREA N-33* CREAT-4.2* SODIUM-137
POTASSIUM-5.0 CHLORIDE-92* TOTAL CO2-27 ANION GAP-23*
[**2192-1-5**] 02:45PM ALT(SGPT)-150* AST(SGOT)-104* CK(CPK)-46 ALK
PHOS-205* TOT BILI-0.3
[**2192-1-5**] 02:45PM LIPASE-50
[**2192-1-5**] 02:45PM CALCIUM-9.6 PHOSPHATE-3.8 MAGNESIUM-2.2
[**2192-1-5**] 02:45PM WBC-14.1* RBC-4.46 HGB-13.8 HCT-44.2 MCV-99*
MCH-31.0 MCHC-31.3 RDW-17.4*
[**2192-1-5**] 02:45PM BLOOD cTropnT-0.21*
[**2192-1-6**] 01:10PM BLOOD CK-MB-NotDone cTropnT-0.29*
[**2192-1-6**] 12:19AM BLOOD CK(CPK)-77
[**2192-1-5**] 02:45PM BLOOD CK(CPK)-46
[**2192-1-19**] 09:30AM BLOOD WBC-17.8* RBC-3.11* Hgb-9.6* Hct-30.0*
MCV-97 MCH-30.8 MCHC-32.0 RDW-17.8* Plt Ct-280
[**2192-1-19**] 09:30AM BLOOD Plt Ct-280
[**2192-1-17**] 04:00AM BLOOD PT-15.0* PTT-29.6 INR(PT)-1.3*
[**2192-1-19**] 09:30AM BLOOD Glucose-233* UreaN-43* Creat-5.2*# Na-137
K-5.1 Cl-99 HCO3-28 AnGap-15
[**2192-1-12**] 09:00AM BLOOD %HbA1c-7.0*
[**2192-1-6**] 01:10PM BLOOD TSH-2.9
.
ADDITIONAL STUDIES:
[**2192-1-10**] Cardiac MD/Thallium Viability study: IMPRESSION: 1.
Moderate Anterior wall/apical defect that is completely
reversible by 24 h. 2. Moderate septal defect that is partially
reversible by 24 h.
.
[**2192-1-8**] CTA Chest/Pelvis/Abdomen : IMPRESSION: 1. There is
opacification of the SMA, without evidence of ischemic bowel. 2.
Extensive atherosclerotic disease, without aortic aneurysm or
dissection seen. 3. Extensive colonic diverticulosis, with
minimal stranding surrounding the descending colon, suggesting
mild uncomplicated diverticulitis. 4. Incompletely characterized
hypodense lesions in the kidneys again noted. 5. Soft tissue
nodule arising from the medial limb of the left adrenal gland
again incompletely characterized. 6. Increased number of
mediastinal and retroperitoneal lymph nodes, without size
enlargement.
===============================================================
[**Known lastname **],[**Known firstname 108974**] [**Medical Record Number 108975**] F 74 [**2117-9-11**]
Radiology Report CHEST (PA & LAT) Study Date of [**2192-1-19**] 4:15 PM
[**Hospital 93**] MEDICAL CONDITION:
74 year old woman s/p CABG x4
REASON FOR THIS EXAMINATION:
atelectasis
Final Report
HISTORY: Status post CABG with atelectasis.
FINDINGS: In comparison with study of [**1-17**], there is little
overall change.
Extensive opacification at the left base persists, possibly
increasing with
further pleural fluid. Central catheter remains in place. The
right axillary
catheter again remains outside of the hemithorax.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: [**First Name8 (NamePattern2) **] [**2192-1-19**] 6:21 PM
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================================================================
[**Known lastname **],[**Known firstname 108974**] [**Medical Record Number 108975**] F 74 [**2117-9-11**]
Radiology Report [**Numeric Identifier **] PICC W/O PORT Study Date of [**2192-1-17**]
12:30 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2192-1-17**] SCHED
PICC LINE PLACMENT SCH Clip # [**Clip Number (Radiology) 108976**]
Reason: ESRD on HD. LT scv Permacath, s/p mult RIJ caths. Unable
to
[**Hospital 93**] MEDICAL CONDITION:
74 year old woman with s/p cabg
REASON FOR THIS EXAMINATION:
ESRD on HD. LT scv Permacath, s/p mult RIJ caths. Unable to
pass wire into IJs
at time of recent CABG. Has RT femoral Cordis. IV unable to
thread wire for
PICC at bedside. please place as midline only *****
Final Report
INDICATION: 74 year old woman requiring IV access. Request right
mid-line due
to presence of left HD catheter in SVC. The procedure was
explained to the
patient. A timeout was performed.
RADIOLOGIST: Dr. [**Last Name (STitle) 3012**] and Dr. [**First Name (STitle) **] performed the procedure.
Dr. [**Last Name (STitle) 2492**], the attending radiologist, was present and
supervised the
procedure.
TECHNIQUE: Using sterile technique and local anesthesia, the
right brachial
vein was punctured under direct ultrasound guidance using a
micropuncture set.
Ultrasound images were obtained before and immediately after
establishing
intravenous access. A guidewire was advanced into the right
subclavian vein under fluoroscopic guidance. A peel- away sheath
was then placed over the guidewire and a double-lumen PICC
measuring 20 cm in length was placed through the peel- away
sheath with its tip positioned in the axillary vein under
fluoroscopic guidance. Position of the catheter was confirmed by
a
fluoroscopic spot film of the chest. The peel-away sheath and
guidewire were then removed. The catheter was secured to the
skin, flushed, and a sterile dressing applied. The patient
tolerated the procedure well. There were no immediate
complications.
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
double-lumen PICC placement via right brachial venous approach.
Final internal length is 20 cm, with the tip positioned in the
right axillary vein. The line is ready to use.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 2671**] [**Doctor Last Name **]
DR. [**First Name8 (NamePattern2) 95**] [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Approved: WED [**2192-1-18**] 9:17 AM
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=
=
=
=
================================================================
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 108974**] [**Hospital1 18**] [**Numeric Identifier 108977**] (Complete)
Done [**2192-1-13**] at 6:17:28 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2117-9-11**]
Age (years): 74 F Hgt (in): 60
BP (mm Hg): / Wgt (lb): 140
HR (bpm): BSA (m2): 1.61 m2
Indication: Intraop CABG evaluate LV function, Valvular
function, Aortic contours
ICD-9 Codes: 410.92, 440.0, 424.0
Test Information
Date/Time: [**2192-1-13**] at 18:17 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3319**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW1-: Machine: [**Doctor Last Name **]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: *6.3 cm <= 5.2 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.3 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 25% to 30% >= 55%
Aorta - Ascending: *3.5 cm <= 3.4 cm
Findings
LEFT ATRIUM: Marked LA enlargement. No mass/thrombus in the [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline
dilated LV cavity size. Severe regional LV systolic dysfunction.
RIGHT VENTRICLE: Moderately dilated RV cavity. Borderline normal
RV systolic function.
AORTA: Mildly dilated ascending aorta. Focal calcifications in
ascending aorta. Normal aortic arch diameter. Complex (>4mm)
atheroma in the aortic arch. Mildly dilated descending aorta.
Complex (>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Moderate to severe (3+) MR. [**First Name (Titles) **] vena contracta is >=0.7cm
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR. Dilated main PA.
PERICARDIUM: Small pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Pre Bypass: The left atrium is markedly dilated. No
mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is top normal/borderline
dilated. There is severe regional left ventricular systolic
dysfunction with septal hypokinesis at the base and akinesis at
mid and apical levels, and hypokinesis of anteroseptal and
anterior walls.. The right ventricular cavity is moderately
dilated with borderline normal free wall function. The ascending
aorta is mildly dilated. There are complex (>4mm) atheroma in
the aortic arch. The descending thoracic aorta is mildly
dilated. There are complex (>4mm) atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate to severe (3+) central mitral regurgitation
is seen. The mitral regurgitation vena contracta is >=0.7cm.
There is a small pericardial effusion. TEE used for hemodynamic
monitoring throughout. Estimated PASP 43 pre bypass. Frequent
cardiac output measurements obtained. CO 2.0 to start case,
increased to 2.7, then later 3.9 just prior to bypass.
Post Bypass: Patient is on epinepherine infusion (.08) and
phenylepherine (2), AV paced.
Biventricular function is slightly improved on ionotropes. LVEF
30-35%. The anterior wall motion has improved. The septum is
paced with paradoxical movement and cannot be fully evaluated.
Mitral reguritation is now [**1-6**]+. Aortic contours intact. Remaing
exam is unchanged. Cardiac output post bypass initally [**2-7**],
improved by end of case to 4.1 with ionotropes and volume. All
finidings discussed with surgeons at the time of the exam.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2192-1-16**] 14:34
Brief Hospital Course:
Ms. [**Known lastname 108904**] is a 74 year old female with a past medical history
of a recent NSTEMI ([**11/2191**]), extensive coronary artery disease,
hyperatension, diabetes mellitis type II, end stage renal
disease on hemodialysis, who presented to the emergency
department with several hours of epigastric pain and chest
pressure. She ruled out for acute coronary syndrome/myocardial
infarction. A workup for mesenteric ischemia was negative and
she was scheduled for a coronary artey bypass.
On [**2192-1-13**] she underwent a coronary artery bypass grafting times
four. This procedure was performed by Dr. [**Last Name (STitle) 914**]. She
tolerated the procedure well and was transferred in critical but
stable condition to the surgical intensive care unit. On
post-operative day one she was dialyzed, extubated, and weaned
from her pressors. Dialysis resumed on the following day. Her
chest tubes and epicardial wires were removed. She was seen in
consultation by the physical therapy service. Over the next
several days her hospital course was uneventful, she progressed
very slowly with physical activity and on POD7 it was decided
she was ready for discharge to rehabilitation at [**Hospital1 **].
Medications on Admission:
-Vitamin B Complex/Vitamin C
-Folic Acid 1 mg daily
-Renagel 800 mg tablet three times a day.
-Levothyroxine 100 mcg tablet daily
-Atorvastatin 80 mg Tablet PO daily
-Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: 4,000-11,000
unit dwell Injection PRN (as needed) as needed for line flush:
**for use by dialysis ONLY.
-Prevacid 30 mg Capsule, (E.C.)daily.
-Lorazepam 0.5 mg tablet PO Q6H as needed for Anxiety.
-Acetaminophen 325 mg, 1-2 Tablets PO Q6H PRN
-Warfarin 7.5 mg tablet PO daily at 4 PM.
-Aspirin 81 mg tablet once a day.
-Lisinopril 40 mg tablet daily.
-Toprol XL 100mg daily.
.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q4H (every
4 hours) as needed.
4. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**1-6**]
Drops Ophthalmic PRN (as needed).
6. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: 5000 (5000)
units Injection TID (3 times a day).
7. Sevelamer Carbonate 800 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Atorvastatin 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap
PO DAILY (Daily).
11. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
12. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
13. Levothyroxine 50 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
14. Senna 8.6 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a
day) as needed.
15. Ibuprofen 600 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
16. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment [**Last Name (STitle) **]: One (1)
Appl Rectal QID (4 times a day) as needed.
17. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO TID (3
times a day).
18. Glipizide 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
19. Insulin Lispro 100 unit/mL Solution [**Last Name (STitle) **]: sliding scale
Subcutaneous Q AC&HS.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
unsatble angina
s/p coronary artery bypass grafts
end stage renal disease
hypertension
cerebrovascular disease
noninsulin dependent diabetes mellitus
hypothyroidism
s/p thyroidectomy
s/p hysterectomy
s/p splenectomy
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any fever greater than 100.5
report any redness of, or drainage from incisions
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**1-6**] weeks ([**Telephone/Fax (1) 250**])
Completed by:[**2192-1-20**]
|
[
"403.91",
"562.10",
"585.6",
"250.50",
"244.0",
"443.81",
"426.3",
"V12.54",
"426.0",
"459.2",
"564.09",
"372.72",
"411.1",
"428.0",
"997.1",
"300.00",
"V45.11",
"250.70",
"V45.79",
"V88.01",
"512.1",
"E878.2",
"789.06",
"272.4",
"414.2",
"410.72",
"V58.61",
"455.0",
"414.01",
"362.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"14.24",
"39.61",
"36.13",
"36.16",
"99.04",
"39.95",
"38.93",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
18547, 18626
|
14624, 15844
|
337, 463
|
18886, 18893
|
3951, 3951
|
19298, 19522
|
2202, 2339
|
16497, 18524
|
7514, 7546
|
18647, 18865
|
15870, 16474
|
18917, 19275
|
12415, 14601
|
2354, 3932
|
269, 299
|
7578, 12371
|
491, 1206
|
3967, 6248
|
1228, 1821
|
1837, 2186
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,941
| 110,387
|
34098
|
Discharge summary
|
report
|
Admission Date: [**2144-6-22**] Discharge Date: [**2144-7-7**]
Date of Birth: [**2085-7-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4975**]
Chief Complaint:
Hypoxia, tachypnea
Major Surgical or Invasive Procedure:
Pericardiocentesis [**2144-7-5**]
Fine needle aspiration of axillary node [**2144-6-30**]
History of Present Illness:
She is a 58-year-old [**Last Name (un) 18355**] resident with mental retardation,
COPD, and no reported past cardiac history who presents for
examination of distended belly, anemia and noted to have large
pericardial effusion. Given mental retardation, interview with
patient is extremely limited, and pt. minimally able to report
symptoms. Pt. was admitted to [**Hospital3 **] after ECHO for workup
of shortness of breath revealed moderate pericardial effusion
without tamponade. Repeat ECHO 24h later showed
stable-to-improved effusion and was discharged with plans for
f/u ECHO in 14d.
.
Today, she presented to ED from NH with short episode hypoxia
with recovered with albuterol and 02 and started on
levofloxacin. also had KUB given some abdominal distension which
reportedly was concerning for ileus. she was transferred to
[**Hospital1 18**] for evaluation of a distended belly in setting of previous
volvulus. In ED, she had a distended abd with minimal TTP,
normal LFTs, pancreatic enzymes, without leukocytosis. She was
guaiac negative with VSS and received Abdominal CT shich showed
large pericardial effusion and presacral, perihepatic fluid, but
no acute abdominal process. Given large pericardial effusion
without previous comparisons, pt. was admitted for planned f/u
ECHO in the AM.
.
Spoke with pt.'s brother and wife who report that 8 weeks ago,
she started to become pale, have increased shallow breathinig,
low grade temps to 100-101, with some abdominal distension that
has been ongoing. Concern for GERD, COPD, UTI, all diagnosed
within this time period. UTI tx. with levaquin.
she has had no bloody or black stools per family until she
starte Fe So4.
Past Medical History:
- Mental retardation of unknown etiology.
- DJD.
- Bilateral knock knees (talus valgus, pes planus).
- Neurodermatitis.
- Psoriasis.
- History of obesity.
- Status post volvulus and colonic resection.
- Status post left oophorectomy.
- Fe deficiency anemia 28.5 at [**Hospital3 **] 1 week ago
- GERD
Social History:
Social history is significant for the absence or EtoH use.
Patient is a resident at [**Last Name (un) 18355**] Center.
Family History:
Father died of prostate cancer, CABG, MIs; he also had colon CA.
maternal aunt with ovarian and breast cancer. MI and CAD
throughout family on both sides.
Physical Exam:
VS - T 99.8 137/65 HR 101, 95%RA, no pulsus
Gen: middle-aged woman, NAD, repititious and perseverative,
follows commands. Oriented x 1.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pale, no with sublingual pallor, MMM
Neck: unable to assess JVP as pt. will not allow herself to be
reclined. at 45 degrees, JVP flat.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, borederline tachycardic, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no wheezes or
rhonchi. mild, occ. crackles at Right base.
Abd: mildly distended, obese, with difficult abodminal exam as
pt. denies belly pain but seems to grimace on palpation of
RUQ>RLQ. No organomegaly noted in context of bodyhabitus and
difficulty participating in exam. No abdominial bruits.
Ext: 2+ pitting edema to knees (new per PA at bedside. No
femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas. +
hirsutism
Pulses:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ 2+ DP 2+ PT 2+
Neuro: CN II-XII grossly intact, moving all 4 ext.
spontaneously, follows commands.
Pertinent Results:
Echocardiogram [**2144-6-23**]
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size and free wall
motion are normal. Trivial mitral regurgitation is seen. There
is a moderate to large sized circumferential pericardial
effusion. Stranding is visualized within the pericardial space
c/w organization. There is substantial right atrial collapse and
brief diastolic invagination of the right ventricular outflow
tract (cine loops #15 and #28), consistent with low filling
pressures or early tamponade.
IMPRESSION: Moderate-to-large pericardial effusion with
echocardiographic findings of early tamponade.
.
CT chest, abdomen & pelvis W/CONTRAST [**2144-6-29**]
IMPRESSION:
1. Diffuse lymphadenopathy in the axillary, supraclavicular and
mediastinal regions. Pulmonary nodules in the left lung apex is
also noted. This is concerning for a neoplastic process.
Differential diagnosis includes primary lymphoma or lung
neoplasm.
2. Small pericardial effusion, decreased in size.
3. Bilateral small pleural effusions.
4. Splenic hypodensity.
5. Multiple hepatic subcentimeter hypodensities which are too
small to characterize.
6. Cholelithiasis without evidence of cholecystitis.
7. Diffuse colonic distention up to 12.2 cm. No evidence of
obstruction.
.
Pericardial fluid:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield. CD45-bright, low-side scatter
lymphoid cells comprise 23% of total analyzed events. Of these,
B cells comprise approximately 15% of lymphoid-gated events and
do not express aberrant antigens. Surface immunoglobulin
expression is extremely dim-to-absent, precluding evaluation of
clonality. T cells comprise approximately 80% of lymphoid gated
events, express mature lineage antigens, and have a
helper-cytotoxic ratio of 5.0. Natural killer cells represent
approximately 3% of lymphoid gated events. No expansion of
CD34-immunoreactive events are identified in the "blast gate".
Monocytic cells comprise 6% of total analyzed events.
.
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by a
lymphoproliferative disorder are not seen in specimen.
Correlation with clinical findings and morphology (see 08-[**Numeric Identifier 78642**])
is recommended. Flow cytometry immunophenotyping may not detect
all lymphomas due to topography, sampling or artifacts of sample
preparation.
.
L axillary lymph node FNA
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield. B cells comprise approximately 9% of
lymphoid-gated events, are polyclonal, and do not express
aberrant antigens.T cells comprise approximately 89% of lymphoid
gated events and express mature lineage antigens (CD2,3,5,7).
.
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by non-Hodgkin B-cell
lymphoma are not seen in specimen. Review of cytospin slide
(1096V-[**7-1**]) shows predominantly blood with admixed lymphocytes
and numerous degenerated cells precluding definitive morphologic
assessment. Correlation with clinical findings and morphology
is recommended. Flow cytometry immunophenotyping may not detect
all lymphomas due to topography, sampling or artifacts of sample
preparation.
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2144-7-6**] 07:00AM 9.4 3.38* 8.2* 28.6* 85 24.3* 28.7* 16.3*
389
[**2144-7-5**] 07:00AM 9.8 3.21* 7.8* 26.8* 83 24.3* 29.2* 16.5*
381
[**2144-6-25**] 01:36AM 9.6 3.73* 9.0* 29.9* 80* 24.2* 30.1* 15.5
410
[**2144-6-24**] 06:00AM 7.1 3.27* 8.2* 27.0* 83 25.0* 30.2* 15.8*
355
[**2144-6-23**] 10:30AM 10.5 3.40* 8.2* 27.5* 81* 24.2* 29.9*
15.7* 385
[**2144-6-22**] 04:30PM 8.8 3.46* 8.5* 28.2* 82 24.5* 30.1* 15.7*
381
.
DIFFERENTIAL Neuts Lymphs Monos Eos Baso
[**2144-6-30**] 04:20AM 89.0* 5.5* 4.5 0.9 0.1
[**2144-6-25**] 01:36AM 89.3* 5.6* 4.8 0.2 0.1
[**2144-6-22**] 04:30PM 89.1* 4.7* 4.6 1.5 0.2
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3
[**2144-7-6**] 07:00AM 101 13 0.3* 144 3.8 109* 29
[**2144-7-5**] 07:00AM 103 12 0.3* 141 3.6 107 26
[**2144-6-25**] 01:36AM 155* 10 0.4 144 3.6 110* 26
[**2144-6-24**] 03:50PM 109* 8 0.3* 143 3.9 109* 25
[**2144-6-23**] 10:30AM 126* 9 0.4 138 3.9 103 28
[**2144-6-22**] 04:30PM 117* 13 0.4 140 4.1 105 29
.
ENZYMES & BILIRUBIN ALT AST LD(LDH) AlkPhos Amylase TotBili
[**2144-6-30**] 04:20AM 27 19 292 129* 14 0.5
[**2144-6-22**] 04:30PM 14 14 245 134* 0.5
.
OTHER ENZYMES & BILIRUBINS Lipase
[**2144-6-30**] 04:20AM 15
.
Brief Hospital Course:
58 yo F with mental retardation & h/o volvulus s/p colonic
resection admitted with hypoxia & abdominal distention, also
repeat echocardiogram given newly diagnosed pericardial
effusion.
.
# Pericardial Effusion: s/p pericardiocentesis when early signs
of tamponade seen on echocardiogram. Bloody pericardial effusion
~510cc's removed, ?malignancy. However no evidence of malignancy
cells seen on flow cytometry as well as cytology. W/u already
started at [**Hospital6 **] and so far studies negative
except for elevated ESR, CRP & CA 125. Required overnight CCU
stay after pericardial drain placed. Developed afib with RVR
during stay. No evidence of reaccumulation of fluid seen on
repeat echocardiogram or vital signs including nml pulsus.
.
# Atrial fibrillation with RVR: ?r/t pericardial effusion,
worsened after pericardiocentesis during which time she stayed
in the CCU given pericardial drain. She was treated with IV
metoprolol, diltiazem then finally started on an emsolol drip
for good control. This was weaned off with the onset of
Verapamil which was uptitrated during stay. Metoprolol was also
added for better rate control. The decision was made for no
anticoagulation given bloody pericardial effusion, pt was
continued on full strength aspirin.
.
# CT findings: Diffuse lymphadenopathy in the axillary,
supraclavicular and mediastinal regions with pulmonary nodules
in the left lung apex which were concering for neoplastic
process. Pt underwent L axillary lymph node biopsy for concern
of malignancy, ?Lung CA, lymphoma vs. other other cancers.
However, pathology was not diagnostic. Pt with no prior
colonoscopies or vaginal exams, however with nml mammograms &
per report, last [**3-/2144**] nml. Guaiac negative stools during
admission. Pt will need outpt evaluation for excisional lymph
node biopsy vs mediastinoscopy for tissue diagnosis, if desired
by the family.
.
# Abdominal distension: Appeared to be chronic, however worsened
acutely during admission. No evidence of volvulus, cholecystitis
or obstruction; imaging showed significant amounts of air with
colonic distention, likely colonic ileus. Surgery was consulted
and recommended endoscopic decompression per GI. However, GI
recommended rectal tube placement with was effective in
decompressing her abdomen. Pt initially made NPO, however
resumed regular diet gradually. had no episodes of nausea or
vomiting, however it was difficult to access abdominal pain. Per
GI, pt will require intermittent decompression with rectal tube
until ileus resolves. Also given possibility of malignancy, it's
recommended that pt under colonoscopy as part of further workup.
.
# Microcytic anemia: c/w anemia of chronic disease; low retic
count, however hematocrit stable. Guaiac negative stool x 1 in
the ED. We continued iron supplementation, ?other stools
guaiac'ed.
.
# Peripheral edema: Unclear if new, no evidence of chronic
venous stasis and no significant ascites seen on CT despite
abdominal distention. No evidence of proteinuria, however
sl.lower albumin. ?heart failure, however no other evidence on
PE. Liver function appears nml.
.
# Neurodermatitis: continued topicals
# DJD: continued celecoxib & tylenol.
.
DNR/DNI
Medications on Admission:
- Multivitamin 1 tab
- CaCo3 1250mg qdaily
- Celebrex 100 mg twice a day
- artifical tears PRN
- Eucerin cream topical every day,
- Vitamin E and Vitamin D ointments
- Chlorhexidine topical
- FeSo4 325 mg [**Hospital1 **]
- started on levaquin 500mg at NH today given transient hypoxia
.
ALLERGIES: NKDA
Discharge Medications:
1. Calcium Carbonate 500 mg (1,250 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO once a day.
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Celecoxib 100 mg Capsule Sig: One (1) Capsule PO bid ().
4. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic QID (4 times a day) as needed for dry eyes.
5. Eucerin Cream Sig: One (1) application Topical once a
day.
6. Glucosamine-Chondroitin Complx 500-400 mg Capsule Sig: Two
(2) Capsule PO twice a day.
7. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Capsule, Sustained Release PO twice a day.
8. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: 2.5
Tablet Sustained Release 24 hrs PO once a day.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) nebs Inhalation Q6H (every 6 hours) as needed for
wheezing, SOB.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of
breath, wheezing.
12. Verapamil 120 mg Tablet Sig: 1.5 Tablets PO Q8H (every 8
hours).
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) **] center
Discharge Diagnosis:
Pericardial tamponade s/p pericardiocentesis
Atrial fibrillation with RVR
Colonic ileus with abdominal distension s/p rectal decompression
Mental retardation
Degenerative joint disease
s/p volvulus with colonic resection
Discharge Condition:
stable
Discharge Instructions:
You were admitted with pericardial tamponade and you underwent
draining of the fluid around your heart. Laboratory analysis of
the fluid did not reveal a cause. You were also found to have
multiple enlarged lymph nodes in your chest. You had a biopsy of
one of these nodes that was not diagnostic. You should speak
with your doctor about having an excisional biopsy of one of
your lymph nodes.
During your hospitalization, you had abdominal distention from
an ileus that resolved with rectal tube decompression which
should be continued intermittently as needed.
.
MEDICATION CHANGES:
- start Toprol XL 125mg po daily, Verapamil 180mg po q8h
- Aspirin 325mg po daily
Continue to take your other medications as prescribed.
.
Please call your PCP or come to the ED if you develop chestpain,
shortness of breath or any other worrisome symptoms.
Followup Instructions:
Please f/u with PCP at the residence within 1 week of discharge.
You should discuss whether you should have a mediastinoscopy or
excisional biopsy of one of your lymph nodes.
Completed by:[**2144-7-7**]
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20,263
| 125,601
|
54196
|
Discharge summary
|
report
|
Admission Date: [**2196-4-22**] Discharge Date: [**2196-5-3**]
Date of Birth: [**2132-7-5**] Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
PICC
EGD
Colonoscopy
Blood transfusion
History of Present Illness:
66yo female with multiple medical problems including morbid
obesity, obstructive sleep apnea, COPD on 3 L O2, and likely
diastolic dysfunction was admitted from the ED with shortness of
breath.
She reports that she was in the hospital in [**2196-2-4**] for
shortness of breath thought related to a COPD and CHF
exacerbation. She was initially admitted to the MICU and then
transferred to the floor. She was treated with levofloxacin and
steroids with improvement in her symptoms. Her hospital course
was complicated by atrial fibrillation with RVR and guiac
positive stool. She was discharged to rehab, where she was for 3
weeks. She then was doing relatively well and had tapered off
her steroids. Then over the last 24-48 hours, she has had
increasing shortness of breath. Her O2 sat is typically 96% on
3L and had declined to as low as 91% on 3L. Review of systems is
also notable for wheezing. She has chronic lower extremity
swelling, orthopnea, paroxysmal nocturnal dyspnea, and dyspnea
on exertion, which has been relatively unchanged. She otherwise
denies fevers, shaking chills, night sweats, cough, nausea,
vomiting, chest pain, sputum production, and lower extremity
edema.
Review of systems is also notable for the following:
- history of DVT in the past and coumadin was discontinued early
due to melena.
On review of systems, she denies any prior history of stroke,
TIA, 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. She denies
exertional buttock or calf pain. All of the other review of
systems were negative.
Upon arrival to the ED, vital signs were 99.5, HR 130s, BP
151/125, RR 21, 100% on NRB. Exam with wheezing. ECG was
unremarkable. She received aspirin 325mg PO x 1 and 40mg IV
lasix with 850mL UOP. Desat'd to 90s 4L. Upon arrival to the
floor, she reports significant improvement in her breathing.
Past Medical History:
1. Morbid obesity
2. Obstructive Sleep Apnea
3. Hypertension
4. ?peptic ulcer disease (no documentation in the [**Hospital1 **] e-files)
5. Anemia
6. Asthma
7. COPD, O2 dependent
8. CHF with preserved EF
9. h/o DVT; Coumadin stopped because of melenic episode
Cardiac Risk Factors: Dyslipidemia, Hypertension
Cardiac History: CABG: none
Percutaneous coronary intervention: none
Pacemaker/ICD: none
Social History:
Social history is significant for the absence of current tobacco
use. Pt quit smoking in [**2172**]. There is no history of alcohol
abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Her family history is notable for multiple
family members with hypertension, father who died of lung
cancer, and mother who died of CVA and hypertension.
Physical Exam:
VS - T 97.6 / HR 70 / BP 88/36 / RR15 / Pulse ox 98% on 5L
Gen: obese female in no acute distress. 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; JVP difficult to assess given patient's body
habitus
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. harsh 3/6 systolic murmur heard best at the
LUSB. 3/6 systolic murmur heard also at the apex. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. scattered wheezes and
crackles bilaterally and throughout.
Abd: obese, 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.
Pertinent Results:
Admission Labs
[**2196-4-22**] 11:50AM BLOOD WBC-4.3 RBC-3.22* Hgb-8.9* Hct-28.8*
MCV-89 MCH-27.7 MCHC-31.0 RDW-17.5* Plt Ct-139*
[**2196-4-22**] 11:50AM BLOOD PT-13.5* PTT-25.5 INR(PT)-1.2*
[**2196-4-22**] 11:50AM BLOOD Glucose-108* UreaN-18 Creat-0.9 Na-144
K-5.0 Cl-99 HCO3-44* AnGap-6*
[**2196-4-22**] 11:50AM BLOOD CK-MB-NotDone proBNP-1577*
[**2196-4-22**] 11:50AM BLOOD cTropnT-0.02*
[**2196-4-22**] 11:50AM BLOOD CK(CPK)-30
[**2196-4-22**] 11:50AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.1
[**2196-4-23**] 11:03AM BLOOD Type-ART O2 Flow-4 pO2-68* pCO2-85*
pH-7.35 calTCO2-49* Base XS-16 Comment-NASAL [**Last Name (un) 154**]
[**2196-4-28**] 10:55AM BLOOD %HbA1c-5.4
Testing
[**2196-4-22**] ECG:
Atrial fibrillation with rapid ventricular response (118bpm).
Baseline artifact. Diffuse ST-T wave changes. Compared to the
previous tracing of [**2196-2-29**] ST-T wave changes in the inferior
leads are similar. No diagnostic interim change.
[**2196-4-22**] CXR:
1. Findings consistent with volume overload.
2. Bilateral pleural effusions, left greater than right.
3. Bibasilar atelectasis; underlying infection cannot be
excluded.
[**2196-4-26**] CXR:
In comparison with the study of [**4-24**], there may be mild
improvement
in pulmonary vascular status, though some of this may be related
to the
differences in technique. Enlargement of the cardiac silhouette
persists as does a small-to-moderate left pleural effusion with
left basilar atelectasis.
[**2196-5-2**] Colonscopy: Fair preparation
A single sessile 25 mm polyp of benign appearance was found in
the proximal ascending colon
Methylene blue 0.002% solution was injected submucosally beneath
the 25 mm in diameter proximal ascending colon polyp
successfully
Successful complete endoscopic mucosal resection (EMR) in a
piecemeal fashion of the 25 mm in diameter proximal ascending
colon was performed using a 15mm in diameter stiff snare
Successful argon plasma coagulation was performed on the entire
surface of the post-EMR site to prevent recurrence
A single sessile 6 mm polyp of benign appearance was found in
the proximal ascending colon. A single-piece complete
polypectomy was performed using a cold snare.
Small angioectasia without bleeding was identified in the
proximal ascending colon
Successful [**Hospital1 **]-Cap treatment was applied to the small
angioectasia identified in the proximal ascending colon
Multiple diverticula with medium openings were seen in the
descending colon and sigmoid colon. Diverticulosis appeared to
be of moderate severity.
Small grade 1 internal hemorrhoids were noted
Recommendations: Clear liquids when alert, awake, and at
baseline
Follow for response/complications
Please call should severe abdominal pain or rectal bleeding
occur
Please call Dr.[**Name (NI) 2798**] office ([**Telephone/Fax (1) 2799**]) in 10 days to
obtain biopsy results
Surveillance colonoscopy in 6 month's time after Golytely
preparation to reassess post-EMR site in the proximal descending
colon
Follow up with Dr. [**Last Name (STitle) 6431**] as needed
[**2196-5-2**] EGD: Normal mucosa in the esophagus
Erythema, congestion and nodularity in the antrum and stomach
body compatible with mild gastritis (biopsy)
Normal mucosa in the duodenum (biopsy)
Recommendations: Clear liquids when alert, awake, and at
baseline
Follow for response/complications
Call Dr.[**Name (NI) 2798**] office ([**Telephone/Fax (1) 2799**]) in 10 days to obtain
biopsy results
Continue current medications
Procede with colonoscopy today
Follow-up with Dr. [**Last Name (STitle) 6431**] as needed
Brief Hospital Course:
1. Acute on chronic diastolic HF: This, in addition to atrial
fibrillation and COPD (addressed below), likely contributed to
her dyspnea. Pateint was started on furosemide IV then
transitioned to a furosemide gtt and diuresed approximately 3L
daily. (LOS ~30L diuresed total). Then she was started on an
oral diuretic regimen of torsemide 80mg PO BID. This resulted in
marked improvement in her symptoms. Her oxygen requirement
slowly improved and she was weaned down to her home O2
requirement of 3L. Metoprolol was started and uptitrated to 75mg
[**Hospital1 **]. Potassium was repleted, this will continue daily as at
rehab with every other day lab checks. As her blood pressure
was borderline, an ACE-I was not initiated. This will be
discussed at her future cardiology outpatient appointment.
.
2. Atrial Fibrillation with RVR: She was initially on a
diltiazem drip for rate control, then transitioned to diltiazem
PO and metoprolol PO. Her rate was controlled to 70s-80s on this
regimen, although she remained in atrial fibrillation. She was
started on a full dose aspirin and heparin drip with plan to
bridge to warfarin, although she had recurrence of GI bleeding,
which is discussed below so heparin gtt was stopped and aspirin
was continued. At discharge, she was on aspirin for
anticoagulation only, with no coumadin as she has a high risk of
rebleeding. This will also be discussed at her future
cardiology appointment.
.
3. COPD: On 3L home O2. She had wheezing on initial exam which
subsequently improved so was not initially managed as COPD
exacerbation. She then complained of productive cough and
increased wheezing so was treated with a steroid taper, and 5
day course of azithromycin. Her prednisone taper will be
continued for 10mg for the next two days, followed by 5mg QD for
one week, followed by 5mg every other day for the last week,
then discontinued. She was also continued on her home regimen
of spiriva, fluticasone-salmeterol, montelukast, and [**Doctor First Name 130**].
Theophylline was discontinued due to adverse effects and narrow
therapeutic index as well as drug interaction. Weaned 02 down to
95% on 3L.
.
4. Hypertension: On admission, she was borderline hypotensive,
so her home BP medications were held. She was gradually
uptitrated on diltiazem and metoprolol, which was well
tolerated. Her hypotensive episodes were the reason behind not
starting an ACE-I during this hospital stay.
5. Anemia/Recurrent GIB: Patient was tried on a heparin drip for
her atrial fib, and had guaiac positive stools and a
downtrending hematocrit. She was continued on a [**Hospital1 **] PPI. The
heparin was stopped, although she continued to require
occasional blood transfusions, 4 units in total. GI was
consulted and performed EGD/colonoscopy, which showed polyp and
AVM in colon that were intervened upon, and mild gastritis in
stomach. GI recommended holding off anticoagulation for at least
7 and preferably 10 days after the procedure as well as follow
up colonoscopy in 6 months. The patient's pcp will help her
schedule this appointment.
Medications on Admission:
Unsure of her medications.
Discharge Medications after her previous hospitalizations
1. [**Doctor First Name **] 60mg PO bid
2. Docusate 100mg PO bid
3. Lasix 40mg PO daily
4. Spiriva 1 inh daily
5. Fluticasone-Salmeterol 500-50mcg q puff inh [**Hospital1 **]
6. Montelukast 10mg PO daily
7. Lisinopril 10mg PO daily
8. Pantoprazole 40mg PO bid
9. Ferrous Sulfate 325mg PO daily
10. Prednisone 40mg PO daily
11. Potassium Chloride
12. Diltiazem 180mg PO daily
13. Theophylline 100mg PO daily
Discharge Medications:
1. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Inhalation twice a day.
5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
8. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days.
11. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-5**]
Drops Ophthalmic PRN (as needed).
12. Torsemide 20 mg Tablet Sig: Four (4) Tablet PO BID (2 times
a day).
13. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
14. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation q4h () as needed for wheezing.
15. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for
2 days.
16. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO once a day.
17. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
7 days: start [**2196-5-6**].
18. Prednisone 5 mg Tablet Sig: One (1) Tablet PO every other
day for 7 days: start [**2196-5-13**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. COPD Exacerbation
2. Atrial Fibrillation
3. Acute Exacerbation of Chronic Diastolic Heart Failure
4. Morbid Obesity
5. Anemia
6. GI Bleeding
7. Urinary Tract Infection
Discharge Condition:
You are walking with a walker, eating, and breathing on your
home oxygen requirement of 3L.
Discharge Instructions:
You were admitted to the hospital with shortness of breath. This
was related to a COPD exacerbation, heart failure, and an
abnormal heart rhythm. For treatment of your COPD, you were
started on steroids and antibiotics. For treatment of your heart
failure, you were diuresed aggressively with lasix to remove a
lot of excess fluid. You also went into an abnormal heart rhythm
called atrial fibrillation, which you have had before. Atrial
fibrillation comes with a risk of stroke, but you have not been
able to take blood thinners due to bleeding in your GI tract.
You had a EGD and a colonoscopy performed which demonstrated a
polyp in your colon as well as a prominent artery both of which
were treated during the colonoscopy. You also had inflammation
in your stomach. You should not take motrin. Your breathing was
much improved upon discharge from the hospital.
.
We have made the following changes to your medications:
- theophylline: we have discontinued this medication due to
multiple drug interactions.
- coumadin: please do not restart this medication, until you
are seen by Dr. [**Last Name (STitle) 171**].
- diltiazem: we have increased this medication from once a day
to twice a day
- metoprolol: we have started this new medication to help treat
your heart rate
- Ciprofloxacin 500mg twice daily for 7 days (last dose 4/6 in
the am)
- torsemide 80mg by mouth twice daily
- prednisone: Will be tapered over the next weeks. You should
take 5mg every day for the next week. Then 5mg every other day
for the week after. After those two weeks this medication can
be discontinued.
-your combivent was discontinued, Spiriva was continued.
.
Please seek immediate medical attention if you develop shortness
of breath, chest pain, light-headedness, dizziness, passing out,
increased swelling in your legs or arms, weakness, slurred
speech, headache, fevers, shaking chills, night sweats, or
diarrhea.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5L
Followup Instructions:
Primary Care:
[**Doctor Last Name **],[**Month (only) 6436**] ([**Month (only) **]) Phone: [**Telephone/Fax (1) 1144**] Date/time: [**5-9**] at
10:40am.
.
Gastroenerology: Please call Dr.[**Name (NI) 2798**] office
([**Telephone/Fax (1) 2799**]) to follow up your biopsy results in 10 days.
Please then also schedule a follow up colonoscopy in 6 months.
.
Pulmonary:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 575**] Phone: ([**Telephone/Fax (1) 513**] Date/time: [**Hospital Ward Name 23**]
clinical Center, [**Location (un) 436**], [**Location (un) **]. Monday [**5-9**]
at 1:00pm for pulmonary function tests, then appt with Dr.
[**Last Name (STitle) 575**] at 1:30pm.
.
Cardiology:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2196-5-25**] 11:00
Completed by:[**2196-5-4**]
|
[
"491.21",
"278.01",
"599.0",
"211.3",
"455.0",
"518.0",
"569.85",
"401.9",
"280.0",
"427.31",
"327.23",
"562.10",
"416.8",
"428.33",
"511.9",
"535.00",
"276.4",
"428.0",
"041.85"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.42",
"45.43",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
12907, 12987
|
7618, 10697
|
285, 326
|
13221, 13315
|
4027, 7595
|
15399, 16350
|
2897, 3133
|
11239, 12884
|
13008, 13008
|
10723, 11216
|
13339, 14234
|
3148, 4008
|
14263, 15376
|
226, 247
|
354, 2303
|
13027, 13200
|
2325, 2725
|
2741, 2881
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,074
| 118,920
|
18964
|
Discharge summary
|
report
|
Admission Date: [**2156-6-8**] Discharge Date: [**2156-7-24**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1781**]
Chief Complaint:
Ruptured abdominal aortic aneurysm.
Major Surgical or Invasive Procedure:
[**2156-6-8**]
Emergent repair of ruptured infrarenal abdominal aortic aneurysm
with a 14 mm tube Dacron [**Last Name (LF) **], [**First Name3 (LF) **] aorto-to- left common femoral
artery bypass [**First Name3 (LF) **] with 8 mm Dacron.
[**2156-6-10**]
Second look for bleeding andincreasing bladder pressures status
post ruptured abdominalaortic aneurysm repair with a necrotic
rectosigmoid colon.
[**2156-6-12**]
Exploratory laparotomy, sigmoid colostomy, take down of splenic
flexure, cholecystectomy, abdominal washout, post pyloric tube
placement and placementof abdominal wall silo for closure and
maturation of stoma.
Exploration of aortic anastomosis.
[**2156-6-16**]
Exploratory laparotomy, take down of [**Location (un) 5701**] bag,irrigation,
debridement of facial edges an replacement ofDobhoff tube.
[**2156-6-21**]
Open tracheostomy.
History of Present Illness:
The patient is an elderly female who presented emergently to the
emergency room after being found down, hypotensive and in severe
abdominal and back pain. She
had a pulsatile mass and was hypotensive with a systolic blood
pressure of the 50s in the emergency department. She was brought
emergently to the operating room without imaging.
Past Medical History:
-COPD, never intubated, not on home O2
-HTN
-hyperlipid
-h/o "small" CVAs [**3-17**] amyloid angiopathy leading to word-finding
difficulty & aphasia; ?small hemorrhagic stroke seen on MRI
[**12-17**].
-?h/o colon CA
-spinal stenosis
-osteoporosis, s/p L hip fracture & R hip fracture
-glaucoma
Social History:
ambulates with walker
ALF resident
Family History:
NC
Physical Exam:
Pt deceased during this hospital stay.
At time of death:
neg corneal /pappilaary refexes
neg hr / pulse
neg breath sounds / chest wall movement
neg reflexes / withdrawal to painfull stimuli
Pertinent Results:
[**2156-7-24**]
PT-13.9* PTT-103.1* INR(PT)-1.3
[**2156-7-24**]
Glucose-162* UreaN-44* Creat-0.5 Na-138 K-4.6 Cl-107 HCO3-13*
AnGap-23*
[**2156-7-24**]
ALT-3 AST-14 AlkPhos-94 Amylase-26 TotBili-0.3
[**2156-7-24**]
Calcium-7.5* Phos-1.6* Mg-1.8
[**2156-7-24**]
Type-ART pO2-103 pCO2-31* pH-7.21* calHCO3-13* Base XS--14
[**2156-7-24**]
EEG
FINDINGS:
PUSHBUTTON ACTIVATIONS: There were none.
AUTOMATED SEIZURE DETECTIONS: There were none.
AUTOMATED SPIKE DETECTIONS: There were 567. As on prior days,
many
multi-focal independent spikes, sharp waves, and spike and slow
wave
discharges were seen. These were prominent over the left
parietal and
right posterior temporal regions, although discharges in other
locations were seen as well. Some discharges appeared to be left
occipital in location as well.
ROUTINE TIME SAMPLE: Showed a slow and disorganized background
throughout the entire recording. Frequent multi-focal
independent
epileptiform discharges as described above were seen on the
routine time
sampling, at times in runs of 10 to 15 seconds at a time
repeating
at a 1 Hz frequency. However, these discharges were never
prolonged,
persistent, or frequent enough to suggest ongoing seizures,
although
they occurred throughout the entire day's recording.
SLEEP: No clear state changes were seen.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This 24-hour video EEG portable telemetry captured
no
pushbutton activations. Although no discrete seizures were
detected,
there were frequent multifocal epileptiform discharges seen in
an
ongoing fashion throughout the day's recording, sometimes in
runs
lasting 10 to 15 seconds with a 1 Hz frequency. The background
was
suggestive of a mild to moderate encephalopathy. Overall, this
recording appears essentially unchanged from the prior day's.
Brief Hospital Course:
Pt deceased during this hospital stay
[**2156-6-8**] - [**2156-6-9**] ( intubated )
Pt was brought throught the ER: Vascular service notified.
Pt admitted to the SICU
Brought to the OR for:
Emergent repair of ruptured infrarenal abdominal aortic aneurysm
with a 14 mm tube Dacron [**Last Name (LF) **], [**First Name3 (LF) **] aorto-to- left common femoral
artery bypass [**First Name3 (LF) **] with 8 mm Dacron. Abdomen left open.
Transfered to the SICU in critical condition.
Pt on pressors.
Pt has swan ganz / aline / foley / ngt
Surgery consulted.
coagulapathy corrected
Plt 43k / HIT sent in / heparin items were DC'd.
HCT dorpped to 21 from 27
[**2156-6-10**] - [**2156-6-11**] ( intubated )
Second look for bleeding andincreasing bladder pressures status
post ruptured abdominalaortic aneurysm repair with a necrotic
rectosigmoid colon.
Pt brought back to the SICU in critical condition.
Remined on pressors
Pt became hypoxic with o2 in the 60's / lasix given / good
response
Nutrition consult
[**2156-6-12**] - [**2156-6-15**] ( intubated )
Pt brought back to the OR for:
Exploratory laparotomy, sigmoid colostomy, take down of splenic
flexure, cholecystectomy, abdominal washout, post pyloric tube
placement and placement of abdominal wall silo for closure and
maturation of stoma.
Exploration of aortic anastomosis.
Pt brought back to the SICU in critical condition.
Remained on pressors / AB
TPN started
WBC rising / pt becomes febrile - abdominal dressing taken down
/ wound edges necrotic
[**2156-6-16**] - [**2156-6-20**] ( intubated )
Pt brought back to the OR for:
Exploratory laparotomy, take down of [**Location (un) 5701**] bag,irrigation,
debridement of facial edges an replacement of Dobhoff tube.
Pt brought back to the SICU in critical condition.
AB continued / DHFT placed / TPN cont. / Lines changed / CX's
followed / attempt to wean from vent.
TF increased to decrease TPN
[**2156-6-21**] ( intubated )
CX positive for VRE / lineazolid started
[**2156-6-22**] - [**2156-6-24**] ( intubated )
Pt off propofol
responding minimally to painful stimuli
Head CT - no acute process seen / mental decline probably
secondary to metabolic changes
diuresis decreased
Nuerology consulted for sicu neurosis
Per nuerology steroids weaned for questionable steroid
inducedmyopathy / but probable cause is ICU neuropathy.
[**2156-6-25**] - [**2156-6-29**] ( intubated )
Pt remaines on antibiotics - afebrile
still has decreaed MS - pt does not track but opens eyes to
painfull stimuli
considering trach at this time.
[**2156-6-30**] ( intubated )
Pt recieves trach
[**2156-7-1**] - [**2156-7-7**]( intubated )
Mental status improves - steroids still being weaned
TF continued
Pt tranfused
AB continued
[**2156-7-8**] - [**2156-7-9**] ( intubated )
Abdominal wound suture begin to pull out / plastic surgery
consulted
still has low grade temp
remains awake and alert
[**2156-7-10**] ( intubated )
Pt begins rehab screening / OT consult obtained - long term care
planned
[**2156-7-11**] - [**2156-7-14**] ( intubated )
Abd granulating / but bowel still exposed
[**2156-7-15**] ( intubated )
DNR status being discussed with family
[**2156-7-16**] - [**2156-7-19**] ( intubated )
Pt experiences abrupt hypotension with a-fib / increase WBC /
spikes temperature
chemically converted / epi, levo, neo, vasopressin increased for
this episode
suspect sepsis for the aforementioned episode
Pt startes to experience seizures / loaded with dilantin
[**2156-7-20**] - [**2156-7-21**] ( intubated )
MRI of head obtained - neg for acute event.
Pt transfused
[**2156-7-22**] ( intubated )
AFVSS
decreease in u/o noted / pos anascaria / SBP 90's / CVP 15 /
increase creat - urine lytes are sent
[**2156-7-23**]
Pt experiences decrease in BP / hematuria / fingers are molted
b/l - but has 3 plus brachial pulses, toes are with cap refill
lactate checked
[**2156-7-24**] ( intubated )
Pt deteriorates quickly over the next 24 hrs
Cause of death: cardiac arrest
neg corneal /pappilaary refexes
neg hr / pulse
neg breath sounds / chest wall movement
neg reflexes / withdrawal to painfull stimuli
Medications on Admission:
Neurontin 300",
Zoloft 75,
Advair 500",
Cosopt",
Protonix 40,
Lopressor 12.5",
Lasix 20,
Lipitor 10
Discharge Medications:
N/A / pt deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A / pt deceased
Discharge Condition:
N/A / pt deceased
Discharge Instructions:
N/A / pt deceased
Followup Instructions:
N/A / pt deceased
Completed by:[**2156-12-14**]
|
[
"997.4",
"401.9",
"868.04",
"562.10",
"575.0",
"998.11",
"496",
"518.5",
"E878.9",
"995.91",
"998.83",
"441.3",
"557.0",
"272.0",
"998.59",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"00.14",
"54.12",
"38.44",
"51.22",
"99.04",
"96.6",
"96.72",
"48.62",
"31.1",
"54.3"
] |
icd9pcs
|
[
[
[]
]
] |
8356, 8365
|
3998, 8164
|
296, 1157
|
8426, 8445
|
2142, 3975
|
8511, 8560
|
1911, 1915
|
8314, 8333
|
8386, 8405
|
8190, 8291
|
8469, 8488
|
1930, 2123
|
221, 258
|
1185, 1524
|
1546, 1842
|
1858, 1895
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,352
| 180,544
|
44125
|
Discharge summary
|
report
|
Admission Date: [**2185-6-6**] Discharge Date: [**2185-6-13**]
Service: C-MED
CHIEF COMPLAINT: Chest pain, shortness of breath.
HISTORY OF PRESENT ILLNESS: Patient is an 85 year-old woman,
a resident of [**Hospital3 **] with the history of
coronary artery disease and congestive heart failure. She
has no prior history of intervention into her coronary
arteries, who developed and acute onset of chest pain and
shortness of breath around 11 P.M. the night of admission.
The patient was transferred to the [**Hospital1 190**] where she received aspirin and sublingual
nitroglycerin en route. In the emergency department her
electrocardiogram revealed deep around [**Street Address(2) 5366**] depressions
laterally and in the precordial leads the chest x-ray was
consistent with some pulmonary edema. The patient received
Lasix 40 mg intravenous times one and Captopril 25 mg times
one. Patient also received another sublingual nitroglycerin
after which her blood pressure dropped to around 60 systolic
for several minutes. The patient remained with her baseline
mental status throughout. She was given approximately 500 cc
of normal saline after diuresing for her hypotension. Her
blood pressure increased to around 100 systolic. Patient
described onset of her substernal chest pain with radiation
to the left arm, shortness of breath, no nausea, vomiting or
diuresis. At baseline she has positive three pillow
orthopnea and positive lower extremity edema. However,
possibly both of these have been worsening over the past few
days. The patient was still complaining of mild chest pain
in the emergency department and she finally received 0.5 mg
of intravenous morphine to which she responded well.
PAST MEDICAL HISTORY: 1) Coronary artery disease, status
post myocardial infarction in [**2183-9-9**]. 2) Congestive
heart failure. Patient has history of ejection fraction of
20 percent on echocardiogram in 8/[**2183**]. She has severe
global right ventricular hypokinesis. She also has severe
left ventricular dysfunction. On a Persantine median in
[**9-/2183**] she had reversible inferior defect in the apex which
was again not intervened upon at that time. 3) Patient has a
history of hypothyroidism. 4) Chronic urinary tract
infections. 5) Osteoporosis. 6) Choledocholithiasis, status
post papillotomy. 7) Status post appendectomy. 8)
Tuberculosis. 9) Colonic pseudo obstruction.
MEDICATIONS ON ADMISSION: Include Lopressor 12.5 mg p.o.
b.i.d., aspirin 325 mg p.o. q.d., Lasix 80 mg p.o. q. day,
Levoxil 25 mg p.o. q. day, potassium chloride 20 mg p.o. q
day and multivitamin 1 p.o. q. day, Axid 150 mg p.o. q. day,
calcium carbonate 650 mg p.o. t.i.d., Serax 10 mg p.o.
q.h.s., Zyprexa 5 mg p.o. q.h.s., Remeron 30 mg p.o. q.h.s.,
Plavix 75 mg q day and Captopril 25 mg p.o. t.i.d.
ALLERGIES: The patient has an allergy to penicillin.
SOCIAL HISTORY: She is a [**Hospital3 **] resident.
She has been Do Not Resuscitate, Do Not Intubate for some
time now and her health care proxy is her son who lives in
[**Name (NI) **].
PHYSICAL EXAMINATION: At the time of admission her blood
pressure was 156/52, pulse of 82, respirations 30, saturation
96 percent on 3 liters. She is afebrile. Generally she is
pleasant, alert and oriented and in no acute distress. Head,
eyes, ears, nose and throat examination: normocephalic,
atraumatic, extraocular movements intact. Oropharynx moist.
Neck: she had jugular venous pressure around 10 cm. Lungs:
she had a few crackles anteriorly. Cardiac examination:
Regular rate and rhythm, normal S1, S2 with II/VI systolic
ejection border at the left sternal border. Abdomen soft,
nontender, distended, obese with positive bowel sounds.
Extremities: she had about 3+ pitting edema bilaterally.
Her extremities were warm, however, pulses could not be
palpated.
LABORATORY DATA: At time of admission her white count 5.9,
hematocrit 37.0, platelets 207. Sodium 139, potassium 4.1,
chloride 100, bicarb 30, BUN 19, creatinine 0.8, glucose 205.
Her cardiacs were normal. Her initial CK was 85.
Electrocardiogram with [**Street Address(2) 5366**] depressions in lateral and
precordial leads.
HISTORY OF HOSPITAL COURSE: Patient was admitted to the [**Hospital Unit Name 196**]
service for possible coronary ischemia. She had her cardiac
enzymes cycled. Her second CK came back at 412 with an MB of
16. At that point patient was started on heparin drip. She
was continued on her aspirin and Plavix and beta blocker.
The patient had a history of medical management in the past.
However, this issue was readdressed with the health care
proxy, her son in [**Name (NI) **] who at this point decided that
cardiac catheterization is preferable from his standpoint.
She was catheterized on [**6-7**]. At that time it was noted
that she had an occluded LAD which 99.9 percent occluded with
faint collaterals filling from the distal LAD which was
stented. She also had 95 percent large left circumflex to OM
lesion which was also stented and her RCA was totally
occluded which was not intervened upon. The patient
initially did well after catheterization and returned to he
floor with stable vital signs. However, later in the evening
she developed increasing abdominal pain, hypotension with
systolic blood pressure decreasing to the 70s. The patient
was also noted to have tachypnea and hematocrit acutely
dropped. On examination she was found to have a large firm
area on her lower abdomen. She was sent to stat abdominal CT
which showed no evidence of retroperitoneal bleed. However,
it did show an intra-abdominal hematoma tracking from her
right groin at the site of the catheterization as well as a
small hematoma in the right groin. She was transfused and
the patient remained stable overnight after that with her
blood pressure increasing appropriately. The following day
the patient's hematocrit remained stable and the patient
continued to have abdominal pain for which she received
intermittent intravenous morphine with good relief. Her
lipids were checked and she was noted to have an LDL of 171,
HDL of 51 and total cholesterol of 254 at which time she was
started on Lipitor. Her beta blocker had been stopped on the
night of her episode of hypotension when her hematoma was
observed. It was restarted again on [**2185-6-8**] when the patient
did well. She also had an ultrasound of her right femoral
artery which showed evidence of a small pseudoaneurysm
measuring .92 x .92 cm with no evidence of arteriovenous
fistula. Surgery and vascular surgery were consulted who
felt that at this time there was no need for thrombin
injection and that the pseudoaneurysm would most likely
resolve on its own. The following morning on [**6-9**] the
patient had an episode of bradycardia and hypotension at
around noon with her heart rate decreasing to the 30s and her
systolic blood pressure remaining in the 60s to 70s despite
intravenous fluid for approximately an hour. The patient was
also transfused for a unit of blood. Vascular surgery was
called. We had a stat bedside ultrasound which showed that
the pseudoaneurysm was actually resolving. She was sent down
again for repeat stat abdominal CT scan which showed that the
intra-abdominal hematoma was actually smaller in side and the
pseudoaneurysm had likely thrombosed and the patient was
transferred to the Cardiac Care Unit for observation. The
patient did not require any pressors while in the Cardiac
Care Unit and her pressure and hematocrit remained stable
overnight. She was then transferred back to the floor where
she remained stable. Her Lopressor continued to be followed.
Of note, also while the patient was in the Cardiac Care Unit
there was an episode where she had a headache and some
difficulty speaking and some left arm weakness. They got a
stat head CT which was negative for events of bleed or acute
stroke. Her symptoms resolved within a few hours and
neurology was consulted. Neurology noted that she had no arm
weakness or difficulty speaking at the time of their
examination and it was felt that most likely event was
consistent with transient ischemic attack in the setting of
hypoperfusion. The patient was sent down for repeat head CT
several days later which showed again no evidence of acute
change and some evidence of old chronic infarct. Otherwise
the patient had a repeat chest x-ray on [**6-11**] which showed a
question of a right upper lobe opacity which had also been
seen on a portable chest x-ray on [**6-10**] which is concerning
for pneumonia so in spite of the fact that the patient
remained afebrile with stable white count it was felt that
the risks of not treating her pneumonia would be greater than
treating so the patient was started on Levofloxacin and
Flagyl. The patient was also diuresed gently once she
returned back to the floor and the plan is to return to
[**Hospital3 **] facility on Monday, [**2185-6-13**].
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Discharged to [**Hospital3 **].
DISCHARGE MEDICATIONS: Include: 1) ECASA 325 mg p.o. q day,
2) Plavix 75 mg p.o. q. day. This medication is to continue
indefinitely. Do Not Stop the Plavix after 30 days. 3)
Levofloxacin 500 mg p.o. q.d., discontinue [**2185-6-17**]. 4)
Flagyl 500 mg p.o. t.i.d., discontinue [**2185-6-17**]. 6) Captopril
12.5 mg p.o. t.i.d. 7) Calcium carbonate 500 mg p.o. t.i.d.
8) Multivitamin 1 tablet p.o. q day. 9) Zyprexa 5 mg p.o.
q.h.s. 10) Remeron 30 mg p.o. q.h.s. 11) Zantac 150 mg p.o.
q day. 12) Levothyroxine 25 mcg p.o. q day. 13) Lipitor 10
mg p.o. q.h.s. 14) Lasix 80 mg p.o. q day. 15) Potassium
chloride 20 mEq p.o. q. day.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post stents to LAD
and left circumflex on [**2185-6-7**].
2. Congestive heart failure with ejection fraction of
20 percent.
3. Osteoporosis.
4. Hypothyroidism.
5. Resolving intra-abdominal hematoma after cardiac
catheterization.
6. Pneumonia.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 900**] 12-248
Dictated By:[**Last Name (NamePattern1) 1203**]
MEDQUIST36
D: [**2185-6-12**] 10:28
T: [**2185-6-12**] 11:36
JOB#: [**Job Number 29972**]
|
[
"428.0",
"435.9",
"486",
"414.00",
"998.12",
"411.1",
"E879.0",
"412",
"442.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.02",
"37.22",
"36.06",
"88.53",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
8967, 9028
|
9694, 10265
|
9052, 9673
|
2452, 2885
|
4210, 8945
|
3097, 4192
|
108, 142
|
171, 1725
|
1748, 2425
|
2902, 3074
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,841
| 109,101
|
24174
|
Discharge summary
|
report
|
Admission Date: [**2104-6-8**] Discharge Date: [**2104-6-17**]
Date of Birth: [**2041-10-15**] Sex: F
Service: MEDICINE
Allergies:
Lipitor
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
MRCP
Quadricep Muscle Biopsy
History of Present Illness:
62 yo f w/PMH of hypercholesterolemia, CABGx4, HTN that presents
w/ progressive myalgia of bilateral shoulders, triceps &
quadriceps. On the morning of [**2104-6-8**], pt felt weak, used hands
to raise from bed and once had reached her toilet could not
stand up. Needed assistance to get up from toilet & decided to
go to ED. Pt feels decr ROM in shoulder abduction & quadricep
extension, feels legs "weigh 100lbs", and weakness that has been
progressively gotten worse since she began on Atorvastatin
post-op. Her PMH is significant for CABGx4 on [**2104-3-5**]. Pt
complains of malodorous breath, nauseated after eating w/some
vomit, itchiness of scalp, forearm & feet. Pertinent neg: (-)
rebound tenderness, (-)TTP, no RUQ pain on inspiration,(-)
fever, no mental status changes, no palmary erythema; no rashes,
lumps, skin dryness, dermal color changes; no headache,
dizzyness, lightheadness; no hematurea, polyurea, oliguria,
dysurea; no diarrhea, constipation, stool color changes.
In the ED @833a, pt's VS:T 97.2 BP 122/75 HR 74 RR 18 O2 sat
100% pain [**8-18**]. EKG showed no ST wave changes, nl axis, nl
interval , nl sinus rhythm w/reg rate @60bpm. Liver/gallbladder
u-sound showed no signs of cholecystitis & no R kidney, L kidney
was 14cm. U/A significant for hematurea & slight proteinurea 30.
Notable labs include elevated LFTs: ALT 578, AST 1354, AP 1113,
Tbil 5.6, Dbili 4.4; elevated lipsase 350; elevated CK 22,215;
hyponatremia 128, hyperphosphatemia 5.2, hypomagnesiemia 2.7;
elevated BUN 52 & creat 3.1. Incr WBC 11.4 w/L-shift. Incr
sed-rate @ 45. Folate catheter placed. Received 1L 150cc/hr nl
saline, 1L D5W w/NaHCO3 150mEq.
In the floor, pt's VS: T 98.3 BP 120/60 Pulse 88 RR 20 97%O2sat
w/pain 0/10. On PE, pt still felt pain near the spinal scapula
bilaterally w/decr ROM when abducting, had quadricep flexion
weakness yet nl sensory function. Nl MSE & cognitive assesment.
Pt had scleral icterus, nl abdomen w/high pitch high frequency
bowel sounds, unpalpable liver & splenic borders.
Past Medical History:
-CABGx4 repair: On [**2104-3-1**] pt presents to [**Last Name (un) 1724**] w/ substernal
chest pain; cath lab showed severe occlusion of obtuse marginal,
LAD septal branch, LAD diagonal & L circumflex arteries. CABG
repair done using saphenous v & internal mammary arteries.
Received 2 u of packed RBCs. Discharged w/Atorvastatin.
-Hypercholesterolemia: Currently controlled w/atorvastatin
-HTN: Controlled w/Lisinopril/Metropolol.
Social History:
Works at for Partner's in [**Hospital1 **] Occupational Health [**Doctor Last Name **]
Division. Lives alone at home, but has male partner who visits.
No EtOH hx. Smoked 4 cigarettes/day from young age until
[**2104-3-4**].
Family History:
Mother suffered from angina & died @70; father died @ 57 from
CHF & was EtOH abuser. Two maternal uncles who had an MI at the
age of 42, and one at the age of 60. Older brother has DM, 2
cardiac stents. Sister dx w/breast cancer in her 40s
Physical Exam:
VS: T 98.3 BP 120/60 Pulse 88 RR 20 97%O2sat
GEN: Well-appearing female in NAD
HEENT: NC/AT, no LAD, +scleral icterus bilaterally
NEURO: PERRL, EOMI; V, VII-XII intact
MSE: Oriented to time, place, location; nl immediate & lag
recall of 3 words, draws clock hand w/slight hand deviation.
ABDOMEN: non-distended abdomen w/o surgical scars, high pitch
high freq bowel sounds, no TTP, no rebound tenderness,
unpalpable liver & spleen, no renal/epigastric bruits. No
[**Doctor Last Name **] sign. Nl percussion of abdomen w/o signs of ascites.
CARDIO: nl S1 S2 yet loud, slight tachycardia, no m/g/r
RESP: CTAB, no CVA, nl percussion from apex to base, tender
bilaterally near the spinal scapula, non-tender spine.
MUSK: UE: nl motor strength. L LE: weak hamstring 3+, weak
quadricep 3+, weak abduction 4+, otherwise normal; R LE: weak
hamstring 4+, weak quadricep 4+; other wise normal.
SKIN: No rashes, lumps, bumps.
EXTREMITIES: No signs of peripheral edema
PSYCH: Affable & responsive; reliable historian
Pertinent Results:
Admission labs:
[**2104-6-8**] 07:50PM GLUCOSE-104 UREA N-48* CREAT-2.7* SODIUM-143
POTASSIUM-3.9 CHLORIDE-112* TOTAL CO2-18* ANION GAP-17
[**2104-6-8**] 07:50PM ALT(SGPT)-450* AST(SGOT)-1087* CK(CPK)-[**Numeric Identifier 61415**]*
ALK PHOS-806* TOT BILI-3.9*
[**2104-6-8**] 07:50PM PT-13.9* PTT-28.5 INR(PT)-1.2*
[**2104-6-8**] 11:35AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2104-6-8**] 11:35AM URINE RBC-[**3-13**]* WBC-0-2 BACTERIA-0 YEAST-NONE
EPI-0
[**2104-6-8**] 09:00AM GLUCOSE-131* UREA N-52* CREAT-3.1*#
SODIUM-128* POTASSIUM-5.0 CHLORIDE-96 TOTAL CO2-16* ANION
GAP-21*
[**2104-6-8**] 09:00AM ALT(SGPT)-578* AST(SGOT)-1354* CK(CPK)-[**Numeric Identifier 61416**]*
ALK PHOS-1113* AMYLASE-227* TOT BILI-5.6* DIR BILI-4.4* INDIR
BIL-1.2
[**2104-6-8**] 09:00AM LIPASE-350* GGT-528*
[**2104-6-8**] 09:00AM ALBUMIN-3.7 CALCIUM-9.4 PHOSPHATE-5.2*
MAGNESIUM-2.7*
[**2104-6-8**] 09:00AM TSH-0.39
[**2104-6-8**] 09:00AM WBC-11.4* RBC-4.80 HGB-14.3 HCT-43.1 MCV-90
MCH-29.9 MCHC-33.3 RDW-15.6*
[**2104-6-8**] 09:00AM NEUTS-86.7* LYMPHS-8.3* MONOS-4.0 EOS-0.8
BASOS-0.4
[**2104-6-8**] 09:00AM PLT COUNT-323
[**2104-6-8**] 09:00AM SED RATE-45*
.
Liver/Gall bladder ([**2104-6-8**]): 1. Two small hemangiomas in the
liver.
2. Gallstone with no ultrasound evidence of cholecystitis.
3. Right kidney not seen; could be agenesis or ectopic kidney.
Left kidney
measures 14 cm.
.
MRCP ([**2104-6-8**]): 1. No biliary obstruction. Normal-appearing
intra- and extra-hepatic biliary ducts. 2. Pancreas divisum. The
pancreas demonstrates a normal signal without ductal dilatation.
3. Solitary left kidney, with edema and loss of corticomedullary
differentiation, as seen in acute renal failure. No
hydronephrosis. 4. Edema in the musculature of the flanks and
paraspinal muscles, consistent with the history of recent
rhabdomyolysis.
.
Muscle Biopsy Right Thigh ([**2104-6-14**]): pathology pending
.
INR Trend:
[**6-8**] 1.2
[**6-10**] 2.2
[**6-11**] 1.7
[**6-12**] 2.1
[**6-13**] 2.0
[**6-14**] 3.4
[**6-14**] 5.8
[**6-15**] 1.1
[**6-16**] 1.0
[**6-17**] 1.0
.
Creat Trend:
[**6-8**] 3.1
[**6-8**] 2.7
[**6-9**] 2.7
[**6-10**] 2.2
[**6-11**] 1.9
[**6-12**] 1.7
[**6-13**] 1.5
[**6-14**] 1.2
[**6-15**] 1.1
[**6-16**] 1.0
[**6-17**] 1.0
.
CK Trend:
[**6-8**] [**Numeric Identifier 61416**]
[**6-8**] [**Numeric Identifier 61415**]
[**6-9**] [**Numeric Identifier **]
[**6-10**] [**Numeric Identifier **]
[**6-11**] [**Numeric Identifier 61417**]
[**6-12**] [**Numeric Identifier 21712**]
[**6-13**] [**Numeric Identifier 24508**]
[**6-14**] [**Numeric Identifier 61418**]
[**6-15**] [**Numeric Identifier 61419**]
[**6-16**] [**Numeric Identifier 61420**]
[**6-17**] 6784
.
HBsAg NEGATIVE
HBsAb BOREDERLINE
HBcAb NEGATIVE
HAV NEGATIVE
HCV NEGATIVE
AMA NEGATIVE
Smooth NEGATIVE
[**Doctor First Name **] NEGATIVE
SPEP Pending
Acetaminophen NEG
ALPHA-1-ANTITRYPSIN PND
CERULOPLASMIN PND
IGG HERPES SIMPLEX VIRUS 1 AND 2 PND
IGM HERPES SIMPLEX VIRUS 1 AND 2 PND
SOLUBLE LIVER ANTIGEN (SLA) ANTIBODIES PND
.
Discharge labs:
[**2104-6-17**] 05:34AM BLOOD WBC-8.5 RBC-3.21* Hgb-9.5* Hct-27.9*
MCV-87 MCH-29.6 MCHC-34.1 RDW-16.2* Plt Ct-286
[**2104-6-15**] 04:50PM BLOOD Neuts-78.8* Lymphs-15.0* Monos-3.7
Eos-1.8 Baso-0.6
[**2104-6-17**] 05:34AM BLOOD PT-11.6 INR(PT)-1.0
[**2104-6-17**] 05:34AM BLOOD Glucose-92 UreaN-13 Creat-1.0 Na-138
K-2.9* Cl-99 HCO3-34* AnGap-8
[**2104-6-17**] 05:34AM BLOOD ALT-685* AST-758* CK(CPK)-6784*
AlkPhos-647* TotBili-2.6*
[**2104-6-17**] 05:34AM BLOOD Albumin-2.1*
Brief Hospital Course:
#. Acute Hepatic Dysfunction: On admission patient had ALT 578,
AST 1354, ALP 1113, T-BIL 5.6, D-BIL 4.4, Lipase 350, Amylase
227. Patient had scleral icterus and malodorous breath; no
visible signs of encephalopathy, no hepatosplenomegaly and no
abdominal tenderness. Extrahepatic causes ruled out from normal
MRCP & abodminal ultrasound that failed to show biliary tract
dilation and obstruction. Intrahepatic causes were ruled out
including viral hepatitis (negative Hep A, Hep B & C serologies)
& autoimmune hepatitis (anti-smooth, anti-mitochondrial,
anti-[**Doctor First Name **]). It was thought that most likely cause was
statin-induced hepatoxicty resulting in painless cholestatic
jaundice. On [**2104-6-11**] however, liver function tests starting
increasing with worsening of synthetic liver function. Liver
consult team was consulted and were considering liver biopsy if
liver function continued to worsen. Additional tests such as
ceruloplasmin, anti-SLA, HSV serology and alpha-1-antitrypsin
were sent. Her synthetic function continued to worsen with INR
trending from 1.7 to 5.8 over the course of 2 days. It was felt
that she may be developing fulminant hepatic failure at that
time and she was transferred to MICU for closer monitoring as
well as evaluated by liver transplant surgery for possible
transplant. Mental status was normal. Her next INR was measured
at 2.2 however with only 5mg subcutaneous vitamin K administered
between the 2 measurements and she was transferred back to the
floor. On the floor, INR continued to trend down and was 1.0 at
time of discharge. Etiology of liver failure not entirely clear,
but felt to be most likely related to statins. She will follow
up in liver clinic as an outpatient 1 week after discharge. She
will need liver function tests monitored every other day for 1
week then weekly afterwards.
.
#. Rhabdomyolysis: Patient presented with proximal muscle
weakness and was found to have severe rhabdomyolysis, likely
statin-induced. On admission patient had an inability to abduct
shoulder and flex quadriceps secondary to pain. CK levels
improved from 22,215 on admission to 15,900 on [**2104-6-12**] with IV
fluids, however then worsened to 23,500 despite continued
fluids. At time this time it was decided to proceed with muscle
biopsy as she was worsening after an initial improvement. Muscle
biopsy results were still pending at time of discharge, however
CK's started trending down again and were 6784 at time of
discharge. Her IV fluids were discontinued but oral fluids
should be encouraged for 1-2 liters daily. Patient was able to
ambulate with minor assistance. Physical therapy was consulted
and the decision was made to send the patient to a
rehabilitation facility for the improvement of her proximal
muscle weakness.
.
#. Acute Renal Failure: Most likely mechanism is statin-induced
rhabdomyolysis causing myoglobinurea leading to tubular
obstruction and acute renal failure. Patient was treated with
aggressive IV fluid resuscitation for 9 days. Patient's creatine
improved from 3.1 on admission to 1.0 at time of discharge.
Patient should have routine BUN/creat levels checked weekly
after discharge.
.
# Hypokalemia: Patient has several episodes of hypokalemia to
2.9 likely from IV fluid resuscitation. She was repleted without
difficulty. Potassium 2.9 on morning of discharge and she was
repleted with 40mg IV and 40mg PO potassium. Potassium should be
checked daily until normal for 2 consecutive days.
.
#. Volume overload: Development of trace edema in feet, arms &
legs on day 4 of hospitalization that progressively worsened as
IV fluid resuscitation was continued. However, no signs of
crackles, wheezes were noted and she had no oxygen requirement.
She received IV lasix with IV fluids for forced diuresis. She
will continue to mobilize fluids as her mobility improves and IV
fluids are discontinued. She may receive additional diuresis
with lasix if her creatinine remains stable.
#. CAD: Patient with history of On admission patient denies
chest pain. Lisinopril and statin were held as above. She was
continued on her Metoprolol and ASA. Patient remained
normotensive throughout hospitalization with no evidence of
active ischemia. Lisinopril should be restarted when CK returns
to a completely normal value and creatinine is at baseline.
#. Hyperlipidemia: On admission patient was on atorvastatin 80mg
daily for lipid control. This was discontinued as described
above and statins are now described as an allergy and
contra-indicated for this patient. She has history of CAD with
recent CABG therefore needs better control of her cholesterol
with a different [**Doctor Last Name 360**]. She will be referred to lipid clinic
for consideration of another treatment regimen to reduce her
hyperlipidemia once liver function recovers.
.
# Dispo: Patient was discharged to rehab for continued physical
therapy
Medications on Admission:
Atorvastatin 80 mg PO daily
Ibuprofen 400mg PO TID PRN
Lisinopril 5 mg PO daily
Metoprolol Tartrate 50 mg TID
Aspirin 325 mg PO daily
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4316**] Rehab & [**Hospital **] Care Center [**Location (un) **]
Discharge Diagnosis:
Primary:
-Rhabdomyolysis induced by statins
-Statin-induced cholestastic jaundice
-Acute liver failure
-Acute renal failure, [**2-11**] Pigmented Nephropathy
Secondary:
-Hypertension
-Hyperlipidemia
-Coronary Artery Disease
Discharge Condition:
Good. Hemodynamically stable and afebrile.
Discharge Instructions:
It was a pleasure taking care of you during your recent stay at
[**Hospital1 18**]. You were admitted with muscle pain and weakness and found
to have muscle breakdown related to statin use. We stopped the
statin, gave you fluids and provided physical therapy.
You also showed signs of liver damage likely from the statin as
well. You will need to follow up in the liver clinic as
directed.
The following changes were made to your medications:
1) Stop Atorvastatin
2) HOLD Lisinopril - this will be restarted at rehab
Please call Dr. [**Last Name (STitle) **] if you feel worsening muscle
soreness, weakness, chest pain, shortness of breath,
lightheadedness, fevers, chills or any other symptoms that are
concerning to you
Followup Instructions:
Please follow-up with PCP [**Name Initial (PRE) 176**] 2 weeks after discharge.
Please follow up in liver clinic as directed below.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2104-6-25**] 11:30
Completed by:[**2104-6-17**]
|
[
"728.88",
"414.00",
"359.4",
"V45.81",
"E942.2",
"286.7",
"577.0",
"285.9",
"584.9",
"570",
"276.6",
"276.8",
"272.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.21"
] |
icd9pcs
|
[
[
[]
]
] |
13511, 13614
|
7955, 12858
|
277, 307
|
13883, 13928
|
4355, 4355
|
14701, 15018
|
3072, 3313
|
13042, 13488
|
13635, 13862
|
12884, 13019
|
13952, 14678
|
7457, 7932
|
3328, 4336
|
229, 239
|
335, 2358
|
4371, 7441
|
2380, 2814
|
2830, 3056
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,149
| 105,406
|
19749
|
Discharge summary
|
report
|
Admission Date: [**2149-4-20**] Discharge Date: [**2149-4-29**]
Date of Birth: [**2126-4-3**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
MVA complaining of back pain.
Major Surgical or Invasive Procedure:
Anterior T11 corpectomy with T10-12 fusion
Posterior thoracolumbar fusion T8-L1
History of Present Illness:
Mr. [**Known lastname 53387**] was involved in a high speed MVA where he sustained a
T11 burst fracture. He had no left leg movement in the EW and
sensation was patchy throughout both lower extremities.
Past Medical History:
None
Social History:
+ alcohol socially
Family History:
N/C
Physical Exam:
NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at biceps, triceps, wrist extension and
flexion, finger extension and flexion and intrinsics; sensation
intact in all dermatomes; reflexes intact at biceps, triceps and
brachioradialis
LLE- 0/5 strength at hip flexion and
extension/abduction/adduction, knee flexion and extension, ankle
dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation patchy
RLE- 5/5 strength at hip flexion and
extension/abduction/adduction, knee flexion and extension, ankle
dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation patchy
Pertinent Results:
[**2149-4-28**] 07:00AM BLOOD WBC-13.2* RBC-3.08* Hgb-9.5* Hct-27.5*
MCV-90 MCH-30.9 MCHC-34.5 RDW-14.9 Plt Ct-337
[**2149-4-27**] 07:00AM BLOOD WBC-14.9* RBC-3.24* Hgb-9.9* Hct-28.0*
MCV-87 MCH-30.7 MCHC-35.5* RDW-15.4 Plt Ct-303
[**2149-4-26**] 10:28PM BLOOD WBC-16.0* RBC-3.27* Hgb-10.2* Hct-28.2*
MCV-86 MCH-31.3 MCHC-36.2* RDW-15.3 Plt Ct-275
[**2149-4-24**] 04:59AM BLOOD WBC-10.6 RBC-2.77* Hgb-8.9* Hct-25.0*
MCV-90 MCH-32.2* MCHC-35.7* RDW-12.6 Plt Ct-204
[**2149-4-23**] 06:24PM BLOOD WBC-14.9*# RBC-3.02* Hgb-9.5* Hct-27.6*
MCV-91 MCH-31.6 MCHC-34.6 RDW-12.7 Plt Ct-212
[**2149-4-27**] 07:00AM BLOOD Glucose-118* UreaN-7 Creat-0.5 Na-137
K-4.0 Cl-100 HCO3-31 AnGap-10
[**2149-4-24**] 04:59AM BLOOD Glucose-140* UreaN-8 Creat-0.6 Na-138
K-4.2 Cl-102 HCO3-29 AnGap-11
[**2149-4-23**] 06:24PM BLOOD Glucose-180* UreaN-11 Creat-0.5 Na-141
K-4.1 Cl-107 HCO3-26 AnGap-12
[**2149-4-22**] 01:32AM BLOOD Glucose-109* UreaN-18 Creat-0.7 Na-142
K-3.8 Cl-107 HCO3-26 AnGap-13
[**2149-4-27**] 07:00AM BLOOD Calcium-8.0* Phos-3.3 Mg-2.1
[**2149-4-23**] 10:28PM BLOOD Calcium-7.8* Phos-4.2 Mg-1.8
[**2149-4-22**] 01:32AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.5
Brief Hospital Course:
Mr. [**Known lastname 53387**] was admitted to the trauma service for evaluation of
his T11 burst fracture, Grade 1 liver laceration and corneal
abrasion. He was informed and consented for the T11
vertebrectomy and elected to proceed. He was subsequently taken
to the OR by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for a anterior thoracotomy with T11
vertebrectomy and T10-12 stabilization. A chest tube was placed
post-operatively which was managed with suction. He was then
taken back to the OR for posterior stabilization spanning T9-L1.
During this case the chest tube was removed. Please see
Operative Notes for procedures in detail.
The Grade 1 liver laceration will be managed non-operatively by
the Trauma service and no further follow up was required. He
was given erythromycin for his corneal abrasion.
Post-operatively he was administered antibiotics and pain
medication. His catheter and drain were removed POD 3 and he
was able to take PO's. He was able to work with physcial
therapy to improve his strength and balance. At the time of
discharge he had no movement of his left leg and sensation
remained patchy. His pain was well controlled and he remained
afebrile throughout his hosptial course. He will return to
clinic in ten days. He was discharged in stable condition.
Medications on Admission:
None
Discharge Medications:
1. Erythromycin 5 mg/g Ointment Sig: One (1) application
Ophthalmic QID (4 times a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
9. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
10. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
T11 fracture with spinal cord injury
Grade 1 liver laceration
Corneal abrasion
Discharge Condition:
Good
Discharge Instructions:
Please continue to take your pain medication with an over the
counter laxative. Call the clinic if you notice any redness or
discharge from the incision site. Call the clinic for any
additional concerns.
Physical Therapy:
Activity: Activity as tolerated
Thoracic lumbar spine: when OOB
Treatments Frequency:
Please continue to change the dressing daily with dry, sterile
gauze.
Followup Instructions:
Please follow up in the Spine Clinic to schedule an appointment.
Please call [**Telephone/Fax (1) 11061**].
Completed by:[**2149-4-29**]
|
[
"780.6",
"305.1",
"E815.0",
"918.1",
"806.29",
"285.1",
"864.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.63",
"81.62",
"84.51",
"96.71",
"77.89",
"99.04",
"81.04",
"81.05",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
5119, 5189
|
2556, 3891
|
348, 430
|
5312, 5319
|
1382, 2533
|
5753, 5893
|
743, 748
|
3946, 5096
|
5210, 5291
|
3917, 3923
|
5343, 5550
|
763, 1363
|
5568, 5637
|
5659, 5730
|
279, 310
|
458, 663
|
685, 691
|
707, 727
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,898
| 187,225
|
8027
|
Discharge summary
|
report
|
Admission Date: [**2175-5-2**] Discharge Date: [**2175-5-9**]
Date of Birth: [**2116-1-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Bactrim Ds
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
59 year old woman with recent chest pain admitted for cardiac
catheterization. Cath showed diffuse 3VD, patient referred to
cardiac surgery.
Major Surgical or Invasive Procedure:
CABG x3(LIMA-LAD, SVG-OM, SVG-PDA) [**5-2**]
History of Present Illness:
59 yo woman admitted for cardiac cath that revealed 3vd. She was
then referred to cardiac surgery for intervention
Past Medical History:
Type 1 DM (HgbA1c 8.8 [**4-11**])
Hypothyroidism
HTN
Hyperlipidemia
Depression
h/o Pyelonephritis
h/o UTI
Hearing loss
Cervical Spndylosis
Social History:
Social history is significant for the absence of current tobacco
use. Quit tobacco 30 yrs ago, with 13 pack year history. There
is no history of alcohol abuse. Lives in [**Location **] with male
partner
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father with CABG in his 70s.
Physical Exam:
Admission
VS T 97.8 HR 75 BP 131/66 RR 16 O2sat 97% RA
Gen NAD
Neuro Alert, non-focal exam
Skin Unremarkable
Pulm CTA- bilat
CV RRR no murmur
Abdm soft, NT/+BS
Ext warm, well perfused, no edema or varicosities
Discharge
VS T 98.1 HR 64 SR BP 135/58 RR 18 O2sat 94%-RA
Gen NAD
Neuro A&Ox3, nonfocal exam
Pulm CTA-bilat
CV RRR, no murmur. Sternum stable incision CDI
Abdm soft, NT/+BS
Ext warm 1+ pedal edema bilat. SVG site w/steri strips CDI
Pertinent Results:
[**2175-5-8**] 10:10AM BLOOD Hct-23.3*
[**2175-5-7**] 03:45PM BLOOD WBC-12.3* RBC-2.49* Hgb-7.8* Hct-23.0*
MCV-92 MCH-31.3 MCHC-33.9 RDW-14.0 Plt Ct-259
[**2175-5-2**] 12:53PM BLOOD PT-14.6* PTT-45.7* INR(PT)-1.3*
[**2175-5-8**] 05:45AM BLOOD Glucose-88 UreaN-47* Creat-1.7* Na-136
K-4.7 Cl-101 HCO3-27 AnGap-13
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2175-5-8**] 10:10AM 23.3*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2175-5-9**] 05:20AM 268* 41* 1.7* 134 4.5 102 22 15
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2175-5-9**] 05:20AM 8.6 2.9 1.9
CHEST (PA & LAT) [**2175-5-7**] 8:33 AM
CHEST (PA & LAT)
Reason: r/o inf, eff
[**Hospital 93**] MEDICAL CONDITION:
59 year old woman with
REASON FOR THIS EXAMINATION:
r/o inf, eff
CHEST
HISTORY: CABG, pneumothorax.
Comparison with [**2175-5-5**]. Small bilateral pleural effusions and
subsegmental atelectasis in the lower left lung are again
demonstrated. The patient is status post median sternotomy and
CABG as before. The left heart border is not well delineated,
but mediastinal structures appear stable. Compared with the
previous study, volume loss in the left lung has probably
improved. The stomach is no longer distended with air. The very
small left apical pneumothorax is no longer apparent.
IMPRESSION: Interval improvement and volume loss in the left
lung. A left apical pneumothorax is no longer apparent.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 28715**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 28716**] (Complete)
Done [**2175-5-2**] at 9:04:47 AM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2116-1-1**]
Age (years): 59 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Chest pain. Left ventricular function. Preoperative
assessment.
ICD-9 Codes: 440.0, 424.0
Test Information
Date/Time: [**2175-5-2**] at 09:04 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW4-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm
Aorta - Annulus: 2.0 cm <= 3.0 cm
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.3 cm <= 3.0 cm
Aorta - Ascending: 2.7 cm <= 3.4 cm
Aorta - Descending Thoracic: 1.9 cm <= 2.5 cm
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician
Brief Hospital Course:
Ms [**Known lastname **] was a direct admission to the operating room on [**5-2**]
at which time she had a CABG x3 with a LIMA-LAD, SVG-OM,
SVG-PDA, her bypass time was 68 minutes with a crossclamp of 56
minutes. She tolerated the operation well and was transferred to
the cardiac ICU in stable condition. She remained
hemodynamically stable in the immediate post-op period and was
extubated. On POD1 she continued to do well and was tansferred
to the post-op cardiac floors for continued care. She had rapid
atrial fibrillation which converted with IV lopressor. She was
lethargic and was found to be taking her own valium, which was
then taken from her. She was confused and She required a 1:1
sitter. Her mental status improved. She continued to progress
in her activity level and was ready for discharge home on POD
#7.
Medications on Admission:
Adderall 30'
ASA 81'
Cymbalta 60'
folate/B12 1 pkt qd
Lantus 20u QD
Humalog sliding scale
Synthroid 175'
Lisinopril/HCTZ 20/12.5 2tabs QD
Lorazepam 2mg [**Hospital1 **]/PRN
Metoprolol 50"
Simvastatin 40'
Wellbutrin XL 300'
CaCO3 600"
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Adderall XR 30 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO daily: resume preop schedule.
5. Bupropion 150 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO QAM (once a day (in the morning)): resume
preop schedule.
6. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day): resume
preop schedule.
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
12. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
13. Insulin Glargine 100 unit/mL Solution Sig: resume preop
schedule Subcutaneous once a day.
14. Humalog 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day: resume preop schedule/scale.
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
s/p CABG x3(LIMA-LAD, SVG-PDA, SVG-OM)[**5-2**]
PMH: HTN, ^chol, DM1, CRI(1.6), Hypothyroid, Depression,
cervical spondylosis, C-section x2, Carpal tunnel release,
depression
Discharge Condition:
stable
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no swimming or bathing.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds.
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr [**First Name8 (NamePattern2) **] [**Last Name (STitle) 9006**] [**Telephone/Fax (1) 250**] in [**2-5**] weeks
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2386**] in [**2-5**] weeks
Dr [**Last Name (STitle) **] in 4 weeks
Completed by:[**2175-5-9**]
|
[
"427.31",
"414.01",
"969.4",
"401.9",
"593.9",
"311",
"272.4",
"721.0",
"250.01",
"E853.2",
"244.9",
"292.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.72",
"39.61",
"39.63",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
9079, 9140
|
6282, 7110
|
415, 462
|
9359, 9368
|
1613, 2352
|
9570, 9909
|
1014, 1125
|
7394, 9056
|
2389, 2412
|
9161, 9338
|
7136, 7371
|
9392, 9547
|
5492, 6259
|
1140, 1594
|
235, 377
|
2441, 5448
|
490, 606
|
629, 777
|
793, 998
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,074
| 165,473
|
51673+59370
|
Discharge summary
|
report+addendum
|
Admission Date: [**2152-9-7**] Discharge Date: [**2152-9-14**]
Date of Birth: [**2086-7-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatigue and Dyspnea
Major Surgical or Invasive Procedure:
[**2152-9-7**] Aortic valve replacement, 23-mm St. [**Hospital 923**] Medical
Biocor tissue valve.
History of Present Illness:
66 year old female with severe aortic stenosis who has been
experiencing worsening exertional fatigue, dyspnea and activity
intolerance. She was previously able to walk 20 blocks twice
daily but now is only able to walk once daily and she has some
"twinges" in her chest while walking, along with
shortness of breath and fatigue. Given her known history of CAD
and aortic stenosis and recent increase in symptoms, she was
referred for outpatient cardiac catheterization and found to
have clean coronaries. She was seen in clinic for surgical
consultation with Dr. [**First Name (STitle) **] [**Name (STitle) **].
Past Medical History:
Grave's disease/hyperthyroidism s/p med management
Irritable bowel syndrome
Hypertension
Osteoporosis
Aortic stenosis
Hyperlipidemia
CAD s/p DES x2 to RCA [**2145**]
Broken coccyx years ago- difficulty lying flat
Tubal ligation
Past Surgical History:
s/p appendectomy
Social History:
Race:Caucasian
Last Dental Exam:>6 months ago
Lives with: Son
Contact:[**Name (NI) 803**] (daughter) Phone #[**Telephone/Fax (1) 107058**]
Occupation:retired
Cigarettes: Smoked no [] yes [x] Hx:quit last week history of 6
cigarettes/day x 20+ years
Other Tobacco use:denies
ETOH:denies
Illicit drug use:denies
Family History:
Premature coronary artery disease- none
Physical Exam:
Pulse:65 Resp:18 O2 sat:100/RA
B/P 158/69
Height:5'5" Weight:118 lbs
General: NAD. Appears older then stated age.
Skin: Warm, Dry and intact
HEENT: NCAT, PERRLA, EOMI. Sclera anicteric, OP benign. Upper
dentures. Lower teeth in fair repair.
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X], NL S1-S2, III/VI SEM best heard at RUSB
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] trace Edema
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: Left:
DP Right:1 Left:1
PT [**Name (NI) 167**]:1 Left:1
Radial Right: Left:
Carotid Bruit Transmitted vs bruit
Pertinent Results:
[**2152-9-7**]
TTE
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets are severely thickened/deformed. There
is critical aortic valve stenosis (valve area <0.8cm2). Trace
aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is AV-Paced, on no inotropes.
There is an aortic tissue valve with no perivalvular leak or AI.
Mean residual gradient = 4 mmHg.
Preserved biventricular systolic fxn.
MR is now mild.
[**2152-9-13**] 06:20AM BLOOD WBC-6.7 RBC-2.68* Hgb-8.4* Hct-25.0*
MCV-93 MCH-31.4 MCHC-33.7 RDW-12.8 Plt Ct-382
[**2152-9-13**] 06:20AM BLOOD Glucose-92 UreaN-10 Creat-0.5 Na-138
K-4.2 Cl-101
Brief Hospital Course:
Ms. [**Known lastname 780**] was admitted to the hospital and brought to the
operating room on [**2152-9-7**] where the patient underwent Aortic
valve replacement, 23-mm St. [**Hospital 923**] Medical Biocor tissue valve.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Post-operative
day one 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. On
post-operative day four she went into an accelerated junctional
rhythm and the EP service was consulted. They recommended
stopping beta blockers and monitoring her rhythm. She was
hemodynamically stable with the accelerated junctional rhythm
and alternating between junctional and sinus rhythm. The
electrophysiology service recommended that her beta blockade be
held for two weeks, and then started at a low dose. The patient
was evaluated by the physical therapy service for assistance
with strength and mobility. By the time of discharge on
post-operative day six the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged home with visiting nurse services in
good condition with appropriate follow up instructions.
Medications on Admission:
Atenolol 50mg Daily
Methimazole 5mg Daily
LISINOPRIL 20 mg Tablet - 1 Tablet(s) by mouth daily
OMEPRAZOLE 20 mg Capsule, Delayed Release(E.C.)1 Capsule(s) by
mouth daily
PRAVASTATIN 20 mg Tablet - 1 Tablet(s) by mouth daily
ASPIRIN 81 mg Tablet 1 Tablet(s) by mouth daily
CALCIUM CARBONATE-VITAMIN D3 Dosage uncertain
CYANOCOBALAMIN (VITAMIN B-12) Dosage uncertain
MULTIVITAMIN,TX-IRON-CA-FA-MIN [THERAPEUTIC-M
VITAMIN/MINERALS]27
mg-0.4 mg Tablet - 1 Tablet(s) by mouth daily
VITAMINS A,C,E-ZINC-COPPER [PRESERVISION] Dosage uncertain
generic Loperamide-daily
Allergies: NKDA/Lactose intolerant
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. methimazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Aortic stenosis s/p AVR
Grave's disease/hyperthyroidism
Irritable bowel syndrome
Hypertension
Osteoporosis
Hyperlipidemia
CAD s/p DES x2 to RCA [**2145**]
Broken coccyx years ago- difficulty lying flat
Tubal ligation
Discharge Condition:
Sternal - healing well, no erythema or drainage
Edema trace
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**10-11**] at 1:15 pm
Cardiologist: Dr [**Last Name (STitle) 107059**] ([**Telephone/Fax (1) 107060**] on [**9-28**] at 2:15 pm
Wound check - cardiac surgery [**Telephone/Fax (1) 170**] on [**9-19**] at 11:00 am
Please call to schedule appointments with your
Primary Care Dr [**First Name (STitle) 7749**] [**Name (STitle) **] in [**2-29**] 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:[**2152-9-13**] Name: [**Known lastname 1114**],[**Known firstname 1049**] Unit No: [**Numeric Identifier 17483**]
Admission Date: [**2152-9-7**] Discharge Date: [**2152-9-14**]
Date of Birth: [**2086-7-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 741**]
Addendum:
The patient developed supra-ventricular tachycardia and had a
brief self limiting burst of atrial fibrillation. She was kept
remained inhouse for observation of her rhythm and Metoprolol
was titrated as tolerated. On POD# 7 she was in NSR, HR in the
90s on Lopressor 25 mg po twice daily. She was cleared for
discharge to home with VNA. Appropriate follow up appointments
were advised.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2152-9-14**]
|
[
"272.4",
"242.00",
"733.00",
"401.9",
"E878.2",
"427.31",
"427.89",
"564.1",
"424.1",
"997.1",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
9272, 9453
|
3502, 5121
|
329, 430
|
6781, 6843
|
2512, 3479
|
7817, 9249
|
1710, 1752
|
5771, 6439
|
6541, 6760
|
5147, 5748
|
6867, 7794
|
1347, 1366
|
1767, 2493
|
269, 291
|
458, 1074
|
1096, 1324
|
1382, 1694
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,320
| 184,215
|
21562
|
Discharge summary
|
report
|
Admission Date: [**2166-9-14**] Discharge Date: [**2166-9-30**]
Date of Birth: [**2091-12-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
Chest pressure
Major Surgical or Invasive Procedure:
CABG X 3
History of Present Illness:
74 yom with htn, angina, niddm, +tobacco use presents with cp
for several days. Pain worse at night and after eating and
relieved with nitro and rest. this time pt had some chest
pressure prior to going to bed which worsened overnight. He
woke up with sob and sevre substernal 9/10 chest pain. Pt has
h/o angina and states that the pain was similar to his agina.
Pt denied any other associated symptoms. Denied
n/v/diaphoresis. Pt called 911, found diaphoretic and pale by
ems and taken to osh. ecg with t wave inversion at osh and
+troponin. Pt was started on nitro drip, heparin drip and was
transferred to [**Hospital1 **]. Pain relieved after 45 mins at [**Hospital1 **].
Cath here: LMCA 60%, LCx 50%, RCA 99%.
Pt has a recent history of gi bleed 6 wks ago (?work up). Pt
denies any sob/doe prior to admission. Able to walk 1 block
without getting sob.
Past Medical History:
Cardiac cath 25 years ago, occluded rca, per pt.
HTN
Hyperlipidemia
Angina
DM 2
h/o gi bleed 2 months ago
h/o cva 6months ago, s/p bilat CEA
pvd
Social History:
Smoker 50 years 2ppd, etoh up to 6 beers/day, quit 6 mos ago
Family History:
Mother with MI at age 50
Physical Exam:
T:afeb. HR 81, BP119/59, RR 18, O2 sat 99%RA
GEN: Elderly man in NAD
HEENT: Sclera mildly icteric. MMM, no jvp elevation. +carotid
bruit
Chest: bibasilar rales
CVR: RRR, no r/m/g
Abdomen: Soft, mildly tender in epigastric region. no bruits
EXT: nonpalpable peripheral pulses (femoral, [**Doctor Last Name **], dp/pt)
bilateally
Neuro: A&O X3
Pertinent Results:
[**2166-9-14**] 11:39AM GLUCOSE-104 UREA N-18 CREAT-0.7 SODIUM-141
POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-25 ANION GAP-13
[**2166-9-14**] 11:39AM LIPASE-26
[**2166-9-14**] 11:39AM CK-MB-29* MB INDX-7.4*
[**2166-9-14**] 11:39AM WBC-9.2 RBC-4.07* HGB-7.9* HCT-28.9* MCV-71*
MCH-19.4* MCHC-27.3* RDW-19.2*
[**2166-9-14**] 10:30AM cTropnT-0.90*
[**2166-9-14**] 11:39AM PT-22.2* PTT-140.3* INR(PT)-3.1
[**2166-9-17**] 06:30AM BLOOD PT-15.7* PTT-73.1* INR(PT)-1.5
[**2166-9-14**] 11:39AM BLOOD ALT-37 AST-77* LD(LDH)-292* CK(CPK)-394*
AlkPhos-76 TotBili-0.4
[**2166-9-14**] 11:39AM BLOOD calTIBC-411 VitB12-648 Folate-GREATER TH
Ferritn-6.8* TRF-316
[**2166-9-15**] 05:23AM BLOOD Triglyc-60 HDL-35 CHOL/HD-2.1 LDLcalc-27
[**2166-9-14**] 11:39AM BLOOD PSA-0.3
ECG, on presentation:
nsr 86 nl axis, intervals. deep s v3, v4. q v1, v2, jpt elev
v1,v2 <1mm, st depression 2mm v6 with twI, 1mm v5 with twI
Echo [**2166-9-15**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is mildly dilated. Overall left ventricular systolic
function is mildly-to-moderately depressed (ejection fraction 40
percent) secondary to severe hypokinesis of the inferior and
posterior walls. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**12-6**]+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
Brief Hospital Course:
A&P 74 yom with htn, hyperchol, dm, angina, pvd, cva, and recent
gi bleed presented with [**Month/Day (2) **] at OSH. Pt chest pain free on
presentation to [**Hospital1 **].
1) [**Name (NI) 7792**] - Pt symptom free on presentation to [**Hospital1 **]. Admitted
to a cardiac monitoring floor. Pt was switched to metoprolol
100 [**Hospital1 **] inpatient (pt taking atenelol 100 qd, outpt), and
continued on asa and statin. ACEI was also started on
admission. He was continued on nitro gtt and heparin gtt, and
cardiac enzymes were cycled. Integrillin was not started given
pt's INR of 3.1 on presentation, recent history of GI bleed,
Age, recent CVA and no symptoms on presentation, here. Cardiac
enzymes on presentation were CK 394, CK,MB 29, Trop T 0.90.
Enzymes were cycled, results above. Pt experienced an episode
of SOB on HD#1, nitro drip was titrated up and pt remained
symptom free there after. Plan was to have pt undergo cardiac
cath once INR was <1.6. HD #1 INR 2.6, HD#2 INR 2.1. On HD#3
INR was 1.5 and pt underwent a radial approach cardiac cath
since he had non palpable lower extremity pulses. Pt was noted
to have 3 vd, and Left main disease and was scheduled for CABG
[**2166-9-19**].
2) HTN - On admission, HR 81, BP119/59. Pt was started on ACEI
and BB was continued. Pt's htn remained well controlled on this
regimen.
3) PNA - Pt with caugh for a few months and no change, however,
CXR with patchy opacity in RLL. Pt was started on Levofloxacin
for CAP x 7 days.
4) DM - Glyburide was held inpatient and pt was started on ISS.
5) Gi bleed - Per pt gi bleed 6 wks ago, [**Name (NI) 653**] pcp's office
on HD #1. Spoke with Dr. [**Last Name (STitle) 3314**] regarding pt's recent GI
Bleed. He said that pt had an occult bleed in [**5-9**]. At the
time his hct was 24 on presentation and after receiving 2 units
prbc, it was 31 on discharge. He upper endoscopy which revealed
chronic gastritis, and a [**Date Range 2792**] which revealed
diverticulosis. There were no neoplastic lesions identified.
Of not pt's hct was 44 in [**2-6**]. Pt was guiac positive on
admission, however did not have any episodes of BRBPR or melena.
6) Anemia - on presentation hct at 28.9, pt received 2 units of
PRBC during this admission. Iron studies revealed a microcytic
anemia, mcv 74. Iron deficiency anemia in a 74 yom with 40 lbs
wt loss over 4 months is concerning for Colon Ca. However per
phone conv with pcp, [**Name Initial (NameIs) 2792**] 2 mos ago was negative for
neoplastic lesions. PCP should evaluate this further. Pt may
require abdominal and or chest ct scan to evaluate for
malignancy.
7) Wt loss - TSH was within normal limits. Pt also underwent a
CT scan of thorax, abdomen, pelvis which was remarkable for
heavy vascular calcifications and pulmonary nodules <5mm in
lungs.
8) Dispo - Pt was transferred to Cardiothorasic Surgery Service
on [**2166-9-19**].
9) CABG x 3 on [**2166-9-19**] with LIMA -> LAD, SVG -> OM and SVG ->
Diag. OR course uneventful with total cardio-pulmonary bypass
time 87 minutes and cross-clamp time 70 minutes. He was
transferred to the ICU with a HR of 89 in NSR, MAP 71, CVP 5,
with neosynephrine, milrinone, and propofol drips.
He was extubated on the evening of his operative day. Chest
tubes were removed on POD 2 and cardiac pading wires were
removed on POD 3.
Mr. [**Known lastname **] experienced episodes of confusion and agitation
throughout his recovery requiring 1:1 supervision until [**9-26**]
when his mental status cleared and he was not felt to be a
danger to himself. His mental status continues to be labile
with some benign forgetfulness.
He had been initially in NSR that changed to atrial fibrillation
on the morning of [**9-21**] (POD 2). This was controlled with IV
metropolol, IV amiodarone bolus, and IV amiodarone drip. He
continued in and out of afib through [**9-23**] at which time he was
started on coumadin and IV heparin for anticoagulation. On
[**9-25**] he converted to NSR and was changed from IV to PO
amiodarone. However, he again experienced bursts of afib on
[**9-26**] for which the EP service was consulted. Their
recommendations included IV and PO beta-blockers for rate
control, PO amiodarone, and repletion of electrolytes (all
already being done). Further recommendations were to continue
anticoagulation and follow-up appointment in 6 weeks.
Members of the physical therapy service began seeing Mr. [**Known lastname **]
on [**9-24**] and continued to see him throughout his hospital stay.
Their recommendations were for continued physical therapy in a
rehabilitation setting to maximize function, independence, and
safety.
In the setting of the ICU and Mr. [**Known lastname 31400**] initial confusion, he
was noted to have reddened areas on his coccyx and right heal.
These were treated with duoderm pads and frequent repositioning
without any worsening.
On [**9-29**] it was decided that this patient was safe to be
discharged to a rehabilitation facility and per the wishes of
this patinet and family, he was screened by [**Hospital 27838**] Rehab in
[**Hospital1 1474**].
Medications on Admission:
Atenelol 100 qd
Glyburide 2.5 mg qd
folic acid 1mg qd
coumadin 5 mg
isosorbide 30 mg qd
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. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD ().
Disp:*30 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD ().
Disp:*30 Tablet(s)* Refills:*2*
5. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 vial* Refills:*2*
6. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO QD ().
Disp:*30 Tablet(s)* Refills:*2*
7. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO twice a
day for 7 days: then 400 mg PO QD X 1 week, then 200mg po QD
until d/c'd by Dr. [**Last Name (STitle) 3314**].
Disp:*60 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO ONCE
(once) for 2 days: then check INR on [**10-2**], and dose for target
INT 2.0-2.5 for AFib.
Disp:*60 Tablet(s)* Refills:*0*
10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD ().
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Combivent 103-18 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation four times a day.
Disp:*1 vial* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
Baypointe - [**Hospital1 1474**]
Discharge Diagnosis:
CAD
post-op AFib
post-op delirium
DM-2
Discharge Condition:
Good
Labs: Na 135, K 4.7, Cl 100, CO2 24, BUN 17, creat 0.8, glu 97,
HCT 33.9, INR 2.6 ([**2088-9-27**]).
Last CXR [**9-21**] with left lower love effusion. CXR from day of
discharge not yet done.
Discharge Instructions:
no lifting > 10 pounds or driving for 1 month
may shower, no bathing or swimming for 1 month
no creams, lotions, or ointment to incisions
Followup Instructions:
with Dr. [**Last Name (STitle) 3314**] in [**1-7**] weeks
with Dr. [**Last Name (STitle) 70**] in 5 weeks
with the EP team in 6 weeks
Completed by:[**2166-9-30**]
|
[
"272.4",
"443.9",
"486",
"250.00",
"293.9",
"433.10",
"427.31",
"783.21",
"410.71",
"414.01",
"424.0",
"280.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"37.22",
"36.12",
"39.61",
"88.56",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
10424, 10483
|
3649, 8781
|
337, 348
|
10566, 10765
|
1920, 3626
|
10951, 11116
|
1508, 1535
|
8919, 10401
|
10504, 10545
|
8807, 8896
|
10789, 10928
|
1550, 1901
|
283, 299
|
376, 1245
|
1267, 1414
|
1430, 1492
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,171
| 162,332
|
861
|
Discharge summary
|
report
|
Admission Date: [**2121-5-18**] Discharge Date: [**2121-5-27**]
Date of Birth: [**2086-12-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Nsaids / Levaquin
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
defibrillation
History of Present Illness:
34 yo woman with h/o hypertrophic CMY, multifocal atrial
tachycardias s/p failed PVI [**3-21**], c/b pericardial tamponade c
window c/b PEA arrest x 45 minutes [**3-21**] with temporary CVVHD,
and recent admission for SOB, treated for volume overload, who
was admitted with chief complaint of shortness of breath and
chest pain. Initial vitals in ED showed T 97, HR 55, BP 124/66,
RR 19, with o2 sat 100% on 4L. Pt. being evaluated by resident
in ED, denying CP, when she acutely c/o dyspnea and was noted to
have wide complex rhythm on tele and lost pulse. Given 2 rds
epi, 1 rd atropine, 2 rds bicarb/ca chloride/insulin/D50 for
presumed hyperkalemia as initial EKG showed sine wave pattern.
Also given 2L IVFs. She was coded for 30 minutes after which she
regained pulse and EKG showed NSR with wide complex with RBBB.
Initial BP 202/68. She then developed wide complex ventricular
tachycardia with BP 68/p, for which she was defibrillated X 1
200J and started on dopamine. At that point, she returned to NSR
and was quickly weaned off dopamine gtt.
.
She had non-sterile R femoral line placed for access. Initial
labs (during code) showed K 5.5 on ABG (unclear if before or
after tx. for hyperkalemia) with ABG of 6.92/63/50. Bedside TTE
without pericardial effusion. CXR showed new R>L pleural
effusions, and given difficulty of oxygenating, R Chest tube
placed with estimated 200cc out. She was transiently placed on
dopamine gtt for hypotension s/p code, but quickly SBPs returned
and dopamine weaned.
.
Per patient care referral, pt. c/o nausea and pain at 8:30 this
AM, with SOB, lethargy, diaphoresis. Per initial nursing note in
[**Name (NI) **], pt. also reports diarrhea, nausea, abdominal pain over last
few days. EKG showed sinus bradycardia, with RBBB. Pt. reported
to weigh 192.9 lbs, which is [**2-12**] lb. decrease from admission.
Vitals were significant for no fever, BP 80s-100s/50s-70s,
satting 100% on 2L. Pt. with cold extremities, so was
transferred to [**Hospital1 18**].
Past Medical History:
# Hypertrophic cardiomyopathy.
- Cardiac MR on [**2121-2-28**] with asymmetric LVH with maximal wall
thickness of 19mm at mid septum with focal hyperenhancement
consistent with hypertrophic CM. EF 55%.
# SVT with A fib, left atrial tach and AVNRT s/p pulmonary vein
isolation on [**2121-3-18**].
# Questionable history of WPW
# Tobacco use with bronchitis and associated multifocal a tach.
# Anxiety
# Obesity
# Asthma, ?COPD
Cardiac History:
The patient initially presented with syncope at age of l2. At
l3, the patient was seen at [**Hospital3 1810**] for history of
syncope, chest pain and progressive exercise intolerance. She
was found to have hypertrophic cardiomyopathy. She was
subsequently cathed. Left ventricular end diastolic pressure was
found to be 20. She was then started on chronic Verapamil
therapy. At age l6, she experienced cardiac arrest secondary to
complex tachycardia. She was successfully resuscitated. Repeat
catheterization showed left ventricular end diastolic pressure
of 36-40 without outflow tract obstruction. EP showed inducible
atrial flutter with a rapid ventricular blood pressure. She was
felt to have a rapid antegrade conduction and possible
pre-excitation. She was started on Norpace. Since then, the
patient has been stable on Verapamil and Norpace with occasional
palpitations, chest pain and light headedness.
Social History:
Currently on disability. 40 pack-year smoker (2ppd x20 years)
quit since recent bronchitis. No EtOH. Regular marijuana use.
Family History:
Family history remarkable for hypertrophic cardiomyopathy and
congenital aortic stenosis s/p cardiac surgery during infancy.
No family history of sudden cardiac death or premature CAD.
Physical Exam:
VS T 99.4 HR 68 BP 129/79 RR 32 100% on vent AC
100%/Tv:480/RR28/PEEP 14.
.
Gen: pale woman, intubated, without spontaneous facial movements
HEENT: NCAT, + periorbital ad conjunctival edema
Neck: supple, no LAD, JVP
CV: Distant heart sounds. RRR. Normal S1 and S2. No M/R/Gs.
Pulm: minimal crackles at bases, but mostly clear. no wheezes.
chest tube in place on R lateral chest
Abd: Obese, Soft, nondistended, No organomegaly or masses noted
Ext: Trace bilateral lower extremity edema. Cool extremities. 2+
DP pulses bilaterally.
Neuro: done prior to any sedation or paralytics given. PERRL, +
Doll's, + corneal reflex, + gag reflex, is overbreathing vent.
nl. bulk, tone flaccid, some spontaneous movements in distal
UEs. none noted in LEs. not withdrawing to pain or sternal rub.
reflexes absent in upper and lower extremities. mute to
babinski.
Pertinent Results:
[**2121-5-18**] 11:12PM TYPE-ART TEMP-37.4 PO2-206* PCO2-25* PH-7.54*
TOTAL CO2-22 BASE XS-1
[**2121-5-18**] 11:12PM LACTATE-7.3* K+-4.0
[**2121-5-18**] 11:12PM HGB-8.2* calcHCT-25
[**2121-5-18**] 08:32PM TYPE-ART TEMP-37.7 PO2-353* PCO2-32* PH-7.40
TOTAL CO2-21 BASE XS--3
[**2121-5-18**] 08:32PM LACTATE-9.9*
[**2121-5-18**] 08:32PM HGB-9.1* calcHCT-27 O2 SAT-98
[**2121-5-18**] 08:32PM freeCa-1.27
[**2121-5-18**] 08:25PM GLUCOSE-119* UREA N-32* CREAT-1.2*
SODIUM-131* POTASSIUM-4.6 CHLORIDE-92* TOTAL CO2-15* ANION
GAP-29*
[**2121-5-18**] 08:25PM ALT(SGPT)-128* AST(SGOT)-452* ALK PHOS-121*
AMYLASE-36 TOT BILI-1.8*
[**2121-5-18**] 08:25PM LIPASE-27
[**2121-5-18**] 08:25PM ALBUMIN-2.8* CALCIUM-10.6* PHOSPHATE-6.7*
MAGNESIUM-1.9
[**2121-5-18**] 08:25PM WBC-21.1*# RBC-2.74* HGB-8.5* HCT-26.9*
MCV-98# MCH-31.0 MCHC-31.7 RDW-20.4*
[**2121-5-18**] 08:25PM PLT COUNT-279
[**2121-5-18**] 08:25PM PT-93.1* PTT-59.9* INR(PT)-12.2*
[**2121-5-18**] 06:32PM TYPE-ART RATES-/29 TIDAL VOL-430 PEEP-14
O2-100 PO2-76* PCO2-46* PH-7.07* TOTAL CO2-14* BASE XS--16
AADO2-604 REQ O2-97 INTUBATED-INTUBATED
[**2121-5-18**] 06:12PM TYPE-ART TIDAL VOL-400 PEEP-14 O2-100 PO2-30*
PCO2-59* PH-6.94* TOTAL CO2-14* BASE XS--23 AADO2-637 REQ O2-100
INTUBATED-INTUBATED
[**2121-5-18**] 06:12PM LACTATE-12.6*
[**2121-5-18**] 05:27PM PO2-50* PCO2-63* PH-6.92* TOTAL CO2-14* BASE
XS--22
[**2121-5-18**] 05:27PM GLUCOSE-216* LACTATE-16.4* NA+-129* K+-5.5*
CL--94*
[**2121-5-18**] 05:27PM HGB-8.2* calcHCT-25 O2 SAT-54 CARBOXYHB-2.5
MET HGB-0.3
[**2121-5-18**] 05:27PM freeCa-1.16
[**2121-5-18**] 05:23PM GLUCOSE-223* UREA N-27* CREAT-1.1 SODIUM-131*
POTASSIUM-5.6* CHLORIDE-91* TOTAL CO2-11* ANION GAP-35*
[**2121-5-18**] 05:23PM CK(CPK)-55
[**2121-5-18**] 05:23PM CK-MB-NotDone cTropnT-0.03*
[**2121-5-18**] 05:23PM CALCIUM-9.3 PHOSPHATE-6.7*# MAGNESIUM-2.1
[**2121-5-18**] 05:23PM WBC-13.7* RBC-2.66* HGB-8.2* HCT-28.5*
MCV-107*# MCH-31.0 MCHC-28.9* RDW-20.4*
[**2121-5-18**] 05:23PM NEUTS-63.0 LYMPHS-34.1 MONOS-2.3 EOS-0.1
BASOS-0.5
[**2121-5-18**] 05:23PM PLT COUNT-207
[**2121-5-27**] 07:45AM BLOOD WBC-12.2* RBC-2.86* Hgb-8.5* Hct-28.0*
MCV-98 MCH-29.8 MCHC-30.4* RDW-18.3* Plt Ct-675*
[**2121-5-27**] 07:45AM BLOOD PT-23.5* PTT-36.5* INR(PT)-2.3*
[**2121-5-27**] 07:45AM BLOOD Glucose-87 UreaN-13 Creat-0.7 Na-134
K-3.8 Cl-91* HCO3-32 AnGap-15
[**2121-5-21**] 04:28AM BLOOD ALT-469* AST-362* LD(LDH)-500*
AlkPhos-132* TotBili-3.2*
[**2121-5-23**] 12:00PM BLOOD CK(CPK)-24*
[**2121-5-18**] 08:25PM BLOOD Lipase-27
[**2121-5-23**] 12:00PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2121-5-27**] 07:45AM BLOOD Calcium-8.6 Phos-4.1 Mg-1.6
[**2121-5-20**] 04:02PM BLOOD Calcium-8.9 Phos-3.8 Mg-1.9 Iron-18*
[**2121-5-18**] 08:25PM BLOOD Albumin-2.8* Calcium-10.6* Phos-6.7*
Mg-1.9
[**2121-5-20**] 04:02PM BLOOD calTIBC-260 VitB12-1744* Folate-12.4
Ferritn-995* TRF-200
[**2121-5-19**] 03:11PM BLOOD Osmolal-277
[**2121-5-22**] 03:34PM BLOOD Type-ART Temp-36.9 FiO2-98 pO2-86 pCO2-41
pH-7.51* calTCO2-34* Base XS-8 AADO2-579 REQ O2-94 Intubat-NOT
INTUBA
[**2121-5-20**] 04:11AM BLOOD Lactate-1.2
[**2121-5-20**] 04:41PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-1 pH-5.0 Leuks-TR
[**2121-5-20**] 04:41PM URINE RBC-0-2 WBC-3 Bacteri-MOD Yeast-NONE
Epi-0-2
[**2121-5-20**] 04:00AM URINE Hours-RANDOM K-37
[**2121-5-20**] 04:00AM URINE Osmolal-364
.
BCx negative
UCx negative
Sputum gs/cx negative
.
CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN
[**Name Initial (PRE) **]: As compared to the previous radiograph, the extent of
right-sided parenchymal opacity is minimally resolving.
Unchanged areas of cardiomegaly. No newly appeared parenchymal
opacities. Newly placed right chest tube sideport appears
outside of the hemithorax with reduced right effusion noted. NGT
is within the stomach.
.
CHEST (PORTABLE AP) [**2121-5-18**] 5:51 PM
CHEST AP: Moderate cardiomegaly is present. There is bilateral
vascular engorgement and perihilar opacities, greater on the
right. A small right pleural effusion has developed or increased
in size. Endotracheal tube tip is 9 mm above the carina. Osseous
structures are unremarkable.
IMPRESSION:
1. Interval development of moderate-to-severe pulmonary edema.
2. Endotracheal tube 9 mm above the carina and should be
withdrawn 2 cm.
.
ECG Study Date of [**2121-5-18**] 4:29:28 PM
Sinus rhythm. The P-R interval is prolonged. The QRS interval is
profoundly prolonged at 200 milliseconds and raises
consideration of hyperkalemia. Compared to the previous tracing
QRS interval prolongation is new.
TRACING #1
.
ECG Study Date of [**2121-5-18**] 4:46:36 PM
Probable sinus rhythm with a sinusoidal pattern consistent with
severe
hyperkalemia or agonal rhythm. Clinical correlation is advised.
Compared to the previous tracing these findings are new.
TRACING #2
.
ECG Study Date of [**2121-5-18**] 5:08:10 PM
Probable sinus rhythm with a sinusoidal [**Doctor Last Name 5926**] consistent with
severe
hyperkalemia or agonal rhythm. Compared to the previous tracing
there
is no significant change.
TRACING #3
.
ECG Study Date of [**2121-5-18**] 5:14:06 PM
Probable ectopic atrial rhythm. The QRS is profoundly prolonged
consistent
with severe hyperkalemia. Compared to the previous tracing
agonal rhythm is no longer present.
TRACING #4
.
ECG Study Date of [**2121-5-18**] 5:17:34 PM
Probable sinus rhythm. The P-R interval is prolonged. The QRS
duration is
profoundly prolonged consistent with severe hyperkalemia.
Compared to the
previous tracing QRS interval prolongation persists.
TRACING #5
.
ECG Study Date of [**2121-5-18**] 6:42:16 PM
Sinus rhythm. Left axis deviation. Non-specific intraventricular
conduction delay. Diffuse non-specific ST-T wave changes.
Compared to the previous tracing multiple severe abnormalities
have improved.
TRACING #6
.
CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN
[**Name Initial (PRE) **]: In comparison with study of [**5-19**], the right chest tube
has been removed. No evidence of pneumothorax.
Otherwise, little overall change. The right-sided parenchymal
opacification persists, as does the retrocardiac opacification
consistent with atelectasis and effusion. The other tubes remain
in place.
.
CHEST (PORTABLE AP) [**2121-5-19**] 8:10 AM
As compared to the previous radiograph, the monitoring and
support devices are in unchanged position. Unchanged position of
the right-sided chest tube, the side port of the chest tube is
still in the thoracic wall and slightly outside the lung. The
right-sided parenchymal opacity is further resolving. Subtle
increase of the retrocardiac atelectasis. Otherwise, no
newly-appeared parenchymal opacities. No evidence of pleural
effusions.
.
ECHO [**2121-5-19**]:
Conclusions
The left and right atria are moderately dilated. There is
moderate symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
There is no valvular [**Male First Name (un) **] or resting LVOT gradient. 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 aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). The estimated pulmonary artery systolic pressure
is high normal. There is a trivial/physiologic pericardial
effusion.
Compared with the prior study (images reviewed) of [**2121-5-1**], the
magnitude of tricuspid regurgitation and the estimated pulmonary
artery systolic pressure have decreased.
CLINICAL IMPLICATIONS:
Based on [**2120**] 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.
.
ECG Study Date of [**2121-5-19**] 8:57:12 AM
Sinus rhythm. The P-R interval is 120 milliseconds. Left axis
deviation.
Non-specific intraventricular conduction delay. Diffuse
non-specific ST-T wave changes. Compared to the previous tracing
there is no significant change.
TRACING #7
.
CHEST PORT. LINE PLACEMENT [**2121-5-20**] 2:06 PM
FINDINGS: In comparison with earlier films of this date, there
has been placement of a right subclavian PICC line with its tip
in the upper portion of the SVC. The opacification at the right
base is slightly less prominent and there has been a better
inspiration.
The endotracheal tube and nasogastric tubes have been removed.
.
ECG Study Date of [**2121-5-20**] 11:22:44 AM
Sinus rhythm. Peaked P waves consistent with right atrial
enlargement. Right bundle-branch block. Compared to the previous
tracing of [**2121-5-19**] right bundle-branch block has appeared.
Clinical correlation is suggested
.
CHEST (PA & LAT) [**2121-5-21**] 11:19 AM
PA AND LATERAL VIEWS OF THE CHEST: The heart remains enlarged,
and there are new, ill-defined airspace opacities at both bases,
most likely due to edema given the rapid time appearance.
Pulmonary vasculature remains slightly engorged. A focus of
linear opacity in the left lung base is likely atelectasis. The
upper lung zones remain relatively well aerated with no focal
consolidation or pneumothorax.
A right PICC terminates at the origin of the SVC.
IMPRESSION: Interval increase in pulmonary edema, with
persistent cardiomegaly and fluid overload.
.
ECG Study Date of [**2121-5-22**] 4:45:32 AM
Coarse atrial fibrillation. Minimal left axis deviation with
right
bundle-branch block. Compared to the previous tracing of [**2121-5-20**]
atrial
fibrillation has replaced normal sinus rhythm. Coarse atrial
fibrillation is stated by some to be more frequent with valvular
heart disease than coronary heart disease.
.
ECG Study Date of [**2121-5-23**] 3:17:28 AM
Coarse atrial fibrillation with a rapid ventricular response.
Left axis
deviation with probable left anterior fascicular block. Probable
right
bundle-branch block. Non-specific ST-T wave changes. Compared to
the previous tracing of [**2121-5-22**] no significant change.
TRACING #1
.
ECG Study Date of [**2121-5-23**] 8:21:56 AM
Coarse atrial fibrillation/atrial flutter with a rapid
ventricular respo nse. Compared to the previous tracing no
significant change.
TRAcING #2
.
ECG Study Date of [**2121-5-25**] 8:15:26 AM
Atrial fibrillation with rapid ventricular response. Compared to
the previous tracing no significant change.
TRACING #3
Brief Hospital Course:
34 yo woman with hypertrophic cardiomyopathy, multifocal atrial
tachycardia, atrial fibrillation/flutter, h/o AVNRT, with
multiple previous cardiac arrests with PEA arrest, likely [**3-15**]
hyperkalemia.
.
# s/p PEA arrest: Etiologies include hyperkalemia, vs. other
acidosis which precipated hyperkalemia. Unsure of what
precipitated hyperkalemia. patient was receiving KDur
supplements at [**Hospital1 **], however this still should not have been
enough to cause her degree of hyperkalemia. patient has been
hypokalemic since admission, and has required K supplements.
During resuscitation patient had two lines placed which were
non-sterile. She was therefore given prophylactic vancomycin
and aztreonam until the lines could be removed. The lines were
removed after two days, once her INR was reversed with IV
vitamin K. She did not develop any ekg findings suggestive of
hyperkalemia throughout her hospitalization. She did not
develop any further episodes of ventricular tachycardia
throughout her hospitalization. She will need follow up of her
electrolytes as per discharge orders.
.
# Fluid Status: Patient was total body fluid overloaded
throughout her hospitalization, requiring IV lasix to improve
urine output. She was eventually transitioned to her home dose
of lasix 80mg PO daily. Her lasix dosing was increased to 80mg
PO BID on [**5-26**], as she still had an oxygen requirement and was
still reporting edematous extremities.
.
# Rhythm. History of multiple atrial tachyarrhythmias s/p recent
failed ablation. Anticoagulated w/ coumadin as outpatient given
frequent AT with RVR. the patient developed atrial flutter on
[**5-21**]. This was treated with amiodarone, verapamil and increased
doses of metoprolol. An ablation was considered to be
unnecessary at this time given her history of complications with
procedures. Her coumadin was restarted, and eventually
increased to 4mg PO daily, which is double her home dose, to be
titrated according to INR goal [**3-16**]. She should have her INR
drawn according to discharge orders, on [**2121-5-29**].
.
# Respiratory status: She was extubated on [**5-20**], and was weaned
to 96% O2 saturation on 4L. CXR showing possible RLL opacity
vs. fluid overload. Her montelukast and atrovent was continued.
.
# Fever: Unclear etiology. had persistent leukocytosis at
previous admission, s/p 10 day course with aztreonam and clinda,
finished on [**2121-5-19**]. Spiked temp to 101.9 [**5-20**]. However, her
leukocytosis persisted during this admission. She was pan
cultured and cultures have been negative. She was not started
on another regimen of antibiotics during this admission after
completing her previous 10 day course.
.
# Weakness: PT evaluated Ms. [**Known lastname **] and recommended rehab
placement. However, she refused. She also refused to attempt
climbing [**Last Name (LF) 5927**], [**First Name3 (LF) **] her ability to do so was not able to be
evaluated. She was sent home in an ambulance and with help to
get into her house.
.
# Anxiety: sertraline, bupropion, clonazepam were continued.
.
# FEN: Patient required thin liquid diet.
.
# Code: full
Medications on Admission:
Amiodarone 200 mg [**Hospital1 **]
lasix 80mg qdaily
Warfarin 2.0 mg Tablet qdaily
Verapamil 40 mg PO Q8H
Metoprolol Tartrate 100 mg tid
Calcium Acetate 667 mg tid
Montelukast 10 mg Daily
Pantoprazole 40 mg Daily
Clonazepam 1 mg tid
Bupropion 75 mg Daily
Sertraline 150 mg Daily
Trazodone 25 mg
Ascorbic Acid 500 mg [**Hospital1 **]
Dulcolax 30mg q6hPRN
Magnesium Hydroxide 30ml 16hPRN
Docusate Sodium 100 mg [**Hospital1 **]
Ferrous Sulfate 325 mg qdaily
Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID
B Complex-Vitamin C-Folic Acid 1 mg qdaily
Percocet 5-325 mg 1-2 Tablets twice a day as needed
Acetaminophen 650mg q4h PRN
Kdur 20meq qdaily
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*60 Capsule(s)* Refills:*2*
3. Sertraline 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. Bupropion 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Disp:*1 bottle* Refills:*0*
9. 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*
10. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY16 (Once
Daily at 16).
Disp:*60 Tablet(s)* Refills:*2*
13. labwork
sodium, potassium, chloride, bicarb, BUN, creatinine, glucose,
magnesium, phosphorus, calcium, and INR on [**2121-5-29**]. Please fax
results to his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5861**] (Office Fax:[**Telephone/Fax (1) 5928**],
Phone:[**0-0-**]) and to his cardiologist, Dr. [**Last Name (STitle) **]
(Office Fax:[**Telephone/Fax (1) 3341**], Phone:[**Telephone/Fax (1) 285**]).
14. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Inhalation four times a day.
Disp:*1 inhaler* Refills:*0*
15. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for pain.
Disp:*14 Tablet(s)* Refills:*0*
16. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
17. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO twice
a day.
18. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO
once a day.
19. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day.
20. B Complex Plus Vitamin C Oral
21. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary
Hyperkalemia
Hypertrophic Obstructive cardiomyopathy
Atrial Flutter/Atrial fibrillation
Discharge Condition:
good
Discharge Instructions:
You were admitted to the hospital with shortness of breath.
Shortly after presentation you were found to be in cardiac
arrest, possibly secondary to elevated potassium. It is unclear
what precipitated the hyperkalemia.
.
Please follow-up as below.
.
Please continue to take your medications as prescribed. Do not
take your K-Dur unless otherwise instructed by a physician at [**Name Initial (PRE) **]
later time. Your metoprolol was changed to Toprol XL. Your
amiodarone was decreased. Your lasix was increased, as was your
warfarin, and your calcium acetate. Please discuss all of your
medications with your primary care provider and your
cardiologist. You may benefit from an increased dose of Toprol
XL. Your whole medication regimen will need to be monitored
closely and changed accordingly.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
You should call your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5861**], or your
cardiologist, Dr. [**Last Name (STitle) **], or return to the emergency
department if you experience palpitations, chest pain, shortness
of breath, loss of consciousness, fever greater than 101.5
degrees F, or any other symptoms that concern you.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5861**]. An appointment has
been set up for you on [**Last Name (LF) 5929**], [**6-5**] at 2:30. Phone:
[**0-0-**]
Please follow up with Dr.[**Name (NI) 1565**] nurse [**First Name8 (NamePattern2) 3639**] [**First Name8 (NamePattern2) 5930**] [**Last Name (NamePattern1) 5931**]. An appointment has been set up for you on [**6-17**] at
2pm. Phone:[**Telephone/Fax (1) 285**]
Other appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2121-7-25**] 1:40
|
[
"278.00",
"780.6",
"427.32",
"427.1",
"799.02",
"425.1",
"493.20",
"511.9",
"276.2",
"584.9",
"428.33",
"790.92",
"276.6",
"427.31",
"300.00",
"276.7",
"427.5",
"288.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.62",
"96.71",
"99.60",
"38.91",
"96.04",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
21596, 21647
|
15481, 18623
|
323, 339
|
21787, 21794
|
4978, 12608
|
23112, 23753
|
3905, 4092
|
19318, 21573
|
21668, 21766
|
18649, 19295
|
21818, 23089
|
4107, 4959
|
12631, 15458
|
264, 285
|
367, 2368
|
2390, 3747
|
3763, 3889
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,080
| 152,638
|
53495
|
Discharge summary
|
report
|
Admission Date: [**2188-2-21**] Discharge Date: [**2188-2-24**]
Date of Birth: [**2136-6-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
1. Intubation in ED [**2188-2-20**] - extubated [**2188-2-21**].
History of Present Illness:
51yo F with metastatc breast cancer presents with acute
shortness of breath today after receiving a blood x-fusion at
her oncologists office the day prior to admission. Per her
brother she has had a stuttering course of dyspnea over the past
several weeks and the morning of admission she awoke with acute
dyspnea lasting fifteen minutes which was somewhat responsive to
her inhalers.
In the ED she was noted to be in resp distress with RR 34, O2sat
97% on 4L, 101.4, 160/90, HR 144. A CXR showed a stable left
pleural effusion and progression of a right pleural effusion.
She was intubated due to resp distress and given one dose of
cefepime and admitted to the [**Hospital Unit Name 153**]. Of note she had a recent
admission ([**Date range (1) 97780**]) for dyspnea which seemed to improve
without major intervention - left thoracentecis revealed an
exudative effusion with negative cytology.
Past Medical History:
- breast cancer diagnosed in [**2179**](ER+ Her2neu-)followed by Dr.
[**Last Name (STitle) **] .Chest CT in [**2187-11-8**] showed pulmonary nodules
and enlarged lymph nodes in chest and abdomen. SHe also has left
parietal brain mets s/p resection and XRT. She also has
widespread bony metastasis. SHe is currently receiving cytoxan,
adriamycin and LUpron. Small bilateral pulmonary nodule and
brain mass now stable, CSF negative [**1-14**]
- diabetes x10 years
- hypercholesterolemia
- cervical disc disease
- psoriasis.
- seizure from brain mets
Social History:
She is married. Lives with her husband and 2 of her kids and 1
in college. Works as an administrator at the synagogue. Tobacco
2 pack a per day for 25 years; quit in [**2180**]. No ethanol. No
drugs. She has a brother who is a former [**Name (NI) **] attending at [**Hospital1 18**],
now at [**Hospital1 756**].
Family History:
No strokes. No family history of recent sickness. Dad died of
colon CA at the age of 69. Paternal aunt and maternal aunt with
breast CA. Mother alive with multiple sclerosis. Kids healthy.
Physical Exam:
Vitals: HR 100, BP 111/59, RR 16 O2 100%.
Gen- Sedated, intubated.
HEENT- anicteric, EOMI, PERLA, mucous membrane moist, neck
supple, no JVD, no cervical lymphadenopathy
CV- rrr, no r/m/g
resp- dull at left lung bases, wheezes heard throughout,
prolonged expiratory time
abdomen- soft, nontender, obese
extremity-- no edema
Pertinent Results:
Admission Labs:
[**2188-2-20**] 11:00PM PT-13.5* PTT-36.9* INR(PT)-1.2*
[**2188-2-20**] 11:00PM PLT SMR-NORMAL PLT COUNT-157# LPLT-1+
[**2188-2-20**] 11:00PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL
BITE-OCCASIONAL
[**2188-2-20**] 11:00PM NEUTS-73* BANDS-0 LYMPHS-7* MONOS-12* EOS-0
BASOS-0 ATYPS-5* METAS-0 MYELOS-2* OTHER-1*
[**2188-2-20**] 11:00PM WBC-8.0# RBC-3.97*# HGB-11.0*# HCT-33.6*#
MCV-85 MCH-27.8 MCHC-32.8 RDW-17.8*
[**2188-2-20**] 11:00PM CK-MB-4 cTropnT-0.09*
[**2188-2-20**] 11:00PM CK(CPK)-68
[**2188-2-20**] 11:00PM GLUCOSE-303* UREA N-8 CREAT-0.6 SODIUM-143
POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-26 ANION GAP-23*
[**2188-2-20**] 11:08PM LACTATE-2.5*
.
Microbiology:
[**2-21**] Blood culture: negative
[**2-21**] Viral screen and culture: + for Adenovirus (call to Dr.
[**Name (NI) 3274**], pt's Oncologist on [**3-7**], after discharge)
Screen negative for Paraflu 1,2,3, Flu A,B, and RSV.
Culture: pending.
.
Imaging:
[**2-20**] CXR:
Stable left loculated effusion and progression of right pleural
effusion. Underlying consolidation cannot be fully excluded.
.
[**2-21**] Chest CT:
1. No evidence of pulmonary embolism.
2. Increased metastatic disease within the chest with increased
moderate
bilateral pleural effusions (right greater than left), slightly
increased
infiltrative soft tissue in the right hilum encasing pulmonary
vessels and
segmental bronchi, slightly increased size of several pulmonary
nodules, and opacity in the left lower lobe representing
atelectasis and/or consolidation.
3. Unchanged widespread osseous metastatic lesions.
Brief Hospital Course:
51yo F with widely metastatic breast cancer with recent history
of increasing shortness of breath admitted for dyspnea requiring
intubation.
.
# Dyspnea:
The initial DDx in the ICU included reactive airways as she
sounded wheezy on exam, fluid overload given recent transfusion,
TRALI, cardiac ischemia, progression of lymphangitic spread of
pulmonary metastastases, thromboembolic disease given fairly
acute onset of symptoms, and an atypical or community acquired
pneumonia. A chest CT was negative for a PE but did show
progression of her metastatic disease and some areas of ground
glass opacity. A flu test was negative and a sputum sample
showed only sparse oropharyngeal flora. She was ruled out for
MI with 2 sets of negative cardiac enzymes. Sx were ultimately
thought to be [**1-10**] RAD [**1-10**] a viral infection + perhaps a
component of fluid overload + perhaps lymphangitic spread of
known CA.
.
She was extubated on [**2-21**] after only one day of intubation and
required minimal supplementary oxygen. She was treated with a
course of azithromycin. She was treated with inhalers for
symptomatic wheezing. She was also gently diuresed. Symptoms
improved with these interventions.
.
# Metastatic breast CA: Her oncologist, Dr. [**Last Name (STitle) 3274**] followed
throughout her course.
Overall prognosis quite poor, there are likely few therapeutic
modalities left. Pt. was asked to follow up with Dr. [**Last Name (STitle) 3274**]
after discharge.
.
# Diabetes:
Her outpatient glipizide was continued but her avandia was held
as this has a side effect of edema and congestive heart failure.
She was also covered with a regular insulin sliding scale.
.
# Depression:
She was continued on zoloft and wellbutrin per outpatient
regimen.
.
Medications on Admission:
1. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
2. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Lamotrigine 150 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
8. home O2
home O2
2-3 liters O2 nasal cannula
titrate to keep O2 sat >92%
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
Disp:*2 inhalers* Refills:*6*
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day) as needed.
Disp:*2 inhalers* Refills:*6*
Discharge Medications:
1. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Lamotrigine 150 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): if needed for bowel movements.
Disp:*60 Capsule(s)* Refills:*2*
7. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 1 doses.
Disp:*1 Capsule(s)* Refills:*0*
8. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Disp:*180 nebulizer solutions* Refills:*2*
10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
Disp:*120 nebulizer* Refills:*2*
13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
14. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
16. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO three
times a day as needed for constipation.
Disp:*1000 ML(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
metastatic breast cancer with pulmonary lymphangitic involvement
bilateral pleural effusions
diabetes mellitus type 2
Discharge Condition:
stable, tolerating po, SOB improved
Discharge Instructions:
Please take all of your medications and keep all of your
appointments.
If you get more short of breath, you should use the albuterol
nebulizers.
Your rosiglitazone (Avandia) has been stopped, as it may cause
fluid overload. Please check your sugars 4 times daily; if they
are consistently over 150, please contact your primary care
doctor, as this may need to be restarted.
Followup Instructions:
Please call Dr.[**Name (NI) 109981**] office for an appointment in the next
2-3 weeks: [**Telephone/Fax (1) 109982**].
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**]
Date/Time:[**2188-2-26**] 1:30
Provider: [**Name Initial (NameIs) 4426**] 13 Date/Time:[**2188-2-26**] 2:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10384**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2188-2-26**] 2:00
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
Completed by:[**2188-4-28**]
|
[
"486",
"518.81",
"272.0",
"198.5",
"V10.3",
"197.2",
"197.0",
"780.39",
"696.1",
"250.00",
"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9294, 9343
|
4511, 6278
|
322, 388
|
9505, 9543
|
2785, 2785
|
9969, 10580
|
2235, 2425
|
7293, 9271
|
9364, 9484
|
6304, 7270
|
9567, 9946
|
2440, 2766
|
275, 284
|
416, 1316
|
2802, 4488
|
1338, 1888
|
1904, 2219
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,273
| 175,304
|
52019
|
Discharge summary
|
report
|
Admission Date: [**2174-5-30**] Discharge Date: [**2174-6-1**]
Date of Birth: [**2105-2-23**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone / Spironolactone
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Recurrent Ventricular tachycardia
Major Surgical or Invasive Procedure:
Ventricular tachycardia ablation ([**5-30**])
History of Present Illness:
This is a 69 y/o male with significant medical history of CAD
s/p MI and [**2146**] and [**2152**] CABG( LIMA to LAD, and Y graft with SVG
from the aorta to first OM and diagonal), systolic congestive
heart failure (EF-15% [**1-/2174**]), chronic atrial fibrillation,
severe ischemic cardiomyopathy, monomorphic ventricular
tachycardia, ventricular fibrillation, biventricular [**Company 1543**]
ICD, PVD s/p left fem-[**Doctor Last Name **] bypass who is transferred to CCU s/p
VT ablation on [**5-30**] due to hypotension.
.
The patient was admitted to [**Hospital6 33**] on [**2174-5-24**]
with recurrent ventricular tachycardia (while on Sotalol, beta
blocker, and ICD) associated with syncope while sitting in his
chair at home. Device interrogation revealed an episode of VT
that was initially treated unsuccessfully with pacing and
required 1 shock of 30 joules. The patient's Sotalol was
increased, with beta blocker continued, and his Coumadin was
stopped in preparation for VT ablation. The patient denies
chest pain, shortness of breath, lightheadedness, dizziness,
orthopnea, LE edema or any further episodes of syncope.
.
In the cath lab, found to have inferoposterior and
posterolateral scars, however he is presenting with hypotension.
During the procedure two different ventricular tachycardias
were induced which degenerated into ventricular fibrilliation
and shocked, and both foci were radio frequency ablated. The
procedure was done under general anesthesia, and he recieved
2.5 L fluids. The sheath pulled in recovery room. The patient
has poor lower extremity pulses at baseline and continues to do
so post ablation. He is currently on Dopamine 6 mcg/kg/min,
with systolic BPs in 90s.
.
On review of systems, he denies any prior history of stroke,
TIA, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations.
Past Medical History:
1. CARDIAC RISK FACTORS: neg Diabetes, pos Dyslipidemia,(pos)
HTN
.
2. CARDIAC HISTORY:
-CABG: [**2146**] and [**2152**] CABG
-PERCUTANEOUS CORONARY INTERVENTIONS: [**2173-9-6**] cardiac
catheterization: Occluded LAD, LCX and RCA. LIMA to LAD with
minor luminal irregularities. Y graft with SVG from the aorta
to first OM and diagonal was aneurismal proximal. Diffuse
disease of LIMA to OM. LIMA to diagonal patent.
-PACING/ICD: [**2168**] and [**2170**] Biventricular ICD-[**Company 1543**]
.
3. OTHER PAST MEDICAL HISTORY:
.
PMH:
HTN
Hyperlipidemia
Ischemic cardiomyopathy-EF 15%
Amiodarone pulmonary toxicity
Ventricular tachycardia
Ventricular fibrillation
[**2168**] and [**2170**] Biventricular ICD-[**Company 1543**]
Atrial fibrillation
CHF
[**3-/2170**] STEMI
[**9-/2171**] and [**10/2171**] Respiratory failure
[**2146**] and [**2152**] CABG
[**2165**] Left calf DVT
[**2165**]
[**Location (un) 260**] Filter
[**2173-9-6**] cardiac catheterization: Occluded LAD, LCX and RCA.
LIMA to LAD with minor luminal irregularities. Y graft with SVG
from the aorta to first OM and diagonal was aneurismal proximal.
Diffuse disease of LIMA to OM. LIMA to diagonal patent.
PVD
Left fem-[**Doctor Last Name **] bypass
Ventricular tachycardia ablation [**5-30**].
.
ALLERGIES: Amiodarone-pulmonary toxicity,
Spironolactone-gynecomastia
(-) Food Allergy (-) Contrast Allergy
Social History:
(-) CIGS Smoked 1ppd x 48 years.
Quit [**2152**]. Lives with: wife, [**Name (NI) 3908**]
Occupation: Retired electrician.
ETOH: Occasional ETOH and denies illicit drug use.
Home Services: [**Hospital3 **] VNA for weekly visits.
Contact person upon discharge: [**Name (NI) **] [**Name (NI) 6123**] (son). His cell phone#
is [**Telephone/Fax (1) 107692**].
Family History:
Father, brother and uncle with MI in their early 60's.
Physical Exam:
Ht: 5 feet 8inches
Wt: 123 lbs
VS: T=96.6 BP=104/60 HR=70 RR=14 O2 sat= 98%
GENERAL: 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 JVP.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, crackles in the
middle and lower lung fields bilaterally, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Right foot colder to
touch than left foot.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Pertinent Results:
Admssion Labs
.
[**2174-5-30**] 11:45AM TYPE-ART PO2-86 PCO2-55* PH-7.27* TOTAL
CO2-26 BASE XS--2 INTUBATED-NOT INTUBA
[**2174-5-30**] 11:45AM GLUCOSE-129* LACTATE-0.9 NA+-138 K+-4.4
CL--100
[**2174-5-30**] 11:45AM freeCa-1.16
[**2174-5-30**] 07:15AM GLUCOSE-101* UREA N-36* CREAT-1.4* SODIUM-135
POTASSIUM-5.2* CHLORIDE-93* TOTAL CO2-35* ANION GAP-12
[**2174-5-30**] 07:15AM estGFR-Using this
[**2174-5-30**] 07:15AM WBC-8.3 RBC-4.69 HGB-14.2 HCT-42.3 MCV-90
MCH-30.3 MCHC-33.6 RDW-15.3
[**2174-5-30**] 07:15AM PLT COUNT-210
[**2174-5-30**] 07:15AM PT-14.9* PTT-26.7 INR(PT)-1.3*
.
[**2174-5-31**] 06:08AM BLOOD WBC-6.8 RBC-4.07* Hgb-12.1* Hct-37.0*
MCV-91 MCH-29.7 MCHC-32.7 RDW-15.4 Plt Ct-154
[**2174-5-31**] 06:08AM BLOOD Plt Ct-154
[**2174-5-31**] 06:08AM BLOOD Glucose-78 UreaN-19 Creat-0.8 Na-138
K-4.2 Cl-103 HCO3-30 AnGap-9
[**2174-5-31**] 06:08AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.1
.
Discharge Labs
.
Reports
.
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 107693**]
Reason: eval lung fields
[**Hospital 93**] MEDICAL CONDITION:
69 year old man with h/o CHF, vtach. underwent VT ablation,
VF arrested
intraop. likely fluid overload. +crackles
REASON FOR THIS EXAMINATION:
eval lung fields
Final Report
REASON FOR EXAMINATION: Suspected fluid overload.
Portable AP chest radiograph was reviewed with no prior studies
available for
comparison.
The current study demonstrates moderately enlarged cardiac
silhouette in a
patient after median sternotomy and CABG. The pacemaker
defibrillator leads
terminate in right atrium, right ventricle, and left ventricular
epicardial
vein. There is bilateral hilar prominence with some minimal
perihilar
opacities, findings that might be consistent with mild volume
overload. In
addition, there are bibasal interstitial opacities that although
might
represent part of vascular engorgement, may also be attributed
to chronic
interstitial changes and should be reevaluated after diuresis.
Small amount
of bilateral left more than right pleural effusion is present.
There is no
evidence of pneumothorax.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: MON [**2174-5-30**] 5:18 PM
[**2174-6-1**] 06:04AM BLOOD WBC-8.6 RBC-4.29* Hgb-13.1* Hct-38.3*
MCV-89 MCH-30.6 MCHC-34.3 RDW-15.1 Plt Ct-156
[**2174-6-1**] 06:04AM BLOOD Plt Ct-156
[**2174-6-1**] 06:04AM BLOOD Glucose-102* UreaN-15 Creat-0.7 Na-136
K-4.2 Cl-100 HCO3-26 AnGap-14
[**2174-6-1**] 06:04AM BLOOD Calcium-9.4 Phos-2.8 Mg-2.3
[**2174-6-1**] 06:04AM BLOOD WBC-8.6 RBC-4.29* Hgb-13.1* Hct-38.3*
MCV-89 MCH-30.6 MCHC-34.3 RDW-15.1 Plt Ct-156
[**2174-6-1**] 06:04AM BLOOD Plt Ct-156
[**2174-6-1**] 06:04AM BLOOD Glucose-102* UreaN-15 Creat-0.7 Na-136
K-4.2 Cl-100 HCO3-26 AnGap-14
[**2174-5-31**] 06:08AM BLOOD Glucose-78 UreaN-19 Creat-0.8 Na-138
K-4.2 Cl-103 HCO3-30 AnGap-9
[**2174-6-1**] 06:04AM BLOOD Calcium-9.4 Phos-2.8 Mg-2.3
[**2174-5-30**] 11:45AM BLOOD Type-ART pO2-86 pCO2-55* pH-7.27*
calTCO2-26 Base XS--2 Intubat-NOT INTUBA
[**2174-5-30**] 11:45AM BLOOD Glucose-129* Lactate-0.9 Na-138 K-4.4
Cl-100
Brief Hospital Course:
69 y/o male with ischemic cardiomyopathy, Biventricular
[**Company 1543**] ICD, recurrent ventricular tachycardia and syncope
referred for ventricular tachycardia ablation and presenting
with hypotension.
.
# Hypotension- The patient had systolic blood pressures in the
90's (while he was on Dopamine drip) which is lower than
baseline on presentation to the CCU. A potential cause could
have been general anesthesia he tolerated the procedure
underlying poor baseline systolic function secondary to systolic
congestive heart failure. His baseline systolic blood pressures
are usually between 95-110 as per patient. We monitored
hemodynamics while in the ICU with goal MAPs > 65.
We held home eplerenone, isosorbide, lisinopril, torsemide, and
oxycodone overnight pending resolution of blood pressures. He wa
weaned off his dopamine drip and tolerated well with increase in
systolic blood pressure to 100-110.
.
# Ventricular tachycardia- Patient with monomorphic ventricular
tachycardia, now with ICD in place. S/p catheter ablation with
RFA of 2 foci. Will continue home sotalol and metoprolol as
adjunctive therapy. Most likely caused by arrythmic substrate
from past myocardial infarctions. We monitored hemodynamics
overnight which remained stable. The patient remained in AV
paced rhythm.
.
#Atrial fibrillation/ LV thrombus-Stopped coumadin for case.
- We gave lovenox 1mg/kg [**Hospital1 **]. and started warfarin home dose as
well fr anticoagulation.
.
# Respiratory Acidosis - Patient did not look short of breath on
presentation. In fact, the ABG sample which indicates
respiratory acidosis was done intra operatively under anesthesia
. The patient never felt short of breath in CCU and his O2
saturation on room air was [**Last Name (un) 8585**] 96&.
.
#Left fem-[**Doctor Last Name **] bypass/PVD- Had poor lower extremity pulses which
is consistent with baseline (1+ Left DP and 1+ Right DP) . We
Considered vascular consult if patient has cold extremities or
any other signs of very poor perfusion. However he was found to
have pulses on [**Last Name (un) **] bilaterally in lower extremities, during
his stay in the CCU.
.
#Ventricular fibrillation
- has [**2168**] and [**2170**] Biventricular ICD-[**Company 1543**]
.
#HTN- Continued home medications
.
#Hyperlipidemia-Continued home medications
.
#Ischemic cardiomyopathy-EF 15% on last echocardiogram [**12/2173**]
-[**2146**] and [**2152**] CABG
-[**2173-9-6**] cardiac catheterization:Occluded LAD, LCX and RCA.
LIMA to LAD with minor luminal irregularities.Y graft with SVG
from the aorta to first OM and diagonal was aneurismal proximal.
Diffuse disease of LIMA to OM. LIMA to diagonal patent.
.
#CHF-Continued home medications, but held Eplerenone,Torsemide,
and Isosorbide, for now because patient is hypotensive . He
was discharged on home dose of Lisinopril.
-Checked I and O's with the patient having adequate urine
output.
.
FEN: Cardiac diet
ACCESS: PIV's
PROPHYLAXIS:
-DVT ppx with pneumoboots on the floor, started lovenox and
warfarin
-Pain management with tylenol
-Bowel regimen with senna/colace
.
CODE: Full.
COMM:
DISPO: Regular floos
Medications on Admission:
DIGOXIN - (Prescribed by Other Provider) - 125 mcg Tablet - one
Tablet(s) by mouth daily
EPLERENONE [INSPRA] - (Prescribed by Other Provider) - 25 mg
Tablet - one Tablet(s) by mouth daily
ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 60 mg
Tablet Sustained Release 24 hr - one Tablet(s) by mouth daily
LISINOPRIL - (Prescribed by Other Provider) - 2.5 mg Tablet -
one Tablet(s) by mouth daily
LORAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet - one
Tablet(s) by mouth daily at bedtime
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 25 mg
Tablet Sustained Release 24 hr - 0.5 (One half) Tablet(s) by
mouth daily
OXYCODONE-ACETAMINOPHEN - (Prescribed by Other Provider) - 5
mg-325 mg Tablet - one Tablet(s) by mouth every 4 hours for
shoulder pain
POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 10 mEq
Capsule, Sustained Release - 3 Capsule(s) by mouth daily
PRAVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet -
one Tablet(s) by mouth daily
SOTALOL - (Prescribed by Other Provider) - 160 mg Tablet - one
Tablet(s) by mouth twice a day
TORSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - one
Tablet(s) by mouth twice a day
WARFARIN - (Prescribed by Other Provider) - 5 mg Tablet - one
Tablet(s) by mouth daily as directed by Dr. [**Last Name (STitle) **]. LD [**2174-5-25**]
pre
procedure.
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - one
Tablet(s) by mouth daily
CALCIUM CARBONATE - (Prescribed by Other Provider) - 600 mg
(1,500 mg) Tablet - one Tablet(s) by mouth daily
MAGNESIUM OXIDE - (Prescribed by Other Provider) - 400 mg
Tablet
- one Tablet(s) by mouth daily
.
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Sotalol 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Pravastatin 10 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
6. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringes
Subcutaneous Q12H (every 12 hours): Please self adminster as
taught.
Disp:*20 syringes * Refills:*0*
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain .
Disp:*30 Tablet(s)* Refills:*0*
9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for agitation .
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: [**11-20**] tablet Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Post Ventricular Tachycardia ablation
Discharge Condition:
Medically stable to be discharged
Discharge Instructions:
It was a pleasure to care for you as your doctor.
.
You were brought to the hospital because of a cardiac arrythmia
which was causing you symptoms of dizziness. You underwent a
procedure to get rid of the 2 origins on your heart of this
abnormal heart beat. You tolerated this procedure well. You
initially had a low blood pressure however your pressure
increased and you are medically stable to be discharged.
.
We made a few changes to the medications you were taking before
coming to the hospital. We added: Enoxaparin Sodium 30 mg SC
twice per day (for 10 days).
.
We discontinued the following two medications because of the
concern of lowering your blood pressure too much: Eplerenone,
Torsemide and Isosorbide. You should discuss these three
medications with your primary care doctor, about potentially
restarting them at a later date.
.
You will need to follow up with your cardiologist to discuss
your health management as well as checking your INR; please
follow up with the following outpatient appointments:
.
Provider:[**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
Date: [**6-3**] anytime for INR check
Phone Number [**0-0-**]
.
Dr.[**Last Name (STitle) **]
Date: [**6-6**] 1:30PM
Phone Number [**0-0-**]
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Provider:[**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
Date: [**6-3**] anytime for INR check
Phone Number [**0-0-**]
.
Dr.[**Last Name (STitle) **]
Date: [**6-6**] 1:30PM
Phone Number [**0-0-**]
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Discharge summary
|
report
|
Unit No: [**Unit Number 29494**]
Admission Date: [**2170-10-16**]
Discharge Date: [**2170-10-23**]
Date of Birth: [**2116-11-22**]
Sex:
Service:
HISTORY OF PRESENT ILLNESS: This young 54-year-old gentleman
had a history of increasing shortness of breath with exercise
and exertion with his symptoms becoming worse and more
frequent. He had an exercise tolerance test on [**7-20**]
which was stopped after eight minutes secondary to shortness
of breath. The patient had an echocardiogram followed by a
cardiac catheterization. He did also complain of occasional
chest pain and an increasing number of symptoms of dyspnea on
exertion in the past six months.
Cardiac catheterization on [**2170-8-29**] revealed a
right-dominant system with a 50 percent left main lesion.
The circumflex had a patent stent. The left anterior
descending was normal. The right coronary artery had a 90
percent mid lesion and 100 percent distal lesion with
collaterals to the posterior descending artery and PLV from
the circumflex. Please refer to the final cardiac
catheterization report.
An echocardiogram performed on [**2170-7-20**] showed mild
left ventricular hypertrophy with an ejection fraction of 65
percent and trace mitral regurgitation and tricuspid
regurgitation.
PAST MEDICAL HISTORY:
1. Coronary artery disease and myocardial infarction in [**2164**];
status post stenting.
2. Hypertension.
3. Hypercholesterolemia.
4. Non-insulin-dependent diabetes mellitus.
MEDICATIONS AT HOME: Aspirin 81 mg by mouth once daily,
Toprol-XL 25 mg by mouth once daily, Lipitor 20 mg by mouth
once daily, glyburide 10 mg by mouth twice daily, and
Glucophage 500 mg by mouth four times daily.
ALLERGIES: He has no known allergies.
SOCIAL HISTORY: The patient lives with his wife and is a
machine worker. He admitted to smoking cigarettes;
approximately one to two per day, but he quit smoking
approximately six months ago. He had admitted to no use of
alcohol. He also denied any use of recreational drugs.
PHYSICAL EXAMINATION ON PRESENTATION: The heart rate was 70,
in sinus rhythm. The blood pressure was 148/68 on the right
and 152/75 on the left. He is 5 feet 5 inches tall and 180
pounds. He was in no apparent distress. He had no obvious
skin diseases. He extraocular muscles were intact. The
pupils equal, round and reactive to light and accommodation.
No sinus pressure. The neck was supple without any
thyromegaly or lymphadenopathy. His lungs were clear
bilaterally. No rales or rhonchi. The heart was regular in
rate and rhythm. Positive S1 and S2. No murmurs, rubs, or
gallops. He had positive bowel sounds. The abdomen was soft
and nontender. No evidence of tenderness. The extremities
were warm and well perfused. No clubbing, cyanosis or edema.
He had superficial varicosities of the left leg. He was
alert and oriented times three. He was answering
appropriately. Cranial nerves II through XII were grossly
intact. He had 2 plus bilateral femoral, dorsalis pedis,
posterior tibial pulses, and radial pulses.
RADIOLOGIC STUDIES: Electrocardiogram showed a normal
electrocardiogram with a normal sinus rhythm at 74.
A chest x-ray was normal.
PERTINENT PREOPERATIVE LABORATORY DATA: White blood cell
count was 9, the hematocrit was 42.1, the platelet count was
501. The PT was 12.6, the PTT was 23.2, and the INR was 1.
Sodium was 139, potassium was 4.1, chloride was 101,
bicarbonate was 27, blood urea nitrogen was 15, creatinine
was 0.9, and blood sugar was 197.
SUMMARY OF HOSPITAL COURSE: The patient was brought in for a
same-day admission on [**2170-10-16**] (on the day of
admission) and underwent coronary artery bypass grafting
times three by Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] with a left internal
mammary artery to the left anterior descending, a vein graft
to the obtuse marginal, and a vein graft to the posterior
descending artery. He was transferred to the Cardiothoracic
Intensive Care Unit in stable condition on a Neo-Synephrine
drip at 0.5 mcg/kg per minute, and insulin drip at 2 units
per hour, and a propofol drip titrated for station.
On postoperative day one, he had been extubated overnight.
He revealed intravenous boluses of fluid for intermittent
tachycardia with a blood pressure of 135/70, and a heart rate
of 105 to 125, and a respiratory rate of 16. He was on an
insulin drip at 6 units per hour.
Postoperative laboratories were as follows. White count was
13, hematocrit was 27.2, potassium was 5.8, blood urea
nitrogen was 10, creatinine was 0.8, with a blood sugar of
206. He had no air leak and was putting out some
serosanguineous from his chest tubes. He received 5 mg of
Lopressor times one to slow his heart rate down.
A postoperative chest x-ray showed the tube was in good
position. He was receiving Toradol and morphine
intravenously for pain management on the Unit. His Swan-Ganz
catheter and chest tubes were pulled. He was also seen by
Case Management. The patient was also seen by Social Work.
On postoperative day two, his hematocrit dropped slightly to
23.2. The Lopressor was increased to 25 mg three times daily
to help slow the heart rate down of 97, in a sinus rhythm.
Creatinine remained stable at 0.7. The Foley was
discontinued. The patient was doing well and was ready for
transfer to the floor pending an open bed - which delayed the
transfer - but was transferred out to the floor later in the
day on postoperative day two. The patient was seen and
evaluated by Physical Therapy to begin working with the
nurses and physical therapist on ambulation. The patient was
strongly encouraged to cough and deep breathe and to work
with the incentive spirometer for pulmonary toilet. He was
alert and oriented and was ambulating independently to the
bathroom overnight on postoperative day two. The patient was
feeling well and started to ambulate on the floor. His heart
rate went up to the 120s, with a blood pressure in the
90s/60s. He was given an additional 25 mg of Lopressor - per
medical doctor consultation at 8:00 in the evening. The
patient was also given Percocet for left leg incisional pain.
He voided status post Foley and began doing his incentive
spirometry.
The patient was seen the following day - on postoperative day
three - by the [**Last Name (un) **] attending for an initial consultation
and management of his blood sugars. His sliding scale was
adjusted [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations. The patient was also
restarted on the Glucophage and glyburide. He was not
symptomatic at all from his hematocrit which had again
dropped slightly to 21.2. The decision was made to hold off
on transfusing him as he was not symptomatic.
On postoperative day four, his blood sugar was in the 110 to
180 range. The pacing wires were removed. The patient
continued to work with Physical Therapy and made good
progress on his activity level. Of note, the [**Last Name (un) **] visit
was conducted in Spanish (the patient's native language).
[**Last Name (un) **] had an extended conversation with the patient in
consultation about blood sugar control and the need for
insulin as well as plans for making sure the instructions
were done. Actos oral [**Doctor Last Name 360**] was also added in to the
patient's regimen for blood sugar control.
On postoperative day five, the patient's hematocrit rose
slightly to 23.7. His examination was otherwise
unremarkable. The incisions were clean, dry, and intact. He
was alert and oriented. His blood sugar again was in the
120s to 190s range. He was hemodynamically stable. He was
given Percocet for incisional pain and did a level V
ambulation in preparation for going home.
On postoperative day six, he still had elevated glucose
levels and a 6-beat run of nonsustained ventricular
tachycardia that morning and then back in sinus rhythm at 84.
His blood pressure was 110/60. His hematocrit rose slightly
to 24.1. He had been started on NPH insulin twice daily and
regular insulin sliding scale. Actos was not started at that
time. Lopressor was changed to 25 mg twice daily. The
patient was seen again on [**10-22**] by the [**Last Name (un) **] Service
in consultation with recommendations to increase his NPH
dosing and arrange for followup at the [**Hospital **] Clinic with Dr.
[**Last Name (STitle) **]. The patient remained on the floor for monitoring
after that 6-beat run of nonsustained ventricular
tachycardia. The patient was deemed able to go home on
[**2170-10-23**] - the following morning - with VNA services
with the following discharge diagnoses.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting times three.
2. Non-insulin-dependent diabetes mellitus with a discharge
diagnosis now of insulin-dependent diabetes mellitus.
3. Coronary artery disease; status post myocardial infarction
in [**2164**] with two stents.
4. Hypertension.
5. Hypercholesterolemia.
DISCHARGE FOLLOWUP:
1. The patient was instructed to follow up with Dr. [**Last Name (STitle) 6051**]
[**Name (STitle) **] (telephone number [**Telephone/Fax (1) 25493**]) his primary care
physician in two to three weeks post discharge.
2. The patient to make an appointment with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) 29495**] for his postoperative surgical visit in the office
in four weeks.
3. The patient was instructed to make an appointment with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11712**] - which was already scheduled for [**10-30**]
at 1:30 p.m.
4. The patient was instructed to follow up with Dr. [**Last Name (STitle) **]
in the [**Hospital **] Clinic for diabetes management on [**11-5**]
at 9:00 a.m. Discharge planning and teaching for insulin
delivery was completed.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg by mouth twice daily (times 7 days).
2. Potassium chloride 20 mEq by mouth twice daily (times 7
days).
3. Enteric coated aspirin 81 mg by mouth once daily.
4. Glyburide 10 mg by mouth twice daily.
5. Metformin 1000 mg by mouth twice daily.
6. Lipitor 20 mg by mouth once daily.
7. Ferrous sulfate 325 mg (65-mg tablet) one tablet by mouth
once daily.
8. Vitamin C 500 mg by mouth twice daily.
9. NPH insulin 14 units subcutaneously twice daily.
10. Lopressor 25 mg by mouth twice daily.
11. Acetaminophen/codeine 300/30 mg one to two tablets
by mouth q.4h. as needed (for pain).
12. Regular insulin 6 units twice daily once in the
morning and once at dinner.
The patient was also given a prescription for insulin
syringes as well as lancets for four times daily blood sugar
checks. The patient was also give a prescription for
Glucometer Encore test with instructions to use it four times
daily for blood sugar checks.
DISCHARGE STATUS: The patient was discharged to home with
VNA services on [**2170-10-23**].
CONDITION ON DISCHARGE: Stable.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2170-12-19**] 15:38:03
T: [**2170-12-19**] 16:29:10
Job#: [**Job Number 29496**]
|
[
"272.0",
"401.9",
"V45.82",
"412",
"250.00",
"414.01",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.72",
"36.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
8649, 8966
|
9848, 10906
|
1493, 1728
|
3540, 8628
|
8986, 9822
|
177, 1268
|
1290, 1471
|
1745, 3511
|
10931, 11196
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,140
| 134,128
|
44881
|
Discharge summary
|
report
|
Admission Date: [**2105-5-30**] Discharge Date: [**2105-6-3**]
Service: MEDICINE
Allergies:
Allopurinol
Attending:[**Last Name (NamePattern1) 1572**]
Chief Complaint:
Altered mental status, fever
Major Surgical or Invasive Procedure:
s/p IR percutaneous drainage of GB w/ drain placement
History of Present Illness:
Patient is an 86 y/o M with history of CAD, HTN, recent
diagnosis of Stage I pancreatitic CA compressing the CBD, s/p
ERCP with stent placement on [**5-11**] after presenting to the
hospital with jaundice. Found to have occluded stent on [**2105-5-23**],
now s/p repeat ERCP with restenting. He presents today with
delerium, aphagia and fever x1 day. By report from the Ed, he
has not had a bowel movement in a few days.
.
<br>In the ED, his vitals were T 98.9, BP 150/86, RR 16, HR 84,
spO2 98%. He recieved 3L NS. He had an abd u/s with distended
gall bladder, thickened wall and fat stranding on CT scan.
Surgery was consulted, and he is likely not surgical candidate.
He was given Zosyn 4.5x1 and Levaquin 750mgx1.
.
<br>On arrival to the floor, he is afebrile, RR 30, HR 72 and bp
142/64. He has word finding difficulty, but is able to follow
some commands. He is A&O x0. He c/o of some abdominal pain, but
only to palpation, not independently. Per the family, yesterday
went to Legals Sea food for lunch and he was neurologically
intact, without this degree of word finding difficulty. He was
weaker, more fatigued than baseline. Last night, per his wife,
he woke up around midnight disoriented and then again at 3am,
wandering around the house. He had a fever of 100.8, and was
instructed by the covering doctor to come to the ED.
<br>Brief history of Pancreatic CA:
- started work up for weight loss, diarrhea, and anorexia [**3-11**]
with EGD and colonscopy that were positive only for hiatal
hernia and gastritis
- presesnted [**5-11**] with jaundince, diagnosed with pancreatic CA,
had ERCP with stent placemeht. Stage 1. ERCP brushings positive
for malignanct cells. Surgery evaluated and he was not a
surgical candidate
- [**5-23**]: Oncology office visit, thinking about cyberknife
treatment + chemotherapy (gemcitabine vs TNFerade trial)
- [**5-23**]: increasing jaudince, send from Onc visit for repeat
ERCP, stent occluded, patient restented
Past Medical History:
1. CAD, status post an MI in1982 followed by CABG x2.
2. Peptic ulcer disease.
3. Hypertension.
4. Benign prostatic hypertrophy, status post surgery.
5. Nephrolithiasis.
6. Gout.
7. Status post tonsillectomy.
8. Status post knee arthroscopy in [**2102**].
9. Hypothyroidism.
Social History:
<br><b>Social History:</b> He lives with his wife. His wife and
daughter are accompanying him on his visit today. He smoked
cigarettes but quit in [**2049**] after smoking for approximately 10
years. He does not drink alcohol. He used to be in the navy.
He was an executive during the day but worked at night as a
musician and played behind such bands as the Temptations and
other such groups.
Family History:
<br><b>Family history:</b>
He has a sister with breast cancer. His mother and father died
from heart disease. His sister is alive and he has four
children who are alive and healthy. His daughter is a physician
Physical Exam:
<br><b>Physical Exam:</b>
Vitals: T: 98.4 BP: 142/64 P: 72 RR: 32 O2Sat: 94% on 2L
Gen: Patient confused, aphasia
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: bibasilar crackles
ABD: distended. no bowel sounds. pain to palp of rt upper
quadrant
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox zero. not interactive. facial nerve intact, Patient
moving all 4 extremities. unable to follow commands to do very
thorough neuro exam.
Pertinent Results:
[**2105-5-30**] 04:34PM GLUCOSE-103 UREA N-51* CREAT-3.3* SODIUM-142
POTASSIUM-4.5 CHLORIDE-111* TOTAL CO2-18* ANION GAP-18
[**2105-5-30**] 04:34PM ALT(SGPT)-51* AST(SGOT)-64* LD(LDH)-251*
CK(CPK)-60 ALK PHOS-392* TOT BILI-3.2*
[**2105-5-30**] 04:34PM CK-MB-NotDone cTropnT-0.19*
[**2105-5-30**] 04:34PM TSH-4.4*
[**2105-5-30**] 04:34PM WBC-10.7 RBC-3.54* HGB-11.9* HCT-35.8*
MCV-101* MCH-33.7* MCHC-33.4 RDW-16.1*
[**2105-5-30**] 04:34PM NEUTS-86.4* BANDS-0 LYMPHS-10.2* MONOS-3.1
EOS-0.2 BASOS-0.1
[**2105-5-30**] 08:40AM AMMONIA-17
[**2105-5-30**] 08:10AM LACTATE-2.1*
[**2105-5-30**] 07:45AM LIPASE-9
[**2105-5-30**] 07:45AM ALT(SGPT)-54* AST(SGOT)-52* CK(CPK)-70 ALK
PHOS-436* TOT BILI-3.6*
[**2105-5-30**] 07:45AM WBC-11.5* RBC-3.32* HGB-11.0* HCT-33.5*
MCV-101* MCH-33.1* MCHC-32.8 RDW-16.2*
.
[**2105-5-12**]: STRESS
IMPRESSION: No anginal type symptoms or ischemic EKG changes.
Nuclear
report sent separately.
.
[**2105-5-12**] pMIBI
IMPRESSION: Unchanged multiple moderate to severe fixed defects,
without significant change since the prior study, primarily
involving the distal anterior wall, apex and septum. Global
hypokinesis with dyskinesis of the apex, with the LVEF of 29%.
.
[**2105-5-8**] ABDOMINAL US
IMPRESSION:
1. Dilated intra- and extra-hepatic bile ducts as well as
dilated pancreatic duct. Likely hypoechoic mass in the region of
the pancreatic head. Further evaluation with CT is recommended.
2. Hepatic hemangioma.
.
[**2105-5-11**] CT abd w/wo contrast
IMPRESSION:
1. Hypoenhancing pancreatic head mass causing narrowing of the
common bile duct stent as well as pancreatic ductal dilatation,
highly concerning for pancreatic adenocarcinoma. However, the
SMV and SMA are unaffected and there is no pathologic
lymphadenopathy. No definitely suspicious hepatic lesions.
2. Three peripherally enhancing hepatic lesions most likely
represent
hemangiomas.
3. Progressive enlargement of right renal lower pole hyperdense
lesion.
4. Cardiomegaly with probable right heart strain.
.
ERCP [**5-11**]: stent placed, CBD brushings: POSITIVE FOR MALIGNANT
CELLS consistent with adenocarcinoma.
.
LIVER/GALLBLADDER ULTRASOUND [**5-30**]:
IMPRESSION: Interval development of gallbladder distension, wall
thickening and pericholecystic edema, which may be seen in a
setting of ascites, cholecystitis cannot be entirely excluded.
Extrahepatic CBD stent incompletely visualized. No intrahepatic
biliary ductal dilatation.
.
MR BRAIN [**5-31**]:
IMPRESSION: Infra and suprtentorial multiple subcentimeter foci
of increased FLAIR and restricted diffusion, likely consitent
with thromboembolic acute/subacute ischemic changes, the
possibility of tumoral embolization is a consideration.
Brief Hospital Course:
ACUTE CHOLECYSTITIS
The patient presented with fever and RUQ pain; a RUQ ultrasound
showed acute cholecystitis. Surgery evaluated the patient, but
since he was not a surgical candidate, the gallbladder was
drained percutaneously by IR. The acute cholecystitis did not
appear to be secondary to the stent obstruction that was revised
on [**5-23**], because the LFTs had been trending downward since the
procedure, indicating that the revised stent was not obstructed.
The patient was given flagyl and levaquin for anaerobic and gram
negative coverage.
.
ABDOMINAL DISTENTION / ILEUS
The patient did not appear to have an SBO on imaging. His ileus
on radiography was presumed secondary to cholecystitis. An NG
tube was placed at continuous suction.
.
ALTERED MENTAL STATUS / DYSPHASIA
MRI showed multiple foci of decreased perfusion that were
consistent with embolic infarcts, either from the tumor itself
or another source. Delirium was also considered in the ddx due
to the waxing and [**Doctor Last Name 688**] nature of the symptoms.
.
ELEVATED TROPONIN
Despite the elevated troponins, there was no chest pain or EKG
changes and other cardiac enzymes returned negative. Findings
were not felt to be due to ACS.
.
ACUTE RENAL FAILURE
Considered to be pre-renal and caused by CHF.
.
GOALS OF CARE
On HD 3 patient became less responsive. Goals of care were
addressed with patient's family and the decision was made for
comfort measures only. At time of transfer to the medical
floors, he was minimally responsive to verbal commands (would
squeeze fist and move toes on command) and could not move the
right half of his body. All laboratory and diagnostic tests
were discontinued. Antibiotics and IVF were also stopped.
Patient was given morphine titrated to comfort level and given
scoplomaine patch for oral secretions. He passed away two days
after transfer. Time of death was 19:30 on [**6-3**].
Medications on Admission:
<br><b>Medications on Admission:</b>
Amlodipine 5mg daily
Atenolol 50mg daily
Fluticasone 50mcg 1 puff each nostril daily
Hydrochlorothiazide 12.5 daily
Levothyroxine 25mcg , [**11-26**] tab daily
Omeprazole 20mg daily
Discharge Medications:
Deceased.
Discharge Disposition:
Expired
Discharge Diagnosis:
acute cholecystis s/p percuatenous drainage
Discharge Condition:
Deceased.
Discharge Instructions:
Deceased.
Followup Instructions:
Deceased.
Completed by:[**2105-6-4**]
|
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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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6539, 8449
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255, 310
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8848, 8859
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187, 217
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338, 2301
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2646, 3023
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,053
| 105,189
|
5842
|
Discharge summary
|
report
|
Admission Date: [**2144-12-5**] Discharge Date: [**2145-1-27**]
Date of Birth: [**2081-11-5**] Sex: M
Service: MEDICINE
Allergies:
Demerol / Haloperidol
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
tremors, difficulties with balance
Major Surgical or Invasive Procedure:
1. Posterior cervical laminotomy C3 bilateral.
2. Posterior cervical laminectomy C4 to C7.
3. Posterior thoracic laminectomy T1.
4. Posterior cervical instrumentation C3-T1.
5. Posterior cervical thoracic arthrodesis C3-T1.
6. Autograft augmentation for fusion.
7. Allograft augmentation for fusion
.
Paracentesis, thoracentesis, lumbar puncture, mechanical
ventilation, nasogastric tube, tracheostomy placement, and
central line placement and removal
History of Present Illness:
A 63 year-old man w/ history of Hepatitis C and cirrhosis, and
hepatocellular carcinoma who presented to ED w/ increasing gait
unsteadiness, tremor, and resultant fall PTA. The tremor was
first noted 2mo ago, w/ difficulty shaving. This has progreesed
to significant UE and LE tremor b/l, w/ significant worsening
[**12-22**] wks PTA. Pt has had difficulties w/ writing, tying
shoelaces. No difficulties opening doors. Pt. also had
increasing gait unsteadiness for past 5 weeks, that has become
worse over the past 2-3 days. 2 d PTA, pt fell as he was
pivoting. His legs felt weak and gave out. There was no vertigo,
lightheadedness, tinnitus, hearing loss, changes in vision. No
urinary or bowel incontinence. W/ fall pt hit his hip and knee,
no head trauma. He does not feel like he has slowed down or it
takes pt more time to complete tasks. He denies fevers, chills,
cough, dysuria, abdominal pain. He denies any abdominal pain or
bright red blood per rectum. No hematemesis. There is no
unilateral weakness, no changes in vision, no difficulty
producing or understanding speech. Of note, pt. has had one
episode of AH yesterday, single voice, unintelligeble. He denies
SI, HI. There is no paranoid ideation.
.
Pt reports multiple medication non-adherence issues. He has not
been taking lactulose TID for over 2mo and has taked it QD for
1mo w/ none over past week. Has 1bm/day. In addition, has been
taking bupropion XL 150mg TID inappropriately, sometimes taking
2 tablets at a time if he has to leave the house, vs two tablets
as prescribed. In addition, pt. has hx of being treated w/
Risperdone last year, 1mg [**Hospital1 **] for 3mo.
.
In the ED, initial vitals were T:98.9 BP:139/72 HR:72 RR:15
O2Sat:98% on RA. Abdominal ultrasound was performed without any
acute abnormality. Lithium level was normal. Peripheral IV was
placed and patient was admitted for further evaluation. Li level
was 1.1
.
INTERVAL HPI PRIOR TO DISCHARGE:
Past Medical History:
- Bipolar disorder: Diagnosed in [**2129**], past suicide attempt in
the 70s during a manic phase or s/t to drug and alcohol abuse.
Had been stable on Wellbutrin and Lithium since [**29**] and 93
respectively, except for during a trial of IFN therapy in [**2138**]
where hospitalization was required.
- HCV: Genotype unknown. Liver biopsy in [**9-/2144**] showed stage 4
cirrhosis and small well-differentiated hepatocellular
carcinoma. Found to have grade 1 esophageal varices on EGD in
4/[**2143**]. Developed hepatic encephalopathy in [**2142**] requiring
hospitalization at [**Hospital1 2025**], started on lactulose with good effect.
Past treatments include peg interferon and ribavirin in [**2139**].
These meds were discontinued due to suicidal ideation.
- HCC: Recently noted 1.4 cm enhancing lesion on liver imaging,
proved to be small, well-differentialed HCC on bx in [**9-26**].
- Hypothyroidism. On levothyroxine as an outpatient.
Social History:
He lives [**Location (un) **] w/ wife, who is a nurse. [**First Name (Titles) **] [**Last Name (Titles) 23165**]
beverage for 30 years. No tobacco use ever.
Family History:
Patient recalls no history of neurologic or autoimmune diseases.
Physical Exam:
Vitals: T:97.3 BP:132/71 HR:64 RR:18 O2Sat:100% on RA
GEN: Pleasant well-nourished male, NAD
HEENT: EOMI, PERRL, sclera anicteric, MMM, OP Clear
NECK: No JVD
COR: RR, 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
NEURO:
.
Alert, oriented to: name, [**Hospital1 **], [**2143**], [**12-5**], President [**Last Name (un) 2450**]. Naming, repetition, immediate and 5min
recall intact. Days of week in reverse intact. Clock drawing
intact. No micrographia. Nl affect.
.
CN: VF intact to confrontation, EOMs intact, no nystagmus, PERRL
4->2mm, facial sensation intact b/l, symmetric face, intact
orbicularis occuli, intact mmmm, LLLL, KKKK. Tongue and uvula to
midline. Intact to finger rub b/l. Shoulder shrug intact.
.
Motor: Strength 5/5 throughout. nl bulk, increased tone, trace
cogwheel rigidity at brachialis b/l. None distally or LE. No
clonus.
.
Sensory: Intact to LT, proprioception and temperature. Pin-prick
no tested.
Coordination: slightly imparired FTN, HTS intact. Intention
tremor in UE and LE b/l w/ flexion at elbow and knee. No
nystagmus. Positive romberg, wide based gait. No dysarthria.
Negative pronator drift. Pt. could not do heel to toe.
Asterixis present in hands and feet b/l.
Reflexes: DTRs 3+ throughout, except at R patellar, 2+. Down
going toes b/l.
Pertinent Results:
Admission labs:
[**2144-12-5**] 01:50PM BLOOD WBC-5.6 RBC-3.71* Hgb-12.8* Hct-36.9*
MCV-99* MCH-34.6* MCHC-34.8 RDW-14.1 Plt Ct-92*
[**2144-12-5**] 01:50PM BLOOD Neuts-68.7 Lymphs-14.2* Monos-8.6
Eos-8.0* Baso-0.6
[**2144-12-5**] 01:50PM BLOOD PT-13.8* PTT-30.1 INR(PT)-1.2*
[**2144-12-5**] 01:50PM BLOOD Glucose-93 UreaN-17 Creat-0.9 Na-137
K-4.1 Cl-105 HCO3-24 AnGap-12
[**2144-12-5**] 01:50PM BLOOD ALT-225* AST-291* LD(LDH)-380*
AlkPhos-198* TotBili-2.3*
[**2144-12-5**] 01:50PM BLOOD Albumin-3.3* Calcium-9.3 Phos-3.0 Mg-1.6
.
Discharge labs:
[**2145-1-27**] 05:10AM BLOOD WBC-2.0* RBC-2.39* Hgb-8.4* Hct-25.1*
MCV-105* MCH-35.1* MCHC-33.5 RDW-15.6* Plt Ct-83*
[**2145-1-27**] 05:10AM BLOOD PT-17.4* PTT-42.6* INR(PT)-1.6*
[**2145-1-27**] 05:10AM BLOOD Glucose-95 UreaN-16 Creat-0.6 Na-141
K-4.1 Cl-111* HCO3-25 AnGap-9
[**2145-1-27**] 05:10AM BLOOD ALT-47* AST-97* LD(LDH)-240 AlkPhos-105
TotBili-1.7*
[**2145-1-27**] 05:10AM BLOOD Albumin-2.8* Calcium-7.9* Phos-2.5*
Mg-2.0
[**2145-1-18**] 02:12PM BLOOD TSH-3.7
[**2145-1-18**] 02:12PM BLOOD T4-5.7
.
MICROBIOLOGY (positive studies)
[**2145-1-7**] 11:44 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2145-1-14**]**
Blood Culture, Routine (Final [**2145-1-14**]):
FUSOBACTERIUM NUCLEATUM.
Anaerobic Bottle Gram Stain (Final [**2145-1-11**]):
GRAM NEGATIVE ROD(S).
.
SELECTED IMAGING:
ABDOMEN U.S. (COMPLETE STUDY) Study Date of [**2144-12-5**] 6:14 PM
RIGHT UPPER QUADRANT ULTRASOUND: The liver is uniform in
echotexture, and demonstrating minimal nodularity. No focal
lesions are identified. The portal vein demonstrates normal
hepatopetal flow, with wall-to-wall flow seen. Its Doppler
signal is normal. There is no biliary ductal dilatation. The
common bile duct is normal, measuring 2 mm. Splenomegaly is
again noted, with the spleen measuring up to 16.9 cm. The
gallbladder demonstrates mild wall thickening, and a small
amount of pericholecystic fluid, but there is no gallbladder
distention or gallstones. There is no ascites. IMPRESSION: 1.
Widely patent main portal vein demonstrating appropriate
direction of flow. 2. Cirrhosis and splenomegaly. No ascites. 3.
Non-distended, mild gallbladder wall thickening and
pericholecystic fluid. Findings likely due to hypoproteinemia
and chronic liver disease.
.
MR HEAD W & W/O CONTRAST Study Date of [**2144-12-6**] 8:27 PM Images
of the brain appear normal. There is no evidence of hemorrhage,
edema, masses, mass effect or infarction. There is no abnormal
intracranial enhancement after contrast administration. There
are no diffusion abnormalities. There are two extracranial
incidental findings. First, there is a disk herniation with
severe [**Date Range **] canal narrowing at C4-5 with compression of the
[**Date Range **] cord. Secondly, there is a 16 mm mass apparently arising
within the deep lobe of the left parotid gland. This is
hyperintense on the long TR images and enhances intensely after
contrast administration. The most likely diagnosis is a
pleomorphic adenoma, but consultation with Otorhinolaryngology
may be indicated. CONCLUSION: Normal brain MR. [**First Name (Titles) **] [**Last Name (Titles) 23166**]e disc disease with disk herniation and cord
compression at C4-5. This is incompletely imaged on this brain
MR examination. There is a 16 mm mass apparently arising from
the deep lobe of the left parotid, probably a pleomorphic
adenoma.
.
MR CERVICAL SPINE W/O CONTRAST Study Date of [**2144-12-8**] 12:53 PM
FINDINGS: Vertebral body height is grossly preserved. There is a
grade 1 anterolisthesis at C4/5. Discogenic bone marrow changes
are seen in the endplates ([**Last Name (un) 13425**] type II at C4/5 and C5/6; [**Last Name (un) 13425**]
type I at C6/7). Multilevel spondylosis is present, as detailed
below. At C3/4, there is a broad-based disc/osteophyte complex,
which flattens the [**Last Name (un) **] cord and results in severe [**Last Name (un) **]
canal stenosis. Right uncovertebral joint osteophytes are larger
than the left, resulting in severe right and moderate left
neural foramen narrowing. At C4/5, the level of the grade 1
anterolisthesis, there is a broad-based disc/osteophyte complex
which compresses the [**Last Name (un) **] cord and results in severe [**Last Name (un) **]
canal stenosis. There is mild narrowing of the right neural
foramen and moderate to severe narrowing of the left neural
foramen. At C5/6, there is a broad-based disc/osteophyte
complex, which contacts but does not definitively deform the
[**Last Name (un) **] cord. There is mild to moderate [**Last Name (un) **] canal stenosis.
The right neural foramen is mildly narrowed. At C6/7, there is a
disc/osteophyte complex, which flattens the anterior [**Last Name (un) **]
cord. Thickening of the ligamentum flavum is also present. There
is moderate [**Last Name (un) **] canal stenosis. There is severe narrowing of
the left neural foramen. There is subtle high signal in the
[**Last Name (un) **] cord from C3/4 through C4/5, which may represent edema or
myelomalacia. The imaged portion of the posterior fossa appears
unremarkable. No signal abnormalities are identified in the
imaged paravertebral soft tissues. IMPRESSION: 1. Spondylosis
resulting in severe [**Last Name (un) **] canal stenosis at C4/5 and
moderate-to- severe [**Last Name (un) **] canal stenosis at C3/4, with
compression of the [**Last Name (un) **] cord. Edema or myelomalacia in the
cord at the affected levels. 2. Grade I anterolisthesis at C4/5.
.
MR HEAD W & W/O CONTRAST Study Date of [**2144-12-16**] 5:37 PM
FINDINGS: There have been no significant changes since the
previous study. There is no evidence of hemorrhage, edema,
masses, mass effect, or infarction. There are no diffusion
abnormalities. The ventricles and sulci appear normal in caliber
and configuration. There is no abnormal enhancement after
contrast administration. Incidentally noted is mucosal
thickening in the ethmoid air cells. Again noted is a mass
either within or immediately posterior and deep to the left
parotid gland. This may represent a pleomorphic adenoma or a
seventh nerve schwannoma. CONCLUSION: Normal brain MR. [**First Name (Titles) 2325**] [**Last Name (Titles) 23167**]d mass again identified. A preliminary report was issued
that read postoperative day #5 after laminectomy. No acute
process seen.
.
CT CHEST W/CONTRAST Study Date of [**2144-12-18**] 1:51 PM CT CHEST WITH
IV CONTRAST: There is no axillary, mediastinal, or hilar
lymphadenopathy. Heart and pericardium are grossly unremarkable.
Note is made of bilateral moderate atelectasis and trace pleural
effusions. No clear consolidation. No definite pulmonary nodules
or masses are seen. Coronary artery calcifications are also
noted. CT OF THE ABDOMEN WITH ORAL AND IV CONTRAST: Moderate
ascites is present. No focal hepatic mass is seen. The
gallbladder is moderately distended with some gallbladder wall
edema, although it is unclear whether this may be secondary to
third spacing/NPO status. Please correlate clinically. The
spleen, adrenal glands, and kidneys appear unremarkable aside
from multiple low- density lesions seen within the left kidney,
the largest of which measures approximately 4.5 cm with
appearances consistent with cysts, and the smaller ones are too
small for accurate characterization, particularly given the
motion artifact during the study. A post-pyloric enteric tube is
seen, with the tip at the junction of the third-fourth portions
of the duodenum. Spleen and pancreas appear grossly
unremarkable. There is diffuse edema within the mesentery and
omentum. Left gastric varices are seen. No abdominal
lymphadenopathy is evident. CT OF THE PELVIS WITH ORAL AND IV
CONTRAST: Rectal tube and Foley catheter are present, with a
decompressed appearance to the bladder. Small-to-moderate pelvic
free fluid, tracks down from the abdomen. Assessment of the
large bowel is grossly unremarkable. Examination of osseous
structures does not show lytic or sclerotic lesions concerning
for malignancy. Upper thoracic pedicle screws are seen, but not
clearly visualized or characterized on this study. Degenerative
changes of the lumbar spine are seen, with a focal scoliosis
with an S-shape in the lumbar spine, left convex at L3 and right
convex at L4-5, with transitional vertebral body anatomy and
slight anterolisthesis of L3 on L4. Multiplanar reformatted
images were also reviewed in our interpretation, supporting
these findings. IMPRESSION: 1. Moderately distended gallbladder
with mild edema. This may be secondary to third spacing, given
the moderate amount of ascites and mesenteric edema seen. Please
correlate clinically. 2. Moderate bilateral atelectasis. 3. No
other focal infectious source identified.
.
MR [**Name13 (STitle) **] W& W/O CONTRAST Study Date of [**2144-12-23**] 2:01 PM The
patient is status post C7-T1 surgery, with hardware noted,
causing artifacts, limiting accurate assessment to some extent.
Grade 1 anterolisthesis of C4 over C5 is again noted and
unchanged. Post-surgical changes are noted, in the posterior
spinous soft tissues, from C3-T1 level, with moderate amount of
fluid in the soft tissues. Ther eis thin linear enhancement of
the dura posteriorly. However, there is no abnormal irregular or
rim enhancement, to suggest an abscess in this location. There
is no evidence of epidural abscess. There is mild compression on
the posterior aspect of the cord, C3 level, from the orientation
of the ligamentum flavum thickening, which is unchanged. There
is mild narrowing of the size of the cord at the level of C3-C4
which is again unchanged. Minimal increased signal intensity, at
C3-4 level in the cord is unchanged and likely related to edema
or encephalomalacia. Multilevel degenerative changes noted in
the intervertebral disc spaces are unchanged. There are small
areas of edema, related to [**Last Name (un) 13425**] type 1 endplate changes at C5-6
and C6-7 levels, again not significantly changed. No pre- or
para-vertebral soft tissue swelling or masses are noted.
IMPRESSION: 1. Status post surgery from C3-T1 level. 2.
Postoperative changes noted in the posterior spinous soft
tissues with moderate amount of fluid/edema. No evidence of
abscess 3. No evidence of epidural abscess. 4. Persistent
moderate indentation/compression on the posterior aspect of the
[**Last Name (un) **] cord at the level of C3, as seen on the sagittal
sequences, not well assessed on the axial sequences due to
hardware artifacts. 5. Multilevel degenerative changes in the
cervical spine, as described above and not significantly changed
compared to the prior study. 6. Linear area of increased signal
in the cervical cord at C3-4 likely related to myelomalacia.
Mild enhancement of the dura noted posterior, likely related to
post-surgical changes.
.
MR HEAD W/O CONTRAST Study Date of [**2145-1-16**] 3:00 PM FINDINGS:
Comparison was made with the previous MRI of [**2144-12-23**]. No evidence
of acute infarct seen. No signs of hypoxic brain injury are
identified on diffusion images. The ventricles and sulci are
normal in size. There is mild prominence of extra-axial spaces
with prominence of pachymeninges which is unchanged from
previous CT examination of [**2145-1-11**]. No midline shift is
identified. Small foci of T2 hyperintensity in the right frontal
lobe are nonspecific nature and unchanged from previous study.
There is a left parotid mass identified, which could be due to
pleomorphic adenoma and is unchanged from previous study.
IMPRESSION: No acute intracranial abnormalities or change seen
since the previous MRI of [**2144-12-23**] and CT of [**2145-1-11**].
.
VIDEO OROPHARYNGEAL SWALLOW Study Date of [**2145-1-25**] 9:35 AM
FINDINGS: Video oropharyngeal swallow evaluation was performed
in conjunction with the speech and swallow division. Exam was
slightly limited by underlying cervical fusion hardware. Thin
liquid, Nectar-thick liquid, pureed consistency barium, &
one-half of a cookie coated were administered. The oral phase
demonstrated moderate oral residue with early spillage. The
pharyngeal phase demonstrated vallecular and piriform sinus
residue. There was penetration into the laryngeal vestibule with
thin liquids but not nectar thick liquids. There was no
aspiration. IMPRESSION: Several episodes of penetration with
thin liquids. There was no aspiration.
.
Brief Hospital Course:
63M with a history of ESLD, HCC, HCV, distant alcoholism,
bipolar disorder compicated by SI, and medication non-compliance
who was admitted on [**2144-12-6**] for gait unsteadiness, tremor, and
falls. In brief, he reported more than a month of increasing
gait unsteadiness culminating in falls and more recently tremor
and difficult with fine motor tasks. Just prior to admission he
developed gastroenteritis and stopped taking lactulose. He
presented to the [**Hospital1 18**] ED encephalopathic. Further work up on
admission revealed several problems. [**Name (NI) **], he was
encephalopathic on admission with asterixis and confusion. He
improved somewhat with lactulose and rifamixin. Second, he was
not taking his medications as ordered. In particular he was
taking bupropion more on an as needed basis - not taking it at
times and taking high doses to tolerate leaving the house. His
lithium level was WNL on admission. Third, he was noted to have
[**Name (NI) **] stenosis which was believed to explain some of his
symptoms. He ultimately underwent C3-7 laminectomy on [**2144-12-11**].
His post- op course was complicated by dramatic altered mental
status. He was persistently delirius and was treated with high
doses of haloperidol and subsequently developed what appeared to
be NMS. On [**2145-1-6**] a code blue was called on the patient for
apneic PEA arrest. Compressions were initiated promptly. He was
intubated and a large mucus plug was suctioned out of his lungs.
He was transfered to the MICU where he was therapeutically
cooled for 24hrs. He was successfully re-warmed and EEG at that
time was consistent with profound encephalopathy. He underwent
bronchoscopy which showed thick, pus-like mucus in the airways
which grew out oral flora. He was treated with a course of
vancomycin and piparacillin/tazobactam. A single blood culture
grew Fusobacterium and he was treated with PCN. He developed
anuric renal failure which was treated with mitodrine,
octreotide, albumin, and IVF and ultimately recovered to
baseline renal function. He had a prolonged intubation and is
now s/p tracheostomy and successfully extubated. He had
hypernatremia which was treated with free water boluses in his
tube feeds and IVF. Finally, his encephalopathy was aggressively
treated with lactulose, rifamixin, quetiapine, and sedation. He
is now weaned off sedation and stable on lactulose and rifamixin
as well as quetiapine. At the time of transfer back to medicine
he was tolerating tube feeds, alert, afebrile, and stable. On
the the [**Doctor Last Name 3271**] [**First Name4 (NamePattern1) 679**] [**Last Name (NamePattern1) 4869**] his respiratory and nutrition
status were optimized and his encephalopathy improved. He
remains on treatment for encephalopathy with both GI
decontamination and neuroleptics. His deconditioning remains an
issue. He is being dischared to skilled rehabilitation.
.
# Hepatic encephalopathy. Pt. w/ marked asterixis on exam on
admission. Most likely cause was felt to be lactulose
non-adherence. There was no evidence of infection on admission.
CXR, UA, UCx, and BCx were WNL. Patient was noted to have
significant asterixis and slight attention deficit on exam. He
was restarted on scheduled lactulose and rifaximin was added.
The gait instability and tremor were felt to be possible
manifestation of the encephalopathy but did not improve with
treatment while his mental status did. Ultimately this was found
to be [**12-21**] [**Month/Day (2) **] cord stenosis (see below) which was treated
surgically. His mental status has cleared significantly with
aggressive bowel regimen and discontinuation of home bupropion
and lithium. He is also s/p NMS from haloperidol given
post-operatively earlier this admission. He will continue
lactulose 60 mL PO Q4H and titrate to >4BM daily + clear mental
status, rifaximin 400 mg PO TID for bowel decontamination, and
quetiapine fumarate 50 mg PO Q6H:PRN for agitation per psych as
well as standing doses (see below). His doses of quetiapine can
be titrated down for over-sedation.
.
#. PO access: S/p prolonged hospitalization. Pulled out multipe
Dophoffs. Now that mental status improved doing very well but
caloric intake is still low. He has repeated passed speach and
swallow evaluations, including on the day of discharge. He was
dischaged on supervised POs with soft solids and thickened
liquids. He will need ongoing nutrition consults.
.
#. Respiratory status: S/p prolonged intubatation now extubated
with tracheostomy placed on [**2145-1-13**]. Doing well with cuff in
place on FiO2 35%. Notable history of aspiration PNA and mucus
plugging which resulted in a PEA arrest (see below). For now on
standing albuterol and iptropium nebs Q6hrs with excellent
effect. Will go to rehab with trach in place and be weaned
there.
.
#. Weakness / deconditioning. Likely a combination of
deconditioning from being bed-ridden for several weeks, upper
motor deficits s/p cervical [**Date Range **] stenosis treated with
laminectomy, and catabolic state. He will require intensive PT
to regain functioning. He is discharged to rehab for this
purpose.
.
# Tremor/Gait instability. Initially improved slightly with
lactulose, suggesting hepatic encephalopathy as a contributor,
but Pt continued to have severe clonus and tremors as well as
worsening gait instability. Tremors were felt to be [**12-21**] to Li
toxicity and this was discontinued. To rule out other causes of
ataxia, B12, folate, and RPR were obtained which were all
normal. Pt. underwent an MRI of head which showed a normal
brain, but incidentally provided evidence of C4,5 [**Month/Day (2) **] cord
compression. MRI of spine showed extensive [**Month/Day (2) **] cord
compression w/ myelomalacia at C3 to C7 levels. Neurology was
consulted who felt patient's gait instability and and clonus
were most likely due to chronic [**Month/Day (2) **] cord compression at these
levels. Ortho-spine consultation was obtained emergently. On
[**12-9**], patient was noted to have worsening gait difficulties and
more pronouced clonus. The clonus was felt to be due to [**Month/Year (2) **]
cord compression. A decision was made to perform [**Month/Year (2) **] cord
decompression to prevent further cord deterioration. On [**12-11**]
patient underwent posterior cervical laminotomy C3 to T1 and
posterior cervical instrumentation C3-T1, posterior cervical
thoracic arthrodesis C3-T1, autograft and allograft augmentation
for fusion. The post operative course complicated by severe
encephalopathy and NMS (see below).
.
# NMS and Post-op encephalopathy: Pt. undergone C3-T1
laminectomy, instrumentation and [**Month/Year (2) **] fusion on [**2144-12-11**] and
was delerious post operatively w/ decompensation of hepatic
encephalopathy. Pt. continued to be unresponsive w/ low grade
temperatures despite marginal improvement w/ haldol (>40mg) and
lactulose. Developed tachypnea, hypertension, tachycardia and
low grade temps. CK > 1400, but pt had been w/ persistent
thrashing for ~ 1wk. QTc 450. Haldol has been d/c [**12-17**] 1400 last
dose. CKs trending down w/ supportive treatment. Ultimately
believed to be consistent with NMS [**12-21**] haloperidol. Psych
recommended switch to Seroquel for agitation and bipolar.
.
# Bipolar d/o. Patient was euthymic on admission until the time
of surgery with no sx of mania or depression. Pt reported recent
auditory halucinations. Lithium dose was reduced then DCed given
concern for tremor. Wellbutrin was also decreased and then DCed
during the post operative course due to the persistent delerium.
Ultimately was started on Quetiapine Fumarate 100 mg PO QAM and
200 mg PO HS with good control of symptoms. This can be
decreased as needed for sedation.
.
#. Cirrhosis: History of HCV and distant alcohol abuse. Known to
have HCC, although seems to be limited disease. Pt with
relatively preserved synthetic function. Will being evaluated
for liver transplant as an outpatient. Plan is to continue
management of encephalopathy with lactulose and rifamixin. Of
note, has known grade I esophageal varices as of [**2-24**]. Not on
Bblocker. On PPI.
.
# Left parotid mass. 1.6cm incidental finding on MRI.
Outpatient follow up with ENT recommended.
.
MICU Course:
# Cardiac / PEA arrest / hemodynamics: On [**1-7**] the patient had a
witnessed PEA arrest. CPR was initiated promptly, the patient
was intubated and given epi/atropine. A large mucous plug was
suctioned from the ET tube, with subsequent restoration of
perfusing rhythm and the patient was transfered to the medical
ICU for further managment. The patient was cooled and then
rewarmed the following day per protocol. Early in the morning
of [**1-8**] the patient became hypotensive, received several IV
fluid boluses, and eventually required levophed to support his
blood pressure. The levophed was weaned off the following day.
Cardiac enzymes trended down post-arrest. Echo was
hyperdynamic without evidence of cardiogenic shock. On [**1-11**],
peri-intubation, the patient had an episode of AF with RVR and
aberrancy that responded to Ca2+.
.
# Respiratory/Ventilation: On transfer to the MICU the patient
had a bronchoscopy showing thick, yellow secretions concerning
for infection, and was started vancomycin and zosyn for a 5 day
course for hospital acquired pneumonia. The patient was
successfully extubated on the morning of [**1-10**], but was
reintubated on [**1-11**] secondary to respiratory distress and
inability to handle secretions. As the latter circumstance was
felt to be unlikely to change the patient had a trachesotomy
placement on [**1-13**]. Placement was complicated by some minor
bleeding for which ENT was consulted and evaluated the patient.
No pharyngeal source was found. On discharge from the MICU the
patient was tolerating his trach collar very well with a
passy-muir valve in place.
.
# Mental Status: The patient had an altered mental status for
most of his MICU stay. Initially this was felt to be secondary
to both cirrhosis and PEA arrest (and anoxic brain injury to
unknown extent) contributing. The patient had an EEG after his
PEA arrest that showed a severe encephalopathy. On the morning
of [**1-10**] following extubation, the patient's mental status was
noted to be the same as that pre-code. CT head was
unremarkable. An MRI on [**1-16**] head showed no evidence of anoxic
brain injury. The patient had multiple episdoes of agitation
and multiple medications were tried. Eventually psychiatry was
consulted and recommended using seroquel, which worked well. In
addition, the patient's lactulose was also uptitrated to 60 mg
Q4H. On the day of transfer out of the MICU, the patient's
mental status had improved markedly.
.
# Renal Failure: Post cardiac arrest the patient was anuric.
This etiology was likely combination of acute tubular necrosis
in the setting of PEA arrest and hepatorenal syndrome. He
received mitodrine, octreotide, and albumin for HRS.
His renal function slowly improved.
.
# Fusobacterium bacteremia: One of two blood culturs drawn on
[**1-7**] grew out Fusobacterium. ID was consulted and the patient
was treated with a 2 week course of penicillin G that ended on
[**2145-1-21**].
.
# Hypernatremia: Likely hypovolemic hypernatremia in the setting
of recent ATN and current HRS. Resolved with free water boluses
through the NG tube. Hypernatremia worsened again with
acceleration of tube feeds and improved with increased free
water boluses and holding of tube feeds due to the patient's
inability to maintain an upright posture.
.
# Thrombocytopenia: The patient had a low platelet count that
was stable. Initial considerations were HIT vs. splenic
sequestration. Smear on [**1-14**] showed no evidence of DIC. The
patient was switched from an H2 blocker to a PPI. His platelets
remained low, but stable.
.
# Cirrhosis: Hep C stable. Lactulose was increased. Rifaxamin
was held when the patient was on vancomycin and zosyn and
resumed when these medications were stopped. Hepatology
followed the patient during his MICU stay and resumed care for
the patient on transfer back to the medical floor.
Medications on Admission:
#. Bupropion XL 150mg TID, but not taken as prescribed. Will
need to verify with psychiatrist in AM
#. Esomeprazole 40mg daily
#. Lactulose 10mg/15mL TID, not taking as prescribed.
#. Levothyroxine 75mcg daily
#. Lithium 600mg [**Hospital1 **] per pharmacy, but 450 CR [**Hospital1 **] in OMR, which
is a more appropriate for [**Hospital1 **] dosing.
#. Spironolactone 50mg daily
#. Vitamin D daily
#. Milk Thistle 400mg daily
#. Omega-3 Fatty acids daily
Discharge Medications:
1. Valsartan 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily):
please hold for sbp < 90.
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. Levothyroxine 25 mcg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
5. Thiamine HCl 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
7. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Sixty (60) ML PO Q4H
(every 4 hours).
8. Quetiapine 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QAM (once a
day (in the morning)) as needed for agitation.
9. Quetiapine 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
10. Rifaximin 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times
a day).
11. Sodium Chloride 0.65 % Aerosol, Spray [**Last Name (STitle) **]: [**11-20**] Sprays Nasal
QID (4 times a day) as needed: for nasal dryness.
12. Acetaminophen 325 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO every
eight (8) hours as needed: Not more than 2 grams daily.
13. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1) treatment
Inhalation Q6H (every 6 hours).
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (2) **]: One (1) treatment Inhalation Q6H (every 6
hours) as needed for shortness of breath or wheezing.
15. Quetiapine 25 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for agitation: Not more than 500 mg total
seroquel per day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary: Hepatic encephalopathy (resolving), [**Month/Day (2) **] cord
compression C3 to C7 status post laminectomies, lithium toxicity
(resolved), neuroleptic malignant syndrome (resolved), left
parotid mass
.
Secondary: [**Month/Day (2) **] and hepatitis C cirrhosis, bipolar disorder
Discharge Condition:
Stable vital signs, tolerating POs, breathing on trach mask and
intermittently on room air
Discharge Instructions:
You were admitted to [**Hospital1 18**] with tremors, difficulty with balance
and hepatic encephalopathy (an imbalance of chemicals in your
brain due to the liver disease). An MRI of your brain and neck
were done to determine whether the abnormalities in your gait an
the tremors were due to problems with your brain or the [**Hospital1 **]
cord. You were found to have [**Hospital1 **] cord compression and
underwent cervical spine laminectomy and [**Hospital1 **] fusion. Your
post operative course was complicated by severe encephalopathy.
This was partially due to an allergy to haloperidol causing a
condition called neuroleptic malignant syndrome. You should not
take this medication ever again.
We treated your encephalopathy with high doses of lactulose,
rifaximin, antibiotics and supportive treatment. You were so
sick that you needed to be placed on a breathing machine
(ventilator). Ultimately an artificial airway called a
tracheostomy was placed in your neck to help you breathe. Your
tremors improved with discontinuing lithium. We ultimately
changed your lithium and bupropion with quetiapine (Seroquel).
.
Also, we noted a mass in your left parotid gland (salivary
gland) that is most appears benign. Nevertheless, you follow up
with an ear nose and throat specialist for this.
.
We have you on a new medical regimen. Please take your
medications as ordered.
.
Please attend your follow up appointments.
.
Please call your doctor or come to the emergency department if
you experience chest pain, shortness of breath, worsening
encephalopathy, fevers, difficulty tolering feedings, or other
concerning symptoms
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in the Liver Center ([**Location (un) 858**]
[**Hospital Unit Name **] at [**Hospital1 18**]) on [**2145-2-16**] at 8:15 am. Please
call [**Telephone/Fax (1) 2422**] if there is a problem with this appointment.
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2145-2-16**] 8:15
.
Please follow up with your primary psychiatrist, Dr. [**Last Name (STitle) 23168**],
within 1-2 weeks of discharge from rehab. Please call Dr. [**Name (NI) 23169**] office for an appointment.
.
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5456**],
within 1-2 weeks of discharge from rehab. Please call
[**Telephone/Fax (1) 5457**] for an appointment.
.
Please follow up the mass in your parotid gland (likely benign)
with an ENT within 3 months of discharge. The [**Hospital **] clinic at
[**Hospital1 18**] can be reached at ([**Telephone/Fax (1) 6213**]. Your PCP can also help
you find an ENT.
Completed by:[**2145-1-27**]
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29,316
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34169
|
Discharge summary
|
report
|
Admission Date: [**2139-10-26**] Discharge Date: [**2139-11-3**]
Date of Birth: [**2085-2-5**] Sex: F
Service: MEDICINE
Allergies:
Adhesive Tape / Ativan
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Respiratory Distress.
Major Surgical or Invasive Procedure:
[**2139-10-28**]: Flexible bronchoscopy and Therapeutic aspiration of
secretions.
History of Present Illness:
54 yo woman with a history of myasthenia [**Last Name (un) 2902**], TBM, obesity,
anxiety, admitted to the medical ICU for weakness, respiratory
distress, possible myasthenia [**Last Name (un) 2902**] exacerbation.
MICU course
==[**2139-10-26**] - [**2139-10-28**]: She complained of neck extensor weakness,
urinary incontinence, and dyspnea. Initially treated with biPAP.
Had excellent NIFs (>-80) with suboptimal VCs (consistently < 1
L, though ?limited by effort and able to count [**1-21**] on single
breath). Had bronchoscopy with IP; tracheal stent unremarkable.
IVIG started [**2139-10-28**] to [**10-30**]. Psychiatry also consulted for
anxiety management. She was transferred to neuro service where
she felt well though c/o intermittent diplopia.
==[**2139-10-29**] - [**2139-10-31**]: readmitted to the MICU for dyspnea,
shallow breathing, diplopia, ptosis, concerning for myasthenic
crisis. ABG with significant respiratory acidosis 7.10/143/59.
NIFs -80s. improved after placed on BiPap and flumenazil trial
to counteract clonazepam 0.25mg given in the AM. given
solumedrol 125mg stress dose steroids. Azathioprine started
[**2139-10-29**] to supplement immunosuppression (cellcept, prednisone).
Urine culture with klebsiella, ciprofloxacin started on
[**2139-10-30**]--> changed to ceftriaxone on [**2139-10-31**].
Transfer to the floor with improved respiratory parameters:
[**2139-10-31**].
Currently, she says her breathing has improved though she still
feels tightness in her chest. She has no ptosis, diplopia,
dysarthria, and she can masticate without difficulty. However,
she notes that she increasingly forgets words. She continues to
have a cough productive of thick green to yellow sputum. She
continues to have non bloody loose stools about 4x/day. She has
baseline urinary incontinence, no hematuria, dysuria. No chest
pain, arthralgias, myalgias, leg swelling, abdominal pain.
Past Medical History:
--myasthenia [**Last Name (un) 2902**] (+MUSK Ab): dx [**4-30**], treated with
pyridostigmine, prednisone, cellcept, IVIG, plasmapheresis;
difficult fibroscopic intubation, unable to tolerate BiPAP.
--tracheomalacia s/p flexible and rigid bronchoscopy with stent
placement on [**2139-5-7**], Y stent replacement [**2139-10-15**]
--sinus tachycardia when awake or anxious, thought [**1-24**] to
autonomic instability from myasthenia [**Last Name (un) 2902**]
--DMII, diet controlled, on ISS while on steroids
--anxiety
--GERD
--obesity
--anxiety
--s/p cholecystectomy, appendectomy, tonsillectomy
--nephrolithiasis
Social History:
No smoking, etoh, illicit drug use. Lives alone. Does not use
home O2 since she has a gas stove, feels uncomfortable with
BiPAP. used to work as a case manager.
Family History:
father with CAD and DM, brother with bronchitis, no family hx of
myasthenia [**Last Name (un) 2902**], autoimmune disease.
Physical Exam:
VS: 96.8 140/80 134 20 90%3L
Gen: NAD, speaking in [**2-25**] word sentences, not using accessory
muscles to breathe
HEENT: PERRL, sclera anicteric, MMM, O/P clear
Neck: obese
Cor: tachycardic, no mrg
Pulm: rhonchorous bronchial sounds diffusely
Abd: obese, soft, NT ND
Ext: +1 non pitting edema, +DP and PT pulses b/l
Neuro: alert, oriented x 3. able to count [**1-18**] in 1 breath.
EOMI. Upgaze held for >20 seconds with no ptosis, however,
during conversation eyelids would droop. CNII-XII intact. [**4-27**]
strength upper and lower extremities. [**4-27**] neck extension and
flexion.
Pertinent Results:
[**2139-10-26**] WBC-7.5 Hct-43.2 Plt Ct-419
[**2139-10-29**] WBC-16.9* Hct-36.5 Plt Ct-322
[**2139-11-3**] WBC-7.4 Hct-39.4 Plt Ct-360
[**2139-10-26**] Glucose-119* UreaN-10 Creat-0.7 Na-143 K-4.5 Cl-103
HCO3-37*
[**2139-11-3**] Glucose-204* UreaN-14 Creat-0.8 Na-138 K-3.7 Cl-93*
HCO3-40*
[**2139-10-26**] cTropnT-<0.01
[**2139-11-1**] Calcium-8.8 Phos-2.6* Mg-2.1
[**2139-10-26**] FiO2-20 pO2-66* pCO2-75* pH-7.28*
[**2139-10-30**] pO2-54* pCO2-77* pH-7.36
...
[**2139-10-27**] URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
URINE CULTURE (Final [**2139-10-29**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
...
FECAL CULTURE (Final [**2139-10-30**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2139-10-30**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2139-10-29**]): NO OVA AND PARASITES SEEN.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2139-10-28**]):
Feces negative for C.difficile toxin A & B by EIA.
MICROSPORIDIA STAIN (Pending):
CYCLOSPORA STAIN (Pending):
OVA + PARASITES (Pending):
Cryptosporidium/Giardia (DFA) (Pending):
RESPIRATORY CULTURE (Final [**2139-10-29**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
...
CT-PE:
1. Tracheal stent is seen in situ and is patent throughout its
course.
2. Atelectasis at the lung bases along with retained secretions
in the right as well as the left lower lobe bronchi.
3. No pulmonary embolism or aortic dissection. Coronary arteries
arise from the normal expected anatomical location.
...
CXR [**2139-10-26**]: Low lung volumes which limits examination
sensitivity. Persistent bibasilar atelectasis. Early pneumonia
cannot be excluded.
CXR [**2139-10-31**]: Since yesterday, bilateral blunting of
costophrenic angles is unchanged. Lung volumes are still low.
Left basilar ill-defined opacity increased, could be early
pneumonia, aspiration, or atelectasis. Minimal left pleural
effusion increased. There is overall no other change.
Brief Hospital Course:
In brief, the patient is a 54 year old woman with MUSK Ab+
myasthenia [**Last Name (un) 2902**], tracheobroncomalacia, anxiety, and sinus
tachycardia who presented with gradual worsening in weakness
found to have a UTI whose course was complicated by hypercarbic
respiratory failure and intermittent hypoxia.
1. Dyspnea - admitting differential diagnosis included muscle
weakness (from myasthenia or other cause, incited perhaps by
UTI), structural abnormalities/TBM, anxiety, PE (which was ruled
out), CAD/ischemia (no ecg changes, not c/w history). Patient
had no fever, leukocytosis, or clear infiltrate to suggest
pneumonia as cause. Patient noted to have mild hypoxemia with
respiratory acidosis on admit and is a CO2 retainer at baseline.
A bronchoscopy was performed [**2139-10-28**] to rule out stent
obstruction, which revealed a patent stent with minimal mucous
impaction. Patient was followed in the MICU for the first two
days of her stay, with neuro consult, with adequate oxygenation
and NIF at -80 and vital capacity measurements of >500cc, with
assistance of breathing treatments (i.e. nebulizers).
Myasthenia [**Last Name (un) 2902**] exacerbation was not believed to be the sole
etiology of her [**Last Name (un) 7186**] of breath. Klonopin was initiated to
control an element of anxiety, with good relief. Patient
receieved her routine administration of IVIG over a three-day
course of 50g, 55g, and 55g, initated on [**10-28**]. She was
transferred to the neurology floor on [**10-28**]. On [**10-29**], she
developed respiratory distress in setting of not using her BIPAP
overnight, receiving benzos for anxiety, and SOB. CXR stable.
She was transferred back to the MICU where her PCO2 was found to
be 150. NIFs -80s. improved after placed on BiPap and
flumenazil trial to counteract clonazepam 0.25mg given in the
AM. given solumedrol 125mg stress dose steroids. She was then
transferred to the floor, where she continued to have twice
daily NIF and VC measurements (NIF -80s, VC 500-900). She was
weaned off O2, but triggered on [**2139-11-2**] for O2 sat 77% RA and
HR 150s while ambulating, likely related to exertion, minimal
ventilation, and reflex tachycardia on top of baseline
tachycardia. She was discharged on [**2139-11-3**] with instructions
to use 2L NC (while at rest, 93% on room air and 95% on 2L NC.
while walking, 87% on room air and 92-94% on 2L NC).
2. Myasthenia [**Last Name (un) 2902**] - contributation as above, noted to also
have neck weakness. Was continued on her prednisone, mestinon,
cellcept, and Bactrim ppx. As above, she received a 3-day
course of IVIG at 50g, 55g, and 55g, started on [**10-28**].
Azathioprine was started on [**2139-10-29**] to supplement
immunosuppression (cellcept, prednisone). She received bactrim
for prophylaxis. We avoided beta blockers, calcium channel
blockers, and quinolones due to potential exacerbation of
myasthenia [**Last Name (un) 2902**].
3. Anxiety - patient has history of anxiety and has been on
SSRI and benzos in past. A psychiatry consult was placed,
recommending outpatient follow-up. Patient was started on
klonopin tid for anxiety control with good effect. However,
after returning to the MICU for respiratory distress with
possible inciting cause of receiving clonazepam 0.25mg that
morning, all further benzodiazepines were avoided.
4. Tachycardia - had intermittent sinus tachycardia (150s when
walking, 80s when sleeping) with an unchanged ECG, reportedly at
her baseline. Avoided beta blockade and calcium channel
blockade due to myasthenia [**Last Name (un) 2902**] history.
5. Urinary incontinence - chronic problem with recent
worsening. Urine culture [**2139-10-27**] with klebsiella,
ciprofloxacin started on [**2139-10-30**]--> changed to ceftriaxone on
[**2139-10-31**]. WBC trended down. She was discharged on Keflex, with
total antibiotic course of 7 days. She was recommended to
discuss with her PCP [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13511**] to urogynecology.
6. Diarrhea - noted to have [**12-24**] month history of diarrhea with
subacute/chronic fecal incontinence, previously attributed to
mestinon in past. Cdiff cultures were negative and extensive
stool studies were unrevealing, some studies pending at
discharge. Neuro recommended outpatient MRI C-spine to r/o
trauma given her multiple procedures. She was continued on
loperamide.
7. Tracheobronchomalacia: followed by IP service, mucolytic
increased to TID.
8. DM2: placed on insulin sliding scale for better glycemic
control in the setting of steroid use.
Medications on Admission:
Prednisone 20 mg DAILY
Trimethoprim-Sulfamethoxazole 80-400 mg Tablet MWF.
Calcium Carbonate 500 mg TID
Pyridostigmine Bromide 60 mg Q6H
Dextromethorphan-Guaifenesin Ten (10) ML PO Q6H prn
Alendronate 70 mg Tablet QSUN
Fluticasone 50 mcg/Actuation Spray, (2) Spray Nasal [**Hospital1 **].
Alprazolam 0.25 mg Tablet Sig: 0.5 to 1 Tablet PO three times a
day as needed for anxiety.
Paroxetine HCl 10 mg Tablet 1.5 Tablets PO DAILY (Daily).
Guaifenesin 600 mg Tablet Sustained Release (2) Tablet [**Hospital1 **] ().
Loperamide 2 mg Capsule One (1) Capsule PO QID as needed
Insulin ?dosing
Omeprazole 40 mg twice a day.
Sodium Chloride 0.9 % Solution (1) neb Injection q6h
Mycophenolate Mofetil 1000 mg [**Hospital1 **]
Xopenex 0.63 mg/3 mL One (1) neb every 6-8 hours as needed.
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
3. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed.
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal [**Hospital1 **] (2 times a day).
5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
6. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO four times a
day for 2 days.
Disp:*8 Tablet(s)* Refills:*0*
7. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
8. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO TID (3 times a day).
9. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation q2 prn ().
10. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. Paroxetine HCl 10 mg Tablet Sig: 1.5 Tablets PO once a day.
13. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
please take on empty stomach first thing in morning. and remain
upright for 30 minutes after.
14. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO twice a day
for 8 days.
Disp:*16 Tablet(s)* Refills:*0*
15. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q8H (every 8 hours) as needed.
Disp:*30 inhaler* Refills:*0*
17. Home Oxygen
Home Oxygen via nasal cannula (2L) for O2sat <88%
18. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale unit Injection QACHS: please see insulin sliding scale
instructions included with discharge paperwork.
19. Azathioprine 100 mg Tablet Sig: One (1) Tablet PO twice a
day: please start 100mg dose on [**2139-11-12**].
Disp:*60 Tablet(s)* Refills:*0*
20. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO
four times a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis:
myasthenia [**Last Name (un) 2902**] crisis
tracheobronchomalacia
urinary tract infection
sinus tachycardia
Secondary diagnosis:
diabetes
anxiety
diarrhea
Discharge Condition:
stable. breathing comfortably with good oxygen saturation on
room air. 93%RA at rest. 87-88%RA with exertion. 94% with 2LNC
with exertion.
Discharge Instructions:
You were admitted for [**Last Name (un) 7186**] of breath and neck weakness.
You were given BiPAP and then weaned to nasal cannula oxygen.
You underwent flexible bronchoscopy to clean out secretions and
the stent looked in good shape. You received IVIG therapy and
new immunosuppression for your myasthenia [**Last Name (un) 2902**]. You were also
found to have a urinary tract infection and were treated with
antibiotics.
Please use 2L oxygen while exerting yourself. Please continue
your medications. Please continue your new immunosuppressant
azathioprine 50mg twice a day until [**2139-11-11**]. Please take
azathioprine 100mg twice a day starting [**2139-11-12**]. Please
continue your antibiotic Keflex for 2 days.
Please attend your recommended follow-up appointments.
Please call your doctors [**First Name (Titles) **] [**Last Name (Titles) 7186**] of breath, chest pain,
neck weakness, vision changes, or any other symptoms concerning
to you.
Followup Instructions:
Please follow up with:
--[**Last Name (Titles) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 2846**] Date/Time:[**2139-12-8**]
10:30, please call ([**Telephone/Fax (1) 44**] with additional questions.
--Dr. [**First Name (STitle) 9466**] [**Name (STitle) **] on Friday [**2139-11-6**] at 9am. Please call
[**Telephone/Fax (1) 250**] with questions.
--Interventional Pulmonology: The clinic will call you with an
appointment to be seen in ~2 weeks. Please call ([**Telephone/Fax (1) 3020**]
with questions.
--We recommend that you discuss with your PCP how to set up an
appointment with urogynecology to address your urinary
incontinence.
|
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63,298
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46085
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Discharge summary
|
report
|
Admission Date: [**2164-3-13**] Discharge Date: [**2164-4-3**]
Date of Birth: [**2080-10-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Codeine / Erythromycin Base
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2164-3-13**] cardiac catheterization
[**2164-3-15**] coronary artery bypass x3 (LIMA to LAD, SVG to OM, SVG to
PDA) with IABP
[**2164-3-21**] left brachial thrombectomy
History of Present Illness:
This is an 83 yof with history of DM II, HTN, Hyperlipidemia who
presents to the [**Hospital1 18**] ED with chest pain. Ms. [**Known lastname **] states that
this morning at 9am she began to experience [**8-16**] epigastric
burning pain which radiated up into her chest. This was
associated with nausea, diaphoresis and radiated to her back.
She denies any vomiting, palpitations, SOB or pain in her jaw,
shoulder or arms. The pain continued and she went to her
scheduled appointment with her PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 1313**], at 1030am. An
ECG was obtained and showed new ST elevation in V1-V3. EMS was
called and she was sent to the [**Hospital1 18**] ED. Of note, patient
describes similar episodes for the past 6 weeks. Last episode
ocurred last night. She denies any recent DOE, orthopnea or
PND. She does report long standing peripheral edema.
.
In the ED, initial vitals were Temp 98, BP 170/70, HR 76, RR 18
100% RA. She was given ASA 325mg x 1, Lopressor 5mg IV x 1,
Plavix 600mg PO x 1, Integrillin IV 14mg x 1, Nitro 4mg PO x 1.
CODE STEMI was called and patient was taken to the cath lab.
.
In the cath lab LMCA: 50% ostial70%, mid vessel 60%, heavily
calcified; LCx: mild luminal irregularities; RCA: Ostial 90%
stensosis, heavily calcified. An IABP was placed and she was
transferred to the CCU for further monitoring. On arrival to
the CCU, she was chest pain free. She denied and SOB,
palpitations, N/V.
.
Review of systems otherwise negative except for what is reported
above.
Referred for surgery.
Past Medical History:
myocardial infarction
Atrial fibrillation
coronary artery disease
left brachial thrombus
Non-insulin dependent diabetes
hypothyroidism
hyponatremia
hypercholerolemia
Osteoarthritis
GI bleed
thrombophlebitis, pancreatitis, s/p sphincterotomy,
incontinence, osteopenia, sleep apnea, IBS, bradycardia
s/p CABGx3(LIMA->LAD, SVG->OM1, PDA) [**3-15**]; 4/15 L brachial
thrombectomy
Hypertension
Hyperlipidemia
Diabetes Mellitus Type II
Gastro-esophageal reflux disease
Chronic abdominal pains and diarrhea
history of Pancreatitis
Anxiety
Depression
obstructive sleep apnea
history of Cataract Surgery
Social History:
-Tobacco history: None
-ETOH: occasional, one drink a few times per week
-Illicit drugs: none
Patient lives on her own in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. She has a nurse [**First Name (Titles) 1023**] [**Last Name (Titles) 2176**]
her daily. She has a daughter who lives in [**Name (NI) 86**], a son who
lives in [**Name (NI) 614**] and a 2nd daughter who lives in [**Name (NI) 311**],
[**Location (un) **].
Family History:
Father with CAD, Mother with HTN
Physical Exam:
5'7" 83.9 kg
GENERAL: NAD, lying in bed comfortably, pleasantly conversant
HEENT: NCAT, EOMI, PERRLA, MMM, OP clear
NECK: Supple, No JVD, no carotid bruits
CARDIAC: normal S1/S2, +II/VII SEM RUSB, no rubs or gallops
LUNGS: CTAB in anterior lung fields
ABDOMEN: Soft, NTND, normal bowel sounds
EXTREMITIES: No c/c/e, dopplerable pedal pulses, right groin
with IABP catheter in place, no hematoma
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2164-4-3**] 05:14AM 7.3 2.86* 8.5* 25.6* 89 29.7 33.2 16.6*
530*
[**2164-4-3**] 05:14AM INR 2.5*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K
Cl HCO3
[**2164-4-3**] 05:14AM 113* 21* 0.9 132* 4.7 99 24
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
Cholest
[**2164-4-3**] 05:14AM 2.1
Source: Line-rij
DIABETES MONITORING %HbA1c
[**2164-3-15**] 04:21AM 7.3*1
Source: Line-aline
OTHER CHEMISTRY Osmolal
[**2164-3-29**] 08:51AM 274*
Source: Line-central
PITUITARY TSH
[**2164-4-1**] 11:10AM 27*
Source: Line-central
THYROID Free T4
[**2158-3-7**] 09:07PM 1.31
CATH
1. Coronary angiography of this right dominant system revealed
significant 2 vessel coronary disease. The LMCA had an ostial
50%
stenosis with a distal 60% stenosis leading into the LAD. The
LAD had an
ostial 80% stenosis with a proximal 70% hazy lesion and a 60%
stenosis
in the mid-vessel and was heavily calcified. The LCX had minimal
irregularities. The RCA had an ostial 90% stenosis and was also
heavily
calcified.
2. Limited resting hemodynamics revealed moderately elevated
systemic
arterial pressure with an SBP of 164 mm Hg and an elevated LVEDP
of 28
mm Hg. There was no evidence of aortic stenosis with pullback
across the
aortic valve.
3. Left ventriculography was performed and showed..
4. IABP was placed given significant coronary disease as a
bridge to
CABG.
LEFT VENTRICULOGRAPHY:
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA DISCRETE 90
2) MID RCA DIFFUSELY DISEASED
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA DIFFUSELY DISEASED
4) R-PDA NORMAL
4A) R-POST-LAT NORMAL
4B) R-LV NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN DISCRETE 60
6) PROXIMAL LAD DISCRETE 80
6A) SEPTAL-1 NORMAL
7) MID-LAD DISCRETE 60
8) DISTAL LAD DIFFUSELY DISEASED
9) DIAGONAL-1 NORMAL
10) DIAGONAL-2 NORMAL
12) PROXIMAL CX NORMAL
13) MID CX NORMAL
13A) DISTAL CX NORMAL
14) OBTUSE MARGINAL-1 NORMAL
15) OBTUSE MARGINAL-2 NORMAL
17A) POSTERIOR LV NORMAL
Conclusions
PRE BYPASS The left atrium is markedly dilated. The left atrium
is elongated. Mild spontaneous echo contrast is seen in the body
of the left atrium. Moderate to severe spontaneous echo contrast
is present in the left atrial appendage. The left atrial
appendage emptying velocity is depressed (<0.2m/s). A left
atrial appendage thrombus cannot be completely excluded. The
right atrium is dilated. Mild spontaneous echo contrast is seen
in the body of the right atrium. No thrombus is seen in the
right atrial appendage No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is moderate regional left ventricular systolic dysfunction with
septal as well as mid to apical linferoseptal and anteroseptal,
and apical akinesis. There is also inferior wall mild
hypokinesis. The lateral wall displays normal function. Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the ascending aorta. 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 moderately thickened. Mild to moderate ([**12-9**]+)
mitral regurgitation is seen. An intra-aortic balloon is seen in
the descending thoracic aorta with its tip approximately 5 cm
below the distal arch. Dr. [**Last Name (STitle) **] was notified in person
of the results in the operating room at the time of the
procedure.
POST BYPASS The patient is being atrially paced. There is normal
right ventricular systolic function. The left ventricle displays
the same distribution of wall abnormalities noted in the
pre-bypass study except that the akinetic septal segments now
display minimal contractility. The mitral regurgitation may be
slightly worsened but is still in the mild to moderate range.
The thoracic aorta appears intact and the intra-aortic balloon
remains in its pre-bypass position. No other significant
changes.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2164-3-15**] 14:24
?????? [**2157**] CareGroup IS. All rights reserved.
Brief Hospital Course:
83 yof with hx of DM II, HTN, Hyperlipidemia who presents to the
[**Hospital1 18**] ED with chest pain found to have acute MI.
Ms. [**Known lastname **] presented with acute STEMI with STE in V2 along with
Qwave in V1-2 which suggested acute MI > 8 hours old. Patient
was taken to the cath lab which showed 2VD, along with DM II,
recommendation was for CABG. IABP was placed to assist with
coronary perfusion. Patient was hemodynamically stable on
arrival to the CCU. The patient was started on a heparin drip,
IV metoprolol then switched to PO, high dose statin, 325mg of
aspirin. She had a CXR daily to monitor placement of the IABP.
CT surgery was notified and she was taken to the OR two days
following admission for surgery with Dr. [**First Name (STitle) **]. Transferred to
the CVICU in stable condition on titrated phenylephrine and
propofol drips. Extubated and IABP weaned and removed the next
day. On POD #3 she developed transient aphasia. Neuro consult
done and CTA of head/neck did not show any ischemia or infarct.
Started heparin for ? TIA. Went into A Fib on POD #4 and
amiodarone was started. Transferred to the floor on POD #4 to
begin increasing her activity level. Coumadin started for
anticoagulation. Complained of left arm pain on POD #6 with
decreased pulses. Vascular surgery was called and she was taken
to the OR urgently for brachial artery embolectomy. Transferred
to the CVICU. EP was consulted for A Fib recommendations.
Transferred back to the floor on POD #[**8-8**]. Free water restricted
due to hyponatremia. Renal was consulted and recommendations
were followed regarding hyponatremia, including hypertonic
saline infusion. Sodium level did return to normal prior to
discharge. This will need continued follow up as an
outpatient.
Cleared for discharge to rehab on POD # 19/13- on [**2164-4-3**].
Target INR is 2.5 for afib and left brachial thrombectomy.
Pt to make all follow up appts as per discharge instructions.
Medications on Admission:
Glucotrol 5mg daily
Aldactone 50mg daily
Klonapin 0.5mg [**Hospital1 **] PRN
Lipitor ?
plavix 600 mg on [**3-13**]
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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
10. Warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY
(Daily): has been rec'ing 5mg daily
Goal INR 2.5.
11. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
12. Levothyroxine 100 mcg Tablet Sig: 1.5 Tablets PO DAILY
(Daily): follow up free T4 in 3 weeks.
13. Zofran 4 mg Tablet Sig: One (1) Tablet PO q8hrs prn.
14. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
15. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane Q6H (every 6 hours) as needed.
16. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
myocardial infarction
Atrial fibrillation
coronary artery disease
left brachial thrombus
Non-insulin dependent diabetes
hypothyroidism
hyponatremia
hypercholerolemia
Osteoarthritis
GI bleed
thrombophlebitis, pancreatitis, s/p sphincterotomy,
incontinence, osteopenia, sleep apnea, IBS, bradycardia
s/p CABGx3(LIMA->LAD, SVG->OM1, PDA) [**3-15**]; 4/15 L brachial
thrombectomy
Discharge Condition:
deconditioned
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:
call and schedule the following appointments
Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 98068**]
Dr. [**Last Name (STitle) **] in 2 weeks [**Telephone/Fax (1) 2625**]
cardiologist in 2 weeks (daughter arranging cardiologist)
Dr. [**First Name (STitle) 1313**] in 2 weeks- monitor TSH - newly on synthroid
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2164-4-4**]
|
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"401.9",
"410.01",
"444.21",
"327.23"
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icd9cm
|
[
[
[]
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[
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[
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|
8340, 10309
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318, 491
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519, 2084
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,824
| 121,296
|
4579
|
Discharge summary
|
report
|
Admission Date: [**2146-3-26**] Discharge Date: [**2146-4-8**]
Service: SURGERY
Allergies:
Levsin / Shellfish
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Cellulitis with RLE swelling and erythema
Major Surgical or Invasive Procedure:
I&D R groin [**2146-4-1**]
picc line x 2
IR guided aspiration [**3-27**] and [**3-29**]
History of Present Illness:
88 yoM with recent history of Right sided groin lymphadenectomy
for metatatic melanoma. Patient has had difficulty with seroma
and was recently discharged on [**3-22**] home on augmentin after IR
drainage of seroma located just right of
the pudendum. He was at home, doing relatively well until this
morning when he noted progressive swelling of his right upper
leg / thigh area. It also was more erythematous and he called
Dr. [**Last Name (STitle) 519**] who asked him to report to the ED.
Here he is in no apparent distress, afebrile, but has diffuse
swelling of the entire right leg, markedly larger than the left
leg, and erythema which is blanching throughout the anterior
thigh. He is not tender, but there is diffuse edema. His drain
is putting out minimal fluid which is serosanguinous, and
flushes with minimal difficulty. His incision sites are intact.
He
underwent RLE ultrasound to evaluate for DVT which was negative
but could not evaluate the veins well in the calf. There was,
of note, a 4.8 x 1.5 x 4.2 cm and located in the anterior thigh.
Past Medical History:
PMH:
- metastatic squamous cell carcinoma (unknown primary lesion)
- CAD s/p MI (remote), EF 50%
- Aortic stenosis
- Afib on coumadin
- HTN
- BPH
- L retinal artery occlusion in [**2134**] (secondary to emoblic
disease)
PSH:
- R inguinal lymph node dissection ([**2146-2-10**])
- L inguinal hernia repair ([**2135**])
Social History:
nonsmoker, lives with wife, no EtOH
Family History:
CAD in multiple family members
Physical Exam:
EXAM:
Vitals: 97.6 56 99/54 22 97RA
AAO x 3, NAD
RRR, [**4-3**] holosystolic murmur noted on auscultation
CTA B/L no RRW appreciated
soft, NT, ND. Erythema form RLE extends minimally in to RLQ.
RLE: 4.8 x 1.5 x 4.2 cm and located in the anterior thigh.
Dopplerable signals x 2
LLE: no CCE, palpable pulses throughout.
Pertinent Results:
[**2146-3-26**] 06:20PM BLOOD WBC-14.7*# RBC-3.33* Hgb-10.5* Hct-31.7*
MCV-95 MCH-31.5 MCHC-33.1 RDW-13.3 Plt Ct-206
[**2146-3-27**] 07:10AM BLOOD WBC-19.2* RBC-3.01* Hgb-9.2* Hct-28.5*
MCV-95 MCH-30.5 MCHC-32.2 RDW-13.0 Plt Ct-169
[**2146-3-28**] 06:15AM BLOOD WBC-18.3* RBC-2.72* Hgb-8.5* Hct-25.5*
MCV-94 MCH-31.4 MCHC-33.5 RDW-13.2 Plt Ct-159
[**2146-3-29**] 05:22AM BLOOD WBC-13.7* RBC-3.19* Hgb-9.9* Hct-28.6*
MCV-90 MCH-31.1 MCHC-34.6 RDW-13.7 Plt Ct-176
[**2146-4-2**] 04:51PM BLOOD WBC-10.4 RBC-2.50* Hgb-7.7* Hct-23.3*
MCV-93 MCH-31.0 MCHC-33.3 RDW-13.3 Plt Ct-230
[**2146-4-6**] 05:35AM BLOOD WBC-10.4 RBC-3.74* Hgb-11.4* Hct-33.8*
MCV-90 MCH-30.4 MCHC-33.6 RDW-14.2 Plt Ct-263
[**2146-3-26**] 06:20PM BLOOD PT-22.8* PTT-31.6 INR(PT)-2.1*
[**2146-3-27**] 07:10AM BLOOD PT-25.2* PTT-40.6* INR(PT)-2.4*
[**2146-3-31**] 05:58AM BLOOD PT-25.4* PTT-39.1* INR(PT)-2.4*
[**2146-4-3**] 05:34AM BLOOD PT-34.8* INR(PT)-3.5*
[**2146-4-5**] 04:56AM BLOOD PT-21.5* PTT-38.1* INR(PT)-2.0*
[**2146-3-26**] 06:20PM BLOOD UreaN-39* Creat-1.4* Na-136 K-4.8 Cl-103
HCO3-25 AnGap-13
[**2146-4-5**] 05:30PM BLOOD Glucose-119* UreaN-28* Creat-1.7* Na-136
K-4.2 Cl-104 HCO3-26 AnGap-10
[**2146-4-6**] 05:35AM BLOOD Glucose-102* UreaN-27* Creat-1.5* Na-136
K-3.9 Cl-105 HCO3-27 AnGap-8
[**2146-3-27**] 12:04AM BLOOD CK-MB-10 MB Indx-7.9* cTropnT-0.05*
[**2146-3-28**] 03:55AM BLOOD CK-MB-12* MB Indx-3.1 cTropnT-1.25*
[**2146-4-2**] 09:58AM BLOOD CK-MB-3 cTropnT-2.23*
[**2146-4-2**] 04:51PM BLOOD cTropnT-1.81*
[**2146-4-3**] 02:02AM BLOOD cTropnT-1.44*
[**2146-4-5**] 01:10PM BLOOD CK-MB-3 cTropnT-0.85*
CT lower ext [**3-27**]- There is anasarca, particularly on the right
flank and right lower extremity. There are degenerative changes,
but no
suspicious bone lesions are present. A 2.6 x 2.2 cm collection
in the right groin containing a drainage catheter is present,
smaller than on the previous examination. Inferior to the
collection containing a drain is an ovoid collection measuring
3.2 x 1.5 cm (3:164). At the level of the acetabula on the right
is a 3.2 x 1.4 cm collection (3:100).
CTV: Normal venous opacification is seen in the inferior vena
cava and
extending into the common iliac and leg veins without signs for
vascular
distention, or occlusion. There is atherosclerotic disease of
the popliteal, and common femoral artery, but no aneurysm or
occlusion. Increased density of contrast in the right leg veins
compared to the left may indicate increased venous return due to
hyperemia on the right.
CT [**3-29**] - Hypodense fluid collection with areas of hyperdensity
is visualized in the right thigh measuring 13 cm in the
craniocaudal dimension x 3.8 cm in the transverse dimension.
There is also a 4.7 CC x 3.8 TV cm hypodense fluid collection
inferior to the first collection which may be contiguous with
the superior collection.
Upper ext US - Non-occlusive thrombus surrounding the PICC at
site of insertion in the left basilic vein. No proximal thrombus
identified.
Brief Hospital Course:
Patient was admitted to Dr.[**Name (NI) 1745**] surgical service on [**2146-3-26**].
He was started on empiric antibiotics of Vancomycin 1000 mg IV Q
24H and Piperacillin-Tazobactam 4.5 g IV Q8H. Due to concerns
of wound infection and given the location of this complicated
fluid collection, IR aspiration was initially attempted. This
was difficult due to the complexity of the collections. During
his hospital course, he did require a brief ICU admission for
hypotension [**2146-3-28**]. He was transferred to general floor after
stabilization on [**2146-3-29**]. A second IR aspiration was attempted
on [**2146-3-29**]. Due to lack of improvement and continued concerns,
he was taken to the operating room on [**2146-4-1**] for an incision,
debridement and washout. There were no complication to the
procedure. He will be discharged to rehab. Please refer to the
following review of systems to summarize his hospital course.
Neuro: The patient received Tylenol and morphine with good
effect and adequate pain control. Patient remained AAox3
throughout his stay.
CV: The patient an episode of hypotenstion for which he was
transferred to the Intensive care unit. The patient's pressures
remained low at SBP 90-100. Vital signs were routinely
monitored. On admission, on telemetry monitoring, noticed to
have frequent tachyarrhythmias. He did have evidence of demand
cardiac ischemia. He was plavix loaded. Cardiology consulted
with recommendations to start amiodarone. Patient did not have
any more HD instability. He remained stable for the rest of his
hospital stay. Plans for outpatient cardiology appointment and
the following recommendations - ASA, Amio x 1 week, d/c on
dig/metop, no cardiac catherization. F/u c/Dr. [**Last Name (STitle) **] as outpt
for repeat echo.
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 his hospitalization.
GI/GU/FEN: 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
found having a foley catheter to be comfortable and reported
difficulty urinating due to difficulty relaxing. Patient says
having condom catheter helped him relax. Due to overall poor
nutritional status, he was started on nutritional shakes.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. After the washout the
patient was receiving TID dressing changes,wet-to-dry on the R
groin wound. Infectious disease consulted. Final plan was to
discharge patient home with 4 weeks of zosyn for completion
therapy. His wound cultures did return with Pseudomonas and
pan-sensitive enterococcus.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly while on a
sliding scale regimen.
Hematology: The patient's complete blood count was examined
routinely. The patient was transfused with PRBC's when needed
for a total of 7 units of PRBC's during the patient's entire
hospital stay. This likely due to bleeding from his incision
which ceased.
Prophylaxis: The patient received warfarin and ASA. Pt is on
bsased on INR checks. Venodyne boots were used during this stay.
Pt was encouraged to get up and ambulate, though he felt
slightly deconditioned toward end of stay. Rehabilitation was
recommended.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, and pain was well controlled. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
The patient will go to an extended care facility for more
intensive rehabilitation.
Medications on Admission:
digoxin 250 q OTHER day, ditropan 5'', lasix 20', vicodin 5/500
q6h prn, lisinopril 10', metoprolol 25'', nitroglycerin prn
chest pain, simvastatin 40', flomax 0.4', travatan 0.004% 1 drop
in LEFT eye daily, coumadin (5' except 7.5' Wed), vit B12, ASA
81', colace 100'', vit D, augmentin, coumadin
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for costipation.
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
10. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
12. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
13. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
14. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for mouth sores.
16. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
17. Piperacillin-Tazobactam 4.5 g IV Q8H
Please infuse over 4 hours per ID, thanks
18. Morphine Sulfate 2 mg IV Q4H:PRN pain
19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
20. warfarin 2 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Doctor Last Name 5749**] [**Doctor Last Name **] Village - [**Location (un) **]
Discharge Diagnosis:
right groin collection/infection
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:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see 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 in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-7**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
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.
*Please have the groin moist-to-dry dressing changed with a
lightly soaked wet packing into the wound area avergaging [**4-1**]
gauze sponges initially, with subsequent adjustment per provider
charged with dressing changes. For moisture the gauze should be
soaked in Dakin's solution one quarter strength. Every crevice
and space in the wound should be packed tightly. Laying gauze on
wound is insufficient. On top of wet packed dressing, a dry
gauze covering should be placed. An ABD or more gauze may be
placed on top of this and taped to the skin. Paper tape is
recommended due to its minimally abrasive texture and safety for
the skin. Duoderm may be used to further diminish possibllity of
injury to skin.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
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 call Dr.[**Name (NI) 1745**] office in [**1-30**] weeks for anappointment:
([**Telephone/Fax (1) 5323**]
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] ID WEST (SB) Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2146-4-18**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2146-4-22**] 10:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] ID WEST (SB) Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2146-4-25**] 10:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2146-4-8**]
|
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"401.9",
"427.31",
"410.71",
"041.04",
"427.89",
"414.01",
"787.91"
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icd9cm
|
[
[
[]
]
] |
[
"86.01",
"86.28",
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icd9pcs
|
[
[
[]
]
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11287, 11465
|
5275, 9219
|
267, 357
|
11542, 11542
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2267, 5252
|
14864, 15631
|
1876, 1909
|
9568, 11264
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11486, 11521
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9245, 9545
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11725, 13182
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13198, 14841
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1924, 2248
|
185, 229
|
385, 1454
|
11557, 11701
|
1476, 1806
|
1822, 1860
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,308
| 133,220
|
31336
|
Discharge summary
|
report
|
Admission Date: [**2148-9-23**] Discharge Date: [**2148-11-4**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Sigmoid colon cancer
Major Surgical or Invasive Procedure:
OR [**2148-9-23**]: lap converted to open sigmoid colectomy
OR [**2148-10-16**]: closure of abdomen with retention sutures #2 nylon,
#1 prolene figure 8's
ICU [**2148-10-8**]: Trach #8 Portex and PEG tube insertion
ICU [**2148-10-10**]: central line change/resite
History of Present Illness:
Mr. [**Name14 (STitle) 73881**] is a [**Age over 90 **]yo male who developed heme positive
stools in [**2146**], but declined any intervention at that time. This
year ([**2148**]), he developed a T4 compression fracture. His work-up
included a PET scan, which identified a mass in the sigmoid
colon. He underwent colonoscopy at OSH which revealed 3 benign
polyps & 1 polyp at 20cm containing adenocarcinoma. Pathology
revealed positive margns. He presented to [**Hospital1 18**] for further
evaluation and management. He underwent a repeat colonoscopy
with bx, EUS and CT scan which did not reveal any abnormalities.
His preoperative CEA was 2.2. Patient and family counselled that
watch-waiting appropriate at this age. Patient & family strongly
desired surgery.
Past Medical History:
PMH:
afib, HTN, pacemaker, carotid stenosis, CAD, COPD, PUD, ED,
chronic anemia
.
PSH:
s/p vagotomy/?anterectomy [**2085**]
s/p pacemaker placement
s/p ventral Hernia repair
Social History:
[**Age over 90 **] year old widow living alone prior to procedure. 2
children, both married and with married children of their own.
Supportive family. pt highly functional w/ ADL's , involved
in his neighborhood.
Denies use of ETOH, tobacco, and illicit drugs.
Family History:
unknown
Physical Exam:
PAT Pre-Procedure Assessment
Vitals: HR-78, BP-148/62, O2 sat-97%, LB-160, Height-70in
Gen: spry, elderly gentleman accompanied by daughter
Mental: A/Ox3, speech clear, + hand tremors, pupils 3mm &
sluggish bilaterally
Heart: irregular rate, normal S1/S2, no S3/S4, no murmurs, no
carotid bruits bilaterally
Lungs: CTAB
Abd: soft, well healed midline incision, umbilical hernia, no
masses
Extrem: no pedal edema bilaterally, + DP bilaterally
Other: no cervical lymphadenopathy bilaterally, no thyroid
masses, trachea midline
Pertinent Results:
[**2148-11-1**] 09:05AM BLOOD WBC-7.8 RBC-2.94* Hgb-8.5* Hct-26.7*
MCV-91 MCH-28.9 MCHC-31.7 RDW-16.6* Plt Ct-389
[**2148-10-12**] 03:21AM BLOOD WBC-32.0* RBC-2.88* Hgb-8.7* Hct-26.2*
MCV-91 MCH-30.2 MCHC-33.2 RDW-16.9* Plt Ct-752*
[**2148-9-24**] 06:30AM BLOOD WBC-10.3# RBC-3.25* Hgb-10.1*# Hct-30.3*
MCV-93 MCH-31.2 MCHC-33.4 RDW-13.6 Plt Ct-147*
[**2148-11-1**] 09:05AM BLOOD Plt Ct-389
[**2148-11-1**] 09:05AM BLOOD PT-13.0 PTT-39.8* INR(PT)-1.1
[**2148-9-29**] 06:21PM BLOOD PT-14.7* PTT-29.7 INR(PT)-1.3*
[**2148-9-24**] 06:30AM BLOOD Plt Ct-147*
[**2148-11-1**] 09:05AM BLOOD Glucose-127* UreaN-33* Creat-0.9 Na-139
K-4.1 Cl-104 HCO3-30 AnGap-9
[**2148-10-2**] 03:21AM BLOOD Glucose-131* UreaN-41* Creat-2.0* Na-137
K-3.4 Cl-107 HCO3-20* AnGap-13
[**2148-9-24**] 06:30AM BLOOD Glucose-125* UreaN-15 Creat-1.0 Na-138
K-4.7 Cl-105 HCO3-26 AnGap-12
[**2148-10-1**] 03:11AM BLOOD ALT-28 AST-57* AlkPhos-47 Amylase-183*
TotBili-1.3
[**2148-10-1**] 12:04AM BLOOD CK(CPK)-218*
[**2148-9-30**] 01:00AM BLOOD ALT-21 AST-32 CK(CPK)-91 AlkPhos-40
Amylase-353* TotBili-0.7
[**2148-9-25**] 09:14AM BLOOD CK(CPK)-467*
[**2148-10-1**] 12:04AM BLOOD CK-MB-8
[**2148-9-30**] 04:53PM BLOOD CK-MB-8 cTropnT-0.11*
[**2148-9-25**] 09:14AM BLOOD CK-MB-9 cTropnT-0.04*
[**2148-11-1**] 09:05AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.8
[**2148-9-24**] 06:30AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.1
[**2148-10-21**] 02:23AM BLOOD Digoxin-0.4*
[**2148-9-25**] 09:14AM BLOOD Digoxin-0.6*
.
[**2148-11-1**] URINE URINE CULTURE-FINAL INPATIENT
[**2148-10-22**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{KLEBSIELLA PNEUMONIAE, SERRATIA MARCESCENS} INPATIENT
[**2148-10-21**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL
INPATIENT
[**2148-10-21**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2148-10-21**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2148-10-17**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2148-10-16**] SWAB GRAM STAIN-FINAL; FLUID CULTURE-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE, PSEUDOMONAS AERUGINOSA};
ANAEROBIC CULTURE-FINAL INPATIENT
[**2148-10-14**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2148-10-14**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2148-10-14**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL
INPATIENT
[**2148-10-14**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2148-10-12**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{GRAM NEGATIVE ROD(S)} INPATIENT
[**2148-10-11**] PLEURAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL;
ANAEROBIC CULTURE-FINAL INPATIENT
[**2148-10-11**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT
[**2148-10-11**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2148-10-11**] URINE URINE CULTURE-FINAL; ANAEROBIC CULTURE-FINAL
INPATIENT
[**2148-10-11**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE, STAPHYLOCOCCUS, COAGULASE NEGATIVE};
ANAEROBIC BOTTLE-FINAL INPATIENT
[**2148-10-7**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2148-10-7**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL
INPATIENT
[**2148-10-7**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2148-10-4**] PLEURAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL
{KLEBSIELLA PNEUMONIAE}; ANAEROBIC CULTURE-FINAL; FUNGAL
CULTURE-FINAL INPATIENT
[**2148-9-30**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2148-9-30**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL
INPATIENT
[**2148-9-30**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2148-9-30**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{KLEBSIELLA PNEUMONIAE, STAPH AUREUS COAG +} INPATIENT
[**2148-9-30**] URINE URINE CULTURE-FINAL {ENTEROCOCCUS SP.}
INPATIENT
[**2148-9-30**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2148-9-29**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
{CLOSTRIDIUM DIFFICILE} INPATIENT
[**2148-9-25**] URINE URINE CULTURE-FINAL {PROBABLE ENTEROCOCCUS,
GRAM NEGATIVE ROD(S)} INPATIENT
Brief Hospital Course:
Mr. [**Known lastname 73882**] was take to the operating room on [**2148-9-23**] for a
laparoscopic resection of the colon mass. Due to multiple
adhesions and friable tissue, the case was converted to open.
The sigmoid colon was resected and an end-to-end anastamosis was
performed via stapler. He tolerated the procedure well with an
EBL of 100cc. He was routinely observed in the PACU. He was
transferred to the floors for routine post-operative care.
.
POD#[**2-3**]: He was triggered for agitation with HR 130's (AFIB), O2
sat 93%RA. He was transferred to telemetry floor. Cardiology was
consulted and he was started on a Diltiazem drip wit improvment
in heart rate. He was ruled out for a myocardial infarction, and
made strict NPO due to altered mental status. Both his cardiac
and mental condition slowly improved, his bowel function
returned, and his diet was advanced over the next few days.
.
POD#6: He developed abdominal distention, profuse diarrhea with
a increased WBC to 18.3. Stool cultures were sent, and he was
empircally started on IV flagyl. He then had an aspiration event
requiring intubation. Bilious material was suctioned from ET
tube. He was transferred to the ICU, pressure support was
started and a PA catheter inserted for fluid management.
.
POD#7: He remained on the respiratory ventilator. His stool
cultures came back postive for C.Difficile ([**2148-9-29**]). His urine
culture was sent and eventually grew out enterococcus. Over
time, his sputum grew Klebsiella pneumonia and S. aureus that
were coagulase positive. Vancomycin, Zosyn, & orals vancomycin
were added to regimen. A TTE echo was performed and revealed
LVEF46%, no thrombus with mild global hypokinesis.
.
POD#11: He continued on the ventilator with mutliple attempts to
wean, but unsuccessful. Patient developed pneumothorax requiring
placement of left sided chest tube. His mentation was gradually
improving throughout his ICU stay. He continued on antibiotics
and intravenous vasopressors.
.
POD#15: Due to inability to wean from ventilator, a tracheostomy
tube and PEG tube were placed at bedside. The procedures were
discussed with the patient's daughter who agreed, and consented.
.
POD#19: His temp spiked to 101 with an increase in WBC to 27
requiring an increase in the Neosynephrine rate. A CT of the
chest & abdomen was obtained revealing bilateral pleural
effusions (loculated on the right), LLL consolodation, and
ground glass opacities bilaterally. A right sided chest tube was
placed, and fluconazole was added to his regimen. At this time,
post-surgical abdominal changes were noted.
.
POD#23: His abdominal staples were removed, and he ws found to
have fascial dehiscence. He was taken back to the OR for a wash
out and closure. Retention sutures were placed.
.
POD#24-29: He was weaned to trach mask, and the antibiotic
regimen was stopped. His tube feeds were advanced to goal, and
the TPN discontinued. His mental status continued to improve.
.
POD#30-32: He was noted to have increased secretions, sputum
cultures were sent and eventually grew out Klebsiella
pneunoniae. He was started on Ciprofloxacin and oral vancomycin
with symptomatic improvement.
.
POD#37-present: He remained stable was transferred to [**Hospital Ward Name 2978**]. He
was evaluated per Physical therapy and occupational therapy.
Both services recommended [**Hospital 73883**] rehabilitation. He
continues to tolerate tube feeds which remain at goal. His
secretions have decreased. He is able to better tolerate the
Passy/Muir valve. He continues to benefit from nebulizer
treatments, aggressive chest PT, and frequent turning &
repositioning.
.
Elim/Skin: He continues to have loose, frequent stools. He is
incontinent of both urine a stools. His last two C.Diff cultures
have been negative. Imodium 2mg tabs were started today;
insufficient time has elapsed to assess efficacy. His perineum
and buttocks are erythematous. Nystatin powder and ointment have
been applied with some resolution in symptoms. He should have
this therapy continue. His coccyx is intact. No evidence of
pressure ulcers.
.
AFIB/Coumadin: He will continue on Heparin SC TID. He will
re-start Coumadin once his condition stabilizes. This
information was reviewed with his PCP's edical assistant,
[**First Name8 (NamePattern2) 5464**] [**Last Name (NamePattern1) 30834**], who manages the coumadin patients in the office.
.
ABD/PEG: His incision continues to heal, with the rentention
sutures in place. The open areas should continue to be dressed
with aquacel. His peg site is intact, and requires daily
cleaning and flushing to maintain patent.
.
Mental/Psych: His mental status has improved substantially. He
has remained A/O x [**2-3**] since transfer to [**Hospital Ward Name **]. He occasionally
forgets where he is. He did express some hopeless thought
processes; stating, "why me" and "the surgery was a bad idea".
He was evalutated per Psych who reported that he was
appropriately depressed, and recommended re-evaluation once he
was more stable. This can be done in the Rehab setting.
.
Aspiration Precautions: He has remained NPO due to high risk for
aspirating, and copious amounts of respiratory secretions. He
was evaluated per Speech and Swallow who recommended that he be
re-assessed later once his secretions decrease in amount, and he
becomes more stable.
.
Trach: He sats have remained >95%. His #8 Portex trach is
intact. Continue to provide trach care per the Rehab
institutions protocol. Ensure that the inner cannula is cleaned
at least daily, and that the cuff remain deflated with
application of PMV during daytime to allow communication. The
cuff should be inflated for sleep to prevent aspiration.
.
ID: He has remained afebrile, and he has not required
antibiotics for numerous days post-op.
Medications on Admission:
coumadin 2,3 alternating, zebeta 10', digoxin 0.125', xanax
0.25'prn, viagra 75QWK, combivent prn, singulair 10QPM,
pravachol 20', hytrin 5'
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for fungal infection.
3. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours) as needed.
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation Q2H (every 2 hours) as needed.
5. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day): Per GTUBE.
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Per GTUBE.
9. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours): Per GTUBE.
10. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for perineum/gluteus.
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Per GTUBE.
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
13. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day) as needed for diarrhea/loose stools.
14. Lorazepam 0.25-0.5 mg IV Q4H:PRN anxiety
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
sigmoid polyp-biopsied, positive for adenocarcinoma
Post-op Atrial fibrillation
Post-op C/ Difficile infection
Post-op ileus
Post-op aspiration pneumonia
Post-op abdominal wound dehiscence
.
Secondary:
afib, HTN, pacemaker, carotid stenosis, CAD, COPD, PUD, ED,
chronic anemia
Discharge Condition:
Stable
Trach
NPO-Aspiration Precautions
Tolerating tube feedings via PEG tube
Denies pain. Able to tolerate medications via PEG tube
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to amubulate several times per day.
.
Incision Care:
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Anticoagulation:
-Continue to Heparing SC TID.
-Follow-up with PCP regarding [**Name9 (PRE) **] of Coumadin once more
stable
Followup Instructions:
1. Please call Dr.[**Name (NI) 3377**] office for a follow-up appointment.
2. Please follow-up with Dr.[**Last Name (STitle) **] [**Name (STitle) **],[**Telephone/Fax (1) 7660**]
regarding restarting your Coumadin.
|
[
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"511.8",
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"428.0",
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"458.29",
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"599.0",
"579.3",
"153.3",
"998.32",
"427.31",
"493.20",
"414.01",
"E878.2",
"562.10",
"560.1",
"041.04",
"V64.41",
"285.9",
"507.0",
"428.20",
"287.4",
"041.3",
"V45.01",
"995.92",
"401.9",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"34.04",
"99.15",
"96.6",
"45.76",
"96.07",
"38.93",
"54.61",
"31.1",
"96.72",
"97.23",
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] |
icd9pcs
|
[
[
[]
]
] |
13649, 13719
|
6348, 12135
|
282, 548
|
14050, 14185
|
2404, 6325
|
15634, 15852
|
1835, 1844
|
12326, 13626
|
13740, 14029
|
12161, 12303
|
14209, 15253
|
15268, 15611
|
1859, 2385
|
222, 244
|
576, 1341
|
1363, 1539
|
1555, 1819
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,122
| 158,905
|
48044
|
Discharge summary
|
report
|
Admission Date: [**2149-5-13**] Discharge Date: [**2149-5-23**]
Date of Birth: [**2073-1-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Right lower extemity swelling and pain
Major Surgical or Invasive Procedure:
[**2149-5-15**]: Excisional debridement of bilateral lower
extremity ulcers including muscle, fascia and tendon on the
right side with right side VAC placement.
[**2149-5-16**]:
Diagnostic abdominal aortogram, pelvic
arteriogram, aortic ipsilateral catheterization, common
femoral ipsilateral catheterization
[**2149-5-19**]:
1. Antegrade approach to right lower extremity angiography
with angioplasty of tibioperoneal trunk and posterior
tibial artery.
2. Stenting of tibioperoneal trunk and posterior tibial
artery.
3. Perclosure of right common femoral arterial puncture.
History of Present Illness:
76 year old male with a history of chronic venous stasis ulcers
presents with an enlargement of RLE ulcers for 1 week and
shortness of breath. Patient has been followed by podiatry in
the past. Patient reports fever and chills approximately 3
weeks ago.
Past Medical History:
1. Hypertension
2. Chronic venous stasis ulcers, followed by Dr. [**First Name (STitle) 3209**] in
Podiatry
at [**Hospital1 18**].
3. AAA status post repair in [**2138**]
4. PUD status subtotal gastrectomy
5. History of pericarditis and effusion requiring
pericardiocentesis
6. ? Coronary artery disease, recent stress test reportedly
obtained as an out-patient limited by poor exercise capacity.
Cardiac catheterization reportedly without flow limiting disease
3 years ago. Per patient, preserved systolic function.
7. Peripheral vascular disease status post right hallux
amputation.
8. Left eye blindness
Social History:
He lives alone in [**Location (un) 538**], 2 flights of stairs in home.
Ex-smoker, quit 25 years ago. Also prior history of EtOH use,
weekly drinks. He used to work for the Federal Government in
Medical Disability.
Family History:
Non-contributory
Physical Exam:
T=98.3 HR=85 BP=260/109 RR=18 100%RA
GEN: AAOx3
CHEST: mild b/l crackles
HEART: RRR
ABD: soft, NT, ND, well-healed midline scar
EXT: RLE: non-palp pedal pulses, slightly dopplerable DP signal,
exposed Achilles tendon c/ overlying ulcer, pos. fibrotic
material, no probe to bone
LLE: palpable DP/PT pulses, positive ulcer L. medial heel
Pertinent Results:
[**2149-5-13**] 05:45PM PT-12.0 PTT-26.8 INR(PT)-1.0
[**2149-5-13**] 05:45PM PLT COUNT-563*
[**2149-5-13**] 05:45PM HYPOCHROM-3+ ANISOCYT-1+ MICROCYT-3+
[**2149-5-13**] 05:45PM NEUTS-78.7* LYMPHS-14.5* MONOS-5.6 EOS-0.9
BASOS-0.3
[**2149-5-13**] 05:45PM WBC-9.0 RBC-3.54* HGB-8.4* HCT-26.1* MCV-74*
MCH-23.7* MCHC-32.1 RDW-16.3*
[**2149-5-13**] 05:45PM CK-MB-NotDone cTropnT-0.02* proBNP-6129*
[**2149-5-13**] 05:45PM GLUCOSE-99 UREA N-31* CREAT-1.9* SODIUM-135
POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-25 ANION GAP-17
[**2149-5-13**] 05:49PM LACTATE-1.3
[**2149-5-13**] 10:00PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2149-5-13**] 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-0.2 PH-6.5
LEUK-NEG
[**2149-5-13**] 10:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
Micro
[**5-13**] Blood: no growth x2
[**2149-5-13**] 8:46 pm SWAB Source: Right leg.
**FINAL REPORT [**2149-5-20**]**
WOUND CULTURE (Final [**2149-5-17**]):
BETA STREPTOCOCCUS GROUP B. HEAVY GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
STAPH AUREUS COAG +. HEAVY GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.5 S
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- S
VANCOMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2149-5-20**]):
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum. None isolated.
PRESUMPTIVE PEPTOSTREPTOCOCCUS SPECIES. HEAVY GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
[**5-14**] RPR: non-reactive
RADS
[**5-13**] RLE U/S: IMPRESSION: No evidence of right lower extremity
DVT.
[**5-13**] Left foot: 1. Hallux valgus, with osteoarthritis and
possible neuropathic component, involving the first MTP joint,
an unusual site; the Lisfranc joint appears spared.
2. No specific evidence of osteomyelitis at this site, or
elsewhere in the foot.
[**5-13**] Right ankle: Extensive soft tissue ulcers, with no definite
evidence of osteomyelitis.
[**5-13**] Chest: Left ventricular configuration of the heart, with
tortuous aorta. On the lateral view, very mild blunting of both
costophrenic angles. No pneumothorax. Epigastric staples
noted. Lung fields appear clear. The osseous structures are
within normal limits. Mild kyphosis of the thoracic spine.
IMPRESSION: No active lung disease seen
[**5-14**] Arterial Noninvasive Study: Doppler evaluation was
performed of both lower extremity arterial systems at rest. The
distal right leg cannot be examined due to open wounds. In the
right, Doppler tracings are triphasic at the femoral level only.
They are monophasic at the popliteal. No ankle brachial index
could be calculated. The ankle metatarsals PVRs are flat. On
the left, Doppler tracings are triphasic at the femoral,
popliteal, and dorsalis pedis levels. Ankle brachial index is
1.1. Pulse volume recordings are relatively normal to the calf
level and show significant drop off at the ankle and
metatarsals.
IMPRESSION: On the right, there is significant superficial
femoral and tibial artery occlusive disease. On the left, there
is moderate tibial artery occlusive disease.
CARDS
[**5-14**] ECHO:
Conclusions:
The left atrium is moderately dilated. The estimated right
atrial pressure is 5-10 mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Regional left ventricular wall motion is
normal. Right ventricular chamber size and free wall motion are
normal. The 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. Mild to
moderate ([**1-28**]+) mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Mild-moderate mitral regurgitation. Mild symmetric
left
ventricular hypertrophy with preserved global and regional
biventricular
systolic function. Aortic valve sclerosis
Angiography:
[**5-16**]
1. Patent infrarenal abdominal aorta with patent bilateral
single renal arteries. We see a patent distal infrarenal
aorto-[**Hospital1 **]-iliac bypass.
2. Both internal and external iliacs are patent.
3. The right lower extremity runoff revealed patent common
profunda and superficial femoral arteries. There is mild
to moderate diffuse disease throughout the distal SFA and
above-the-knee popliteal. There is a high-grade stenosis
at the distal below-the-knee popliteal just before the
anterior tibialis takeoff, there is also high-grade
stenosis within the tibioperoneal trunk. We see a 3-
vessel runoff with the main runoff given via a patent
posterior tibial. At the foot the anterior tibialis is
bluntly occluded at the ankle. We did not see a dorsalis
pedis. The posterior tibialis continues down into a
patent plantar arch.
Brief Hospital Course:
The patient was admitted to the MICU service on [**5-13**] due to a BP
of 229/104. A labetolol drip was started with appropriate
response. Vascular surgery and podiatric surgery were consulted
for the b/l venous stasis ulcers. Vanco/Levo/Flagyl were
started, cultures were obtained from the leg wound, and the
lower extremities were wrapped with ACE bandages. On [**5-14**] the
patient was transferred to the vascular surgery service. A
dermatology consult was obtained for the patient's self-induced
"prurigo nodularis" and moisturization and hydrocortisone cream
were recommended. On [**5-14**] noninvasive arterial studies showed
significant superficial femoral and tibial artery occlusive
disease on the right and on the left, moderate tibial artery
occlusive disease. The patient was brought to the OR on [**5-15**] for
excisional debridement of B/L LE ulcers and placement of a VAC
dressing. On POD2, the patient was brought for angiography. On
the right, mild
to moderate diffuse disease throughout the distal SFA and
above-the-knee popliteal was found. There was a high-grade
stenosis at the distal below-the-knee popliteal just before the
anterior tibialis takeoff, and a high-grade stenosis within the
tibioperoneal trunk. The anterior tibialis was bluntly occluded
at the ankle, a dorsalis pedis was not found, and the posterior
tibialis continued down into a patent plantar arch. The patient
tolerated the procedure well. PT was consulted and worked with
the patient during this admission. The VAC dressing was changed
on POD4. On POD4, the patient was brought back to the
angiography suite for an antegrade approach to right lower
extremity angiography with angioplasty of the tibioperoneal
trunk and posterior tibial artery, and stenting of the
tibioperoneal trunk and posterior tibial artery. Post-procedure,
the patient had dopplerable DP/PT signals B/L. The VAC dressing
was changed on POD7, PPD6/3. A rehab screen was initiated. On
POD8, the patient remained afebrile, wound healing was improving
with the VAC dressing, and was ambulating with PT. The patient
was discharged to Rehab on POD8 with a VAC dressing in place and
to take a 2 week course of Augmentin.
Medications on Admission:
Lasix 20 mg PO QD
Percocet as needed
Elavil 20 mg daily
Maalox
Tylenol as needed
Advil as needed
Discharge Medications:
1. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold for SBP <100.
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed.
6. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for Pruritus.
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for SBP<100 or HR<55
.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day).
14. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
16. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
17. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed.
18. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours for 2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] of [**Location (un) **]
Discharge Diagnosis:
Venous stasis ulcers
AAA repair [**2138**]
Bleeding Gastric/duodenal ulcer- s/p multiple operations inc
subtotal gastrectomy, vein stripping
HTN
Rheumatoid Arthritis
h/o pericardial effusion/tamponade
L eye blindness
Discharge Condition:
Stable
Discharge Instructions:
Take your medications as directed.
Your VAC dressing should be changed every 3 days. VAC should be
kept at continuous suction 125 mmHg.
[**Name8 (MD) **] MD if you experience:
* Fevers, chills
* Excess bleeding at VAC sites
* Signs of worsening infection
* Other symptoms concerning to you
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2149-6-11**] 11:45
Provider: [**Name10 (NameIs) 6811**] STONE, RVT Date/Time:[**2149-6-11**] 11:00
|
[
"698.3",
"682.6",
"355.9",
"285.9",
"593.9",
"428.0",
"428.30",
"401.9",
"707.15",
"707.13",
"459.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"83.45",
"88.48",
"00.45",
"39.90",
"93.59",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
11806, 11873
|
7848, 10048
|
309, 903
|
12134, 12142
|
2457, 7825
|
12487, 12719
|
2067, 2085
|
10196, 11783
|
11894, 12113
|
10074, 10173
|
12166, 12464
|
2100, 2438
|
231, 271
|
931, 1188
|
1210, 1818
|
1834, 2051
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,930
| 112,909
|
44989
|
Discharge summary
|
report
|
Admission Date: [**2116-1-30**] Discharge Date: [**2116-2-2**]
Date of Birth: [**2038-1-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
78F with h/o HTN, PVD, COPD, osteoporosis, TCC of bladder,
presenting with worsening dyspnea x 4 days. History obtained
from husband revealed URI x 2 days with productive cough. Night
PTA, worsening sx's and agitation. Husband called 911. In
ambulance, noted to have poor air movement, given combivent and
nebs. Last seen by PCP [**2105**], but records from outside
pulmonologist in [**2114**] reveal FEV1 0.7.
On arrival to ED, HR 130, BP 140/100, RR 38, SaO2 97% on NRB.
In ED, received Solumedrol 125mg IV, Combivent nebs, Levoflox
500mg IV x 1. Given terbutaline 0.25mg SC.
Decision made to intubate for worsening O2 sat to 67% on NRB,
and failed CPAP. Received succinylcholine, etomidate, and
propofol peri-intubation. Post-intubation ABG 7.22/75/423 with
lactate 2.1. Post-intubation, VS improved to 99.8F HR 120, BP
146/81, RR 18.
Past Medical History:
1) COPD:
[**2114-12-19**]: FVC 1.46 (57%) FEV1 0.7 (39%) no bronchodilator
response
Resid vOl 215% of predicted
Diffusion 37% predicted
High lung volumes - no restrictive component on interpretation.
Baseline ABG 7.37 | 42 |80 | 24 on RA, SpO2 93% on RA. Baseline
HCT 44. Maintained on albuterol and spireva.
2) HTN
3) PVD, s/p L fem-[**Doctor Last Name **] [**2103**]
4) TCC of bladder - s/p TURBT and local BCG treatments, no
evidence of recurrence at last urology f/u 6 months ago
5) Osteoporosis
6) Hyperlipidemia
7) Cataract surgery [**9-10**]
Social History:
50 p-y hx, quit smoking 7ya, no EtOH, lives at home with
husband. [**Name (NI) 1403**] as film archivist at [**Last Name (un) **]
Family History:
Mother with lung CA
Physical Exam:
BP T 99.6 124/52 HR 103 sinus RR 14 O2 100% SIMV Fi02 50% 500
rr16 peep 5 not overbreathing
Gen: intubated, sedated nad
HEENT: mmm, perrla,
Lungs: diminished bs, low pitched expiratory wheezes, no rales
Heart: distant hs, no m/r/g, rrr
Abd: distended but soft, no organomegaly, hypoactive bs
Ext: distal pulses present, lle cool, scar on lle from fem [**Doctor Last Name **],
no le edema
Neuro: unable to assess due to sedation
Pertinent Results:
Initial [**1-30**] CXR:
The heart size and mediastinal contours are normal. The lungs
are hyperinflated with attenuation of the pulmonary vascularity,
particularly in the right upper lobe, consistent with emphysema.
No focal pulmonary parenchymal consolidation or pleural
effusions identified. No pneumothorax.
Initial ECG:
Sinus tachycardia. Biatrial abnormality. P pulmonale with very
tall P waves in leads II, III and aVF. Compared to the previous
tracing of [**2115-9-12**] tachycardia has appeared. Left atrial
abnormality is more pronounced.
TTE [**1-31**]:
Conclusions:
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF 70%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are severely thickened/deformed. Aortic stenosis is
present but could not be quantitated. An aortic valve
vegetation/mass cannot be excluded. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. There is severe mitral
annular calcification. Mild (1+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] The tricuspid valve
leaflets are mildly thickened. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion. The absence of
a vegetation by 2D echocardiography does not exclude
endocarditis if clinically suggested.
Blood Cultures:
[**1-30**]: Coag negative staph 2/2 bottles
[**1-31**] and [**2-1**]: Pending at time of death
Spurum Cultures:
[**1-31**]: Rare oropharyngeal flora
[**2-2**]: No growth
Urine Culture:
[**1-30**]: No growth
Rapid respiratory virus screen:
Positive for influenza A antigen
[**2116-1-30**] 08:19AM BLOOD WBC-16.6* RBC-4.51 Hgb-14.6 Hct-42.5
MCV-94 MCH-32.3* MCHC-34.3 RDW-12.9 Plt Ct-246
[**2116-2-2**] 04:46AM BLOOD WBC-7.9 RBC-3.88* Hgb-12.3 Hct-36.4
MCV-94 MCH-31.7 MCHC-33.8 RDW-12.7 Plt Ct-227
[**2116-1-30**] 08:19AM BLOOD Neuts-93.3* Bands-0 Lymphs-3.8* Monos-2.7
Eos-0.1 Baso-0.1
[**2116-1-31**] 03:57AM BLOOD PT-11.6 PTT-26.6 INR(PT)-1.0
[**2116-1-30**] 08:19AM BLOOD Glucose-150* UreaN-35* Creat-1.1 Na-137
K-4.1 Cl-92* HCO3-25 AnGap-24*
[**2116-2-2**] 04:46AM BLOOD Glucose-109* UreaN-55* Creat-1.1 Na-138
K-3.7 Cl-100 HCO3-30 AnGap-12
[**2116-1-30**] 08:19AM BLOOD CK(CPK)-315*
[**2116-1-30**] 08:19AM BLOOD CK-MB-9
[**2116-1-30**] 08:19AM BLOOD TotProt-6.4 Calcium-8.8 Phos-6.6* Mg-3.2*
[**2116-1-31**] 03:57AM BLOOD Albumin-3.2* Calcium-8.3* Phos-5.3*
Mg-2.3 Cholest-191
[**2116-1-31**] 03:57AM BLOOD Triglyc-137 HDL-72 CHOL/HD-2.7 LDLcalc-92
[**2116-1-30**] 07:22AM BLOOD Type-ART pO2-473* pCO2-75* pH-7.22*
calHCO3-32* Base XS-0
[**2116-1-31**] 02:47AM BLOOD Type-ART Temp-36.7 Rates-20/ PEEP-5
FiO2-40 pO2-113* pCO2-43 pH-7.36 calHCO3-25 Base XS--1
-ASSIST/CON Intubat-INTUBATED
[**2116-2-1**] 03:04PM BLOOD Type-ART Temp-36.2 Rates-[**11-9**] Tidal V-500
PEEP-5 FiO2-40 pO2-157* pCO2-51* pH-7.31* calHCO3-27 Base XS--1
-ASSIST/CON Intubat-INTUBATED
[**2116-1-30**] 07:22AM BLOOD Lactate-2.1*
[**2116-1-30**] 10:24PM BLOOD Lactate-1.3
[**2116-1-30**] 07:40AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2116-1-30**] 07:40AM URINE Blood-TR Nitrite-NEG Protein-500
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2116-1-30**] 07:40AM URINE RBC-0-2 WBC-0-2 Bacteri-MOD Yeast-NONE
Epi-0-2
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted to the [**Hospital Unit Name 153**], intubated. She was
continued on her COPD regimen of prednisone, levofloxacin, and
albuterol/atrovent MDIs. There were initial difficulties finding
an appropriate ventilatory mode due to problems triggering
breaths. This was present on several modes tried, and it was
decided to keep the ventilator on AC mode, with appropriate
levels of propofol for sedation. The day after her admission,
initial blood cultures grew GPC in pairs and clusters in [**1-9**]
bottles. This was unexpected, given infrequent hospital exposure
and lack of infiltrate on CXR that might suggest a staph PNA. It
was suspected that this was contamination from placement of PIVs
in the ED, but vancomycin was started to cover until speciation
and sensitivities returned. A TTE was also done to assess for
evidence of endocarditis. Thickened AV were noted, but no clear
evidence of vegetations. The team decided that, while a TEE may
be clinically indicated, her wishes, as clearly conveyed by her
son [**Name (NI) 382**] and husband, were that minimal invasive testing be
done, and a TEE was deferred.
Mrs. [**Known lastname **] also had a nasopharyngeal aspirate done for
respiratory viruses, which was positive for influenza A. Droplet
precautions were instituted; however, since her URI symptoms had
been occurring for several days prior to admission, it was not
felt that antiviral therapy would be beneficial, and supportive
measures were continued.
Several conversations were held with Mrs.[**Known lastname 96174**] husband and
son, both physicians. They clearly indicated that Mrs. [**Known lastname **]
would want to be DNR and, if her clinical course did not rapidly
improve within 24-48h of admission, that she would want to be
placed on comfort measures, and the endotracheal tube removed.
While stable from a hemodynamic and respiratory perspective, she
did not demonstrate any increasing ability to be weaned from the
ventilator over this time frame. It was thought by the primary
team that her respiratory failure was probably reversible, given
the likely exacerbation by her inluenza, but that her underlying
COPD was severe enough that it may take 1-2 weeks to wean from
the ventilator. The family decided that Mrs. [**Known lastname **] would not
want this extended course, and decided to switch the goals of
care to comfort measures only. She was given morphine IV prn,
and her endotracheal tube was removed. Over the next several
hours, her SaO2 was in the 60s-70s on face tent, and morphine IV
was given prn for respiratory distress. Housestaff was called to
the bedside at 9:25pm to pronouce the patient. On examination,
she had no palpable pulse for two minutes. She had no
auscultated breaths or heart sounds over that span. She was
pronounced dead at 9:25pm, and her husband and PCP [**Name Initial (PRE) 13109**]. The
family declined an autopsy.
A/P: Patient is a 78 yo female with PMH of copd, htn, pvd, and
bladder cancer who is admitted s/p copd exacerbation requiring
intubation.
COPD exacerbation- fev 1 0.70, cxr with hyperinflation but no
infiltrate, possibly exacerbated by influenza.
-Having difficulties triggering breaths. Currently trying PS
trial 15/5.
-cont prednisone 40mg qD as part of 2 week taper.
-cont levofloxacin 250mg IV qD D4
-cont albuterol q2h and ipratropium q6h.
-Will plan on extubating today, with no reintubation if fails.
Family states pt would want to be CMO.
Coag negative staph bacteremia - BCx growing coag negative staph
in blood, and GPC in sputum. Bacteremia could be due to possible
contamination from placement of PIV, but continuing with vanc
1gm IV q48h due to concommitant finding in sputum..
- TTE showing no vegetations, but does not severely
thickened/deformed AV, may need TEE if pt does well
post-extubation.
HTN- treated in the past with aldactazide with evidence of
borderline lvh on ekg. Last cardiac wkup in '[**03**], nl.
-Holding HCTZ in setting of worsening renal function. Would
treat HTN with standing norvasc for now.
Bladder ca- Appears to be stable, s/p BCG topical therapy [**5-13**]
years ago. Last urologist appt 6 months ago, reportedly normal.
Access: 2 20ga PIVs, a-line
Code: DNR. Would not want to be intubated for long-term, would
not want reintubated if unsuccessful extubation. Verfied with
son/HCP
Contact: [**Name (NI) 4906**], [**Name (NI) 6339**]: [**Telephone/Fax (1) 96175**]
HCP and POA: [**Name (NI) **]: [**Telephone/Fax (1) 96176**] (cell)
Medications on Admission:
Aldactazide 25mg/25mg qD
Zocor 20mg qHS -?taking
Fosamax
Ca supplements
Albuterol
Spiriva
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Influenza
Respiratory failure
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"496",
"443.9",
"518.81",
"584.9",
"401.9",
"995.92",
"487.1",
"733.00",
"038.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
10677, 10686
|
6005, 10508
|
333, 358
|
10759, 10769
|
2450, 5982
|
10821, 10827
|
1965, 1986
|
10649, 10654
|
10707, 10738
|
10534, 10626
|
10793, 10798
|
2001, 2431
|
274, 295
|
386, 1227
|
1249, 1802
|
1818, 1949
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,285
| 181,964
|
17854
|
Discharge summary
|
report
|
Admission Date: [**2169-1-3**] Discharge Date: [**2169-1-31**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
intubation; central line placement
History of Present Illness:
82 M with h/o IPF (on chronic steroids), PVD, h/o VT (on
dofetilide), and P.D. who had chronic constipation and taking 1
Tbsp of milk of magnesia QHS for 2 weeks. He was noted to have
increasing somnulence from his baseline (interactive, able to
feed himself) and [**2169-1-2**] he was more lethargic with
unintelligible speech and visual hallucinations. Per daughter
he was seeing cats and dogs. Pt saw PCP the day prior to labs
drawn and found to have Mg 7.3. He was instructed to go to OSH
where he was found to have Cr 2.2 (baseline 0.8). He was given
3 amps CaGluc, IVF. Transfered to [**Hospital1 18**] where he had Mg 6.3 and
Cr 1.6 --> taken to MICU for furhter monitoring.
Past Medical History:
1. pulm fibrosis (on chronic steroids)
2. h/o VT (on dofetilide)
3. Shy-[**Last Name (un) **]/Parkinson's
4. venous stasis ulcers
5. PVD
6. GERD
7. s/p b/l knee replacement
8. s/p laminectomy
9. s/p R 1st toe amputation for gangrene
Social History:
lives at home with wife, who is HCP. Former [**Name2 (NI) 1818**], quit.
Family History:
NC
Physical Exam:
T 98.9 130/79 62 19 100% (RA)
Gen: lethargic, responds to name, follows commands, not oriented
to time/place
HEENT: dry mm
neck: no jvd, supple, no LAD
CV: s1, s2, no murmurs
Pulm: cta b/l
Abd: sft, nt, nd,
ext: s/p 1st toe amputation - well healing
Pertinent Results:
cxr: no infiltrate; no effulsion; +cardiomegaly
EKG: bigeminy; 1st degree AV block
*
[**2169-1-2**] 11:55PM CALCIUM-9.3 PHOSPHATE-6.0*# MAGNESIUM-6.5*
[**2169-1-2**] 11:55PM GLUCOSE-126* UREA N-67* CREAT-1.6* SODIUM-140
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-31* ANION GAP-14
*
[**2169-1-3**] 10:24PM CREAT-1.1
[**2169-1-3**] 10:24PM CK(CPK)-29*
[**2169-1-3**] 10:24PM CK-MB-NotDone cTropnT-0.04*
[**2169-1-3**] 10:24PM CALCIUM-8.2* PHOSPHATE-5.4* MAGNESIUM-3.7*
[**2169-1-3**] 05:55PM GLUCOSE-101 UREA N-51* CREAT-1.2 SODIUM-141
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-28 ANION GAP-11
[**2169-1-3**] 05:55PM CALCIUM-8.6 PHOSPHATE-5.8* MAGNESIUM-3.9*
[**2169-1-3**] 02:32PM GLUCOSE-124* UREA N-50* CREAT-1.1 SODIUM-141
POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-28 ANION GAP-11
[**2169-1-3**] 02:32PM CK(CPK)-28*
[**2169-1-3**] 02:32PM CK-MB-NotDone cTropnT-0.03*
[**2169-1-3**] 02:32PM CALCIUM-7.7* PHOSPHATE-5.4* MAGNESIUM-3.8*
[**2169-1-3**] 02:32PM HCT-36.0*
[**2169-1-3**] 01:04PM TYPE-ART TEMP-36.5 RATES-/13 TIDAL VOL-500
PEEP-5 O2-50 PO2-193* PCO2-44 PH-7.42 TOTAL CO2-30 BASE XS-4
INTUBATED-INTUBATED VENT-SPONTANEOU
[**2169-1-3**] 01:04PM LACTATE-1.4
[**2169-1-3**] 01:04PM freeCa-1.01*
[**2169-1-3**] 05:25AM GLUCOSE-230* UREA N-61* CREAT-1.3* SODIUM-138
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-28 ANION GAP-12
[**2169-1-3**] 05:25AM CK(CPK)-27*
[**2169-1-3**] 05:25AM CK-MB-3 cTropnT-0.03*
[**2169-1-3**] 05:25AM CALCIUM-8.1* PHOSPHATE-6.4* MAGNESIUM-4.8*
[**2169-1-3**] 05:25AM WBC-6.6 RBC-3.88* HGB-12.4* HCT-35.2* MCV-91
MCH-31.9 MCHC-35.2* RDW-14.5
[**2169-1-3**] 05:25AM PLT COUNT-192
[**2169-1-3**] 05:05AM TYPE-ART TEMP-37.2 RATES-12/ TIDAL VOL-650
PEEP-5 O2-100 PO2-455* PCO2-50* PH-7.42 TOTAL CO2-34* BASE XS-7
AADO2-217 REQ O2-44 -ASSIST/CON INTUBATED-INTUBATED
[**2169-1-3**] 05:05AM LACTATE-1.6 NA+-135 K+-4.0
[**2169-1-3**] 04:39AM LACTATE-0.3* NA+-146 K+-0.7*
[**2169-1-3**] 04:39AM freeCa-0.37*
[**2169-1-3**] 12:47AM LACTATE-3.3*
[**2169-1-3**] 12:20AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2169-1-3**] 12:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2169-1-3**] 12:20AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2169-1-2**] 11:55PM GLUCOSE-126* UREA N-67* CREAT-1.6* SODIUM-140
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-31* ANION GAP-14
[**2169-1-2**] 11:55PM CALCIUM-9.3 PHOSPHATE-6.0*# MAGNESIUM-6.5*
[**2169-1-2**] 11:55PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2169-1-2**] 11:55PM WBC-9.4 RBC-4.66 HGB-14.2 HCT-42.9 MCV-92
MCH-30.4 MCHC-33.0 RDW-14.6
[**2169-1-2**] 11:55PM NEUTS-82* BANDS-8* LYMPHS-6* MONOS-3 EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2169-1-2**] 11:55PM PLT COUNT-206
[**2169-1-2**] 11:55PM PT-13.8* PTT-31.8 INR(PT)-1.2
Brief Hospital Course:
hypermagnesemia - With regards to his hypermagnesemia, it
appears likely that he experienced dangerously elevated levels
of magnesium, with a maximum of 6.5 on admission. The renal
service was consulted, and HD was considered, though his
electrolytes normalized shortly after admission, and his Cr
returned to baseline with rehydration. It is felt that the
etiology of his hypermagnesemia was primarily secondary to
excessive Milk of Magnesia intake prior to admission and ARF (he
had been on oxycontin/oxycodone following toe amputation, and
was using laxative to counteract his constipation).
Hypotension - shortly after hospital admission, Mr. [**Known lastname 21781**]
became hypotensive in setting of hypermagnesemia and lasix
diuresis, and was briefly admitted to the MICU. His MICU course
was notable for placement of a R subclavian line, volume
resuscitation with IV saline, and briefly requiring pressors,
with subsequent rapid resolution of his hypotension.
Hypoxia - MICU course also notable for an apneic episode,
lasting 50 seconds, with O2 desaturation from 100% RA to 90% RA,
and requiring emergent intubation. He was successfully
extubated the following day. It is felt that his hypoxia was
likely secondary to hypermagnesemia. His electrolytes
normalized and he was transfered to the medical floor.
ARF - His Cr 1.6 on admission, and improved back to his baseline
of .5 -.9 with IV hydration. Cr remained stable for remainder
of hospital course
arrhythmia - Mr. [**Known lastname 21781**] has been maintained on dofetilide,
given his history of ventriculra tachycardia (VT). He was noted
to have frequent ectopy while on telemetry and on daily ECGs,
and given his h/o VT, an EP consult was obtained for further
titration of his medication regimen. His dofetilide was
discontinued given his ARF, and out of concern for possible
future episodes of renal insufficiency (as it is not clear what
precipitated his ARF on admission). After an appropriate time,
he was initiated on quinidine, and maintained on a dose of 324
mg SR twice daily. His QT interval was monitored with daily
ECGs for the first several weeks, and remained stable. He has
continued to have frequent ectopy, with frequent episodes of
short runs of supraventricular tachycardia. He was monitored on
telemetry for 9 days, notable only for frequent ectopy and short
runs of SVT. Prior to discharge, he was given [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts
monitor, for further evalution and titration of his quinidine
dosing, and he will follow-up with Dr. [**Last Name (STitle) 3321**], his
cardiologist.
UTI - Mr. [**Known lastname 21781**] was noted to have a proteus UTI, with a
multiply-drug resistant isolate. He was initially treated for 3
days with levofloxacin, though switched to ceftriaxone when the
sensitivities returned (fluoroquinolone resistant isolate), with
resolution of his leukocytosis.
diarrhea - noted to have episodes of diarrhea worrisome for C
difficile colitis. Though the toxin assay was negative, given
his significant leukocytosis and abx exposure, he was treated
with an empiric course of metronidazole via his NG-tube.
Altered mental status - On the medical floor, Mr [**Known lastname 21781**]
continued to be deleirius for much of the hospitalization. A
neurology consult was obtained, and felt that his delerium and
lethargy were likely attributable to toxic/metabolic effects of
his acute illness, that may persist for weeks after
stabilization/resolution of his acute issues. Multiple
medication changes were made to remove or reduce non-essential
medications. EEG demonstrated encephalopathy (toxic-metabolic
pattern), with no evidence of epileptiform activity, and brain
MRI did not reveal any evidence of an acute intracranial
process.
Nutrition - Mr. [**Known lastname 21781**] required NG tube placement for
medications and for nutrition, given his altered sensorium,
which caused him to fail his first three speech and swallow
evaluations. An NG tube was placed on two occasions via IR (he
pulled the first out), and he was maintained on tube feeds for
much of the hospitalization. A fourth Speech and Swallow
evaluation, including videoswallow study, was obtained, and it
was determined that Mr. [**Known lastname 21781**] could in fact resume PO intake
with pureed solids and thin liquids, with Boost supplementation
with all meals, and with strict aspiration precautions. His NG
tube was removed. A calorie count was instated for several
days, and although Mr. [**Known lastname 21781**] only achieved approximately [**12-11**]
of his calorie target and [**12-12**] of his protein target, his family
was quite encouraged by his progress and on multiple occasions
clearly stated that they would not want to have a PEG tube
placed for enteral nutrition. He also had not met his fluid
goals, and required saline rehydration several days prior to
discharge.
Parkinson's - maintained on carbidopa/levodopa, though Mirapex
was discontinued in an effort to simplify his medical regimen,
given his ongoing delerium.
pulmonary fibrosis - maintained on 5mg/day of prednisone for
much of the hospitalizaiton, though dose decreased to 2.5mg/day
several days prior to discharge as above (regimen
simplification).
Gout - Mr. [**Known lastname 21781**], in the setting of dehydration, was noted
to have an erythematous second MCP of the Right hand several
days prior to discharge, tender to palpation. Given his h/o
gout, it is likely that this represented a gouty arthritis, and
was self-limited. I have discussed with his family members that
when his delerium clears, it may be appropriate to restart him
on allopurinol, which he should discuss with his PCP.
s/p toe amputation - vascular surgery was consulted to follow
the patient, and twice daily dressing changes were carreid out,
with evidence of granulation tissue and overall good wound
healing. He is to have once daily dry dressing changes
following discharge.
tinea - axillary rash with likely fungal involvement, and
miconazole was applied.
Medications on Admission:
prednisone 2.5 mg QD
combivent q6
triamterine-hctz 37.5/25 PO Qday
colace 100 mg PO Qday
Oxybutinin 5 mg PO BID
promipetol 0.125 PO BID
senna
percocet
sinemet 25-100 1.5 tabs QD
seroquel 25 mg PO QHS
Zocor 20 mg PO Qday
metoprolol 25 mg PO BID
omeprazole 10 mg PO Qday
Midodrine 10 mg PO TID
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
5000U Injection TID (3 times a day): until ambulatory.
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO Q12H (every 12 hours).
5. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO TID (3
times a day).
6. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO QD
().
7. Carbidopa-Levodopa 25-100 mg Tablet Sig: 1.5 Tablets PO QD
().
8. Carbidopa-Levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO Q
9AM ().
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash in axilla.
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
12. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
Highgate Manor
Discharge Diagnosis:
hypermagnesemia
acute renal failure
hypotension
hypoxia/respiratory failure
s/p gangrene, right great toe amputation
delerium
Parkinson's disease
history of ventricular tachycardia
ectopy
Urinary tract infection (Proteus)
Gout
pulmonary fibrosis
GERD
Discharge Condition:
stable, though with ongoing delerium
Discharge Instructions:
Continue to take your medications as directed.
Your feet, and in particular the amputation site, should be
examined daily for signs of infection. Contact your physician
or return to the emergency room if you notice any redness,
swelling or other concerning signs of infection, or if you
experience fevers or chills.
Contact your physician or return to the emergency department if
you experience any chest pain, shortness of breath, or other
symptoms that are concerning to you.
Followup Instructions:
Mr. [**Known lastname 21781**] should be maintained on strict aspiration
precautions, with pureed solids/thin liquids and Boost
supplementation until mental status (delreium) improves, at
which time repeat Speech and Swallow evaluation should be
carried out, and if he passes, diet can be advanced.
You have been given a 'King of Hearts' monitor, and should
follow up with the heart monitor laboratory at [**Hospital1 771**] ([**Telephone/Fax (1) 3104**]) and with Dr. [**Last Name (STitle) **]
to discuss the results, as well as possible changes in your
Quinidine dosing.
Follow-up with Dr. [**Last Name (STitle) 23155**]. Please phone his office to
schedule your appointment within the next 1-2 weeks
([**Telephone/Fax (1) 3121**]).
Follow-up with your primary care physician and with your
neurologist. Please call to schedule your appointments within
the next 1-2 weeks.
You have the following appointments:
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2169-2-17**]
9:55
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 611**]/DR. [**Last Name (STitle) **] Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2169-2-17**] 10:10
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,872
| 184,060
|
32574
|
Discharge summary
|
report
|
Admission Date: [**2136-9-25**] Discharge Date: [**2136-10-4**]
Date of Birth: [**2065-5-20**] Sex: M
Service: MEDICINE
Allergies:
Atenolol / Tricor
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
transfer for treatment and further evaluation of CHF
Major Surgical or Invasive Procedure:
paracentesis
Swan-ganz catheter placement
History of Present Illness:
Mr. [**Known lastname 3647**] is a 71yo man with a history of atrial fibrillation/
flutter, CAD s/p PTCI, CHF EF of 45%, h/o ascites without known
liver disease, who is transferred from Lakes [**Hospital 12018**] Hospital
for further evaluation of CHF, including possible right and left
heart cath. Pt presented to OSH on [**2136-9-23**] with CHF
exacerbation after not taking his medications for three days (pt
reportedly unable to pay for the medications). He was diuresed
approx 1L. Developed acute renal failure with diuresis (crt
1.5--->2.3). Additionally, on admission to OSH, he was noted to
have increasing LE edema & ascites (which he has had in
"moderate" amounts in past, as documented by US & CT at OSH).
His LFTs were WNL (ALT 20, AST 29, alk phos 130) as they have
been in past. Despite reported h/o ascites & LE edema, pt
reportedly has no pulm HTN/RV failure on OSH imaging. Concern
raised about possible constrictive/restritive pericarditis
causing sx's. Pt was transferred for further evaluation of this.
.
On arrival to [**Hospital1 18**], pt was brought directly to the floor. He
reported feeling slightly more dyspneic at rest than earlier in
day. His VS were 95/52, 94, 16, 98% on 4L nasal cannula. He
appeared uncomfortable breathing & had near tense ascites. This
was thought to be impairing his ventilation. He reported never
having had a paracentesis. The decision was made to perform
diagnostic and therapeutic paracentesis. His most recent labs
from OSH were reviewed, with INR of 1.95, plt 180, crt 2.3 and
normal LFTs.
The patient underwent a 4.3L paracentesis with fluid sent for
diagnostic studies (serosanguinous fluid removed). The pt
reported some improvement in his dyspnea following the
procedure.
.
On review of systems, pt notes occasional pleuritic CP with deep
breath. Pt has significant LE edema at baseline. No orthopnea,
actually pt reports feeling better while laying flat. Decreased
exercise tolerance, particularly as his abd girth has enlarged.
He reports no yellowing of skin, light colored stool, abdominal
pain, or pruritis. No n/v. No fevers/chills. He denies any prior
history of stroke, TIA, deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. He denies
recent fevers, chills or rigors. Cardiac review of systems is
notable for absence of palpitations, syncope or presyncope.
All of the other review of systems were negative.
Of note, pt had not been taking home meds prior to presentation
to OSH since he cannot afford his to pay for his meds as he has
gone over his insurance plan's cap for medication spending.
Past Medical History:
- Coronary artery disease w/ stent to PDA & D1 in [**4-1**] per
notes; From [**2135-6-8**] cath at [**Hospital3 17921**] Center the pt has a
"R dominant system, distal LAD w/ severe atherosclerosis, first
diag w/ mild atherosclerosis, circ w/ mild atherosclerosis at
OM1, 60% PDA lesion w/ patient D1 stent. Last cath in
[**12-4**]-->stent to RPL1 and right PDA.
- Atrial fibrillation/flutter s/p ablation of flutter in [**4-1**]
- s/p full EP study at oSH w/ no inducible V tach (done after pt
had NSVT)
-CHF w/ EF 40-45%, nml RV function (per OSH note)
- H/o ascites (confirmed on prior abd u/s & CT scan per OSH
notes: pt hospitalized in [**12-4**] w/ mod ascites, mod L sided
effusion & small R pl effusion. Reportedly no evidence of
cirrhosis on imaging & no splenomegaly)
- H/o LE edema
- H/o Diabetes Mellitus
- Hyperlipdemia
- Obstructive sleep apnea on CPAP
- GERD-->reportedly confirmed w/ EGD
- Lumbar disc disease
- L ear hearing loss
- L sided retinal vein occlusion in [**2126**]
- Chronic adnemia (has had endocsopy in past--unclear results)
- S/p Abd hernia repair
Social History:
Married lives with wife in [**Name (NI) 3844**]. Former tracker truck
driver, now retired. Previously heavy drinker; though has not
drank for over 15years. No h/o tobacco use. No IVDU.
Family History:
Mother had h/o premature coronary artery disease--had MI in her
40s.
Physical Exam:
VS - 98.8, 95/52, 94, 12, 97% on 4L
(manual BP: L arm 94/50 & R arm 92/55; pulsus of 10mmhg)
Gen: obese man, appears to be in mild distress, though answering
all questions appropriately & a&o x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Large neck. Unable to assess level of JVP due to size of
neck.
CV: IRRG, IRRG, normal S1, S2. ? 2/6 SEM. No thrills, lifts.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were slightly labored. Crackles anteriorly & posteriorly, though
posterior exam limited.
Abd: Distended, large amount of shifting fluid. No HSM or
tenderness.
Ext: [**12-31**]+ pitting edema b/l lower exts. Mild stasis dermatitis.
Skin: warm, dry
Pertinent Results:
EKG demonstrated low voltages, afib w/ average ventric response
of 100bpm, LAD, poor R wave progression, TWI in aVL & flattening
in I. No prior to compare with.
.
Stress MIBI performed on [**6-1**] at [**Hospital3 17921**] Center
demonstrated: mild global hypokinesis, EF 45%, and no evidence
of ischemia
.
CXR (portable) [**2136-9-25**]) -- Two frontal views of the chest were
obtained. Low lung volumes are noted. A left retrocardiac
opacity is noted. In addition there is a well-circumscribed
round opacity at the right base seen on one image. The right
lung is otherwise clear. There is prominence of the pulmonary
vasculature that is slightly indistinct with associated cephalad
re-distribution suggestive of underlying pulmonary edema. There
is soft
tissue fullness within the AP window. This may be exaggerated
secondary to the patient's low lung volumes however cannot
exclude underlying lymphadenopathy and/or mass. The bony thorax
is grossly intact.
IMPRESSION:
1. Mild pulmonary edema.
2. Left retrocardiac opacity likely secondary to underlying
atelectasis and a small-to-moderate sized effusion, difficult to
exclude pneumonia.
3. Fullness within the AP window concerning for underlying
lymphadenopathy. Consider CT for further evaluation.
4. Right basilar rounded opacity. Again this can be further
characterized with a chest CT.
.
TTE Conclusions
The left atrium is mildly dilated. The estimated right atrial
pressure is >20 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is moderate global
left ventricular hypokinesis (LVEF = 35 %). Right ventricular
chamber size is mildly dilated with moderate global free wall
hypokinesis. 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 structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Symmetric left ventricular hypertrophy with normal
cavity size and moderate biventricular global hypokinesis. Mild
mitral regurgitation. Pulmonary artery systolic hypertension.
In the absence of a history of systemic hypertension, an
infiltrative process (e.g., amyloid) should be considered.
.
CARDIAC CATH:
1. Selective coronary angiography revealed a right dominant
system with
patent LMCA. LAD nad LCX had only mild disease. RCA had mild to
moderate
disease.
2. Left vetriculography was deferred given renal insufficiency.
3. Hemodynamic assessment revealed near equalization of the
right and
left sided filling pressures. There was no respiratory variation
in the
RA pressure or RVEDP. RA tracing had prominent X and Y descents.
There
was discordance with respirations between RV and LV pressures
consistent
with contriction.
.
[**2136-9-25**] 05:27PM PT-19.3* INR(PT)-1.8*
[**2136-9-25**] 03:55PM GLUCOSE-103 UREA N-50* CREAT-2.5* SODIUM-137
POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-30 ANION GAP-14
[**2136-9-25**] 03:55PM ASCITES TOT PROT-4.1 GLUCOSE-121 LD(LDH)-114
AMYLASE-22 TOT BILI-0.9 ALBUMIN-2.3
[**2136-9-25**] 03:55PM ALT(SGPT)-16 AST(SGOT)-22 LD(LDH)-186 ALK
PHOS-136* TOT BILI-1.3
[**2136-9-25**] 03:55PM ALBUMIN-3.6 CALCIUM-9.5 PHOSPHATE-5.2*
MAGNESIUM-2.4 IRON-42*
[**2136-9-25**] 03:55PM calTIBC-274 FERRITIN-454* TRF-211
[**2136-9-25**] 03:55PM HBsAg-NEGATIVE HBs Ab-NEGATIVE
[**2136-9-25**] 03:55PM HCV Ab-NEGATIVE
[**2136-9-25**] 03:55PM ASCITES WBC-100* RBC-[**Numeric Identifier 3374**]* POLYS-8*
LYMPHS-29* MONOS-27* MESOTHELI-2* MACROPHAG-34*
[**2136-9-25**] 03:55PM WBC-6.5 RBC-3.58* HGB-10.2* HCT-31.5* MCV-88
MCH-28.5 MCHC-32.3 RDW-15.7*
[**2136-9-25**] 03:55PM PLT COUNT-201
Brief Hospital Course:
71yo man with a h/o CHF EF~45%, afib, CAD, & ascites, who is
transferred for evaluation of CHF & possible constrictive
pericarditis.
.
# CHF: acute on chronic, likely systolic failure. This was
likely caused by pt missing 3-4 days of his medications. Patient
given IV boluses of Lasix PRN for fluid diuresis. Right sided
heart cath showed:Selective coronary angiography revealed a
right dominant system with patent LMCA. LAD nad LCX had only
mild disease. RCA had mild to moderate disease. Left
vetriculography was deferred given renal insufficiency.
Hemodynamic assessment revealed near equalization of the right
and left sided filling pressures. There was no respiratory
variation in the RA pressure or RVEDP. RA tracing had prominent
X and Y descents. There was discordance with respirations
between RV and LV pressures consistent with constriction.
Echocardiography was suggestive of infiltration and there was
concern for an infiltrative process but a Heme-onc consult did
not feel this was consistent with amyloidosis. Further workup
as below.
.
# Ascites: pt has had ascites for at least 10 months according
to OSH notes. SAAG from tap >1.1, suggesting transudative
process. No abd discomfort. No h/o liver disease/cirrhosis.
Nml LFTs. Heavy drinker in past, but has not drank for
>15-20yr. No h/o IVDU or h/o hep B/C. Ascites likely of
cardiac origin. Serosanguinous ascitic fluid likely from
traumatic tap, cytology was negative for malignant cells and
pathology shows inflammatory cells and histiocytes. Patient
screened for hemochromatosis, and multiple myeloma. Skeletal
survey was negative. An abdominal fat pad biopsy was not
performed, and may be reconsidered as an outpatient workup.
Ceruloplasmin was slightly elevated. B2 microglobulin and
Kappa2 were pending at the time of discharge and will need to be
followed up as an outpatient.
.
# Atrial fibrillation chronic condition. Patient was continued
on b-blockade for rate control. Coumadin was held for procedure
and then restarted. Bridged with Heparin. Currently has
therapeutic INR levels.
.
#. CAD: h/o of PTCI as above. Patient was continued on
b-[**Last Name (LF) 7005**], [**First Name3 (LF) **], plavix, statin/zetia.
.
# NSVT: pt has had long h/o this, including EP study at OSH w/o
inducible VT. No h/o syncope. Patient was monitored on tele;
repleted lytes PRN. The patient was asymptomatic during all of
these episodes during this hospitalization.
.
# Renal failure: acute on chronic, though not clear what
baseline crt is. Urine lytes (fe-urea<35%) suggest pre-renal
process. Creatinine improved with diuresis, and at discharge
was 1.6.
.
# OSA: Patient continued on cpap.
.
# Pleural effusion: per OSH cxr. Patient was treated for CHF
with improvement of effusions with diuresis.
.
#. DM II: Patient was placed on an insulin sliding scale and
given a diabetic diet. He was not discharged on any medications
since his glucose levels were near normal. This will need to be
readdressed with his PCP.
.
#. Anemia: reportedly chronic. Hct in low 30s at OSH. Iron
studies consistent with anemia of chronic disease.
.
# GERD: continued PPI.
Medications on Admission:
1. demedex 50mg [**Hospital1 **]
2. aldactone 50mg daily
3. norvasc 5md daily
4. coumadin dosed to INR [**12-31**] for AFib
5. zetia 2mg daily
6. diovan 40mg daily
7. toprol xl 75mg [**Hospital1 **]
8. plavix 75mg daily
9. aspirin 81mg daily
10. Lasix 60 mg [**Hospital1 **]
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Warfarin 5 mg Tablet Sig: AS DIRECTED Tablet PO once a day: 1
tablet 6x/WK ([**Doctor First Name **]/Tu/We/Th/Fr/Sa) and 0.5 tablet Monday.
Disp:*45 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO twice a day.
Disp:*90 Tablet(s)* Refills:*2*
8. Omeprazole 20 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:
Congestive Heart Failure Exacerbation
Acute Renal Failure
Atrial Fibrillation
Discharge Condition:
Fair
Discharge Instructions:
You have been diagnosed with a worsening of your Congestive
Heart Failure. This was likely caused by abruptly stopping your
medications for the 3 days prior to comming to the hospital. Any
changes in medication should be discussed with your cardiologist
if possible. You will have a follow up apointment with your
cardiologist after you have been discharged. Your medications at
home will continue to keep removing fluid after you have left
the hospital.
During this hospitilization, you recieved a cardiac
catheterization to evalauate the function of your heart and how
well it moves blood forward. Initially it was decreased, but by
removing extra fluid it has improved.
You should return to the hospital if you again feel short of
breath, dizzy, weak, or start to retain a large amount of fluid.
Followup Instructions:
Please see your cardiologist [**Doctor First Name **]-[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 11250**] within one
week of discharge.
|
[
"427.31",
"272.0",
"780.57",
"427.1",
"250.00",
"428.23",
"414.01",
"789.59",
"599.7",
"428.0",
"V45.82",
"V15.81",
"585.9",
"403.90",
"584.9",
"285.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"54.91",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
13472, 13478
|
9102, 12240
|
330, 373
|
13600, 13606
|
5272, 9079
|
14456, 14613
|
4394, 4464
|
12566, 13449
|
13499, 13579
|
12266, 12543
|
13630, 14433
|
4479, 5253
|
238, 292
|
401, 3066
|
3088, 4172
|
4188, 4378
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,103
| 123,788
|
21877
|
Discharge summary
|
report
|
Admission Date: [**2103-6-11**] Discharge Date: [**2103-6-14**]
Date of Birth: [**2040-7-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Codeine / Vicodin
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
relapsing polychondritis w/ trach here for decannulation
Major Surgical or Invasive Procedure:
decannulation-recannulation after respiratory arrest.
History of Present Illness:
62 yr old female w/relapsing polychondritis requiring trach
since [**2103-8-23**]. presents to [**Hospital1 18**] [**2103-6-11**] from [**State **] for
decannulation.
Past Medical History:
Relapsing polychondritis
PSH: chole, tonsilectomy, trach
Social History:
Married, lives w/ husband in [**State **]. Has very supportive
daughter.
Family History:
non contributory
Physical Exam:
VS: 98.4, 130/72, 76, 16, 99%RA.
General: well appearing trach'd female sitting in w/c in NAD.
HEENT: unremarkable w/ the exception of recent decannulation of
#5 metal [**Location (un) 1661**] Trach. Stoma site covered w/ DSD.
RESP; lungs CTA bilat. no wheezes, no rhonchi.
Heart: RRR S1, S2
ABD: soft, NT, ND, +BS
Extrem: no C/C/E
Brief Hospital Course:
Pt was decannulated on [**6-11**] w/o complication until 7am on
[**2103-6-12**] when pt developed severe resp distress requiring
emergent re-intubation - unable to orally intubate d/t edema.
After multiple attempts pt's stoma was enlarged at the bedside
and a #6 shiley trach was ultimately successfully replaced . Bag
mask ventilation was maintained until secure tracheal airway was
established. Pt was in sinus tacycardia w/ adeq profusion during
event. Post event, pt was awake, alert an approp. She was
monitored in an icu bed overnoc then observed on the floor w/
stable O2 sats on room air. She was able to cough, clear and
expectorate secretions. She is very knowledgeable re: care of
her long standing trach and her family is very supportive.
There are no future plans for decannulation.
Medications on Admission:
pred 5', MTX 15 q tues, Nexium 40",actonel,dyazide 37.5',
zyrtec, singular 10', folic acid, effexor 75', skelaxin
800'''prn, duoneb"", calciumD 600''', ambien 10', xanax 0.25' ,
protonix "
Discharge Medications:
1. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
2. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
3. Zolpidem Tartrate 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. Risedronate Sodium 35 mg Tablet Sig: One (1) Tablet PO q
sunday ().
5. Methotrexate 2.5 mg Tablet Sig: Six (6) Tablet PO 1X/WEEK
(TU).
6. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
7. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO daily ().
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
11. Metaxalone 800 mg Tablet Sig: One (1) Tablet PO tid ().
12. Esomeprazole Magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a
day).
13. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Muco-Fen DM 60-1,000 mg Tablet Sustained Release 12HR Sig:
One (1) Tablet Sustained Release 12HR PO BID (2 times a day).
15. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscell. Q4-6H (every 4 to 6 hours) as needed.
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q2-4H (every 2 to 4 hours) as needed.
17. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO bid.
18. Gentamicin 0.1 % Cream Sig: One (1) Topical QD () as
needed for Tracheostomy site.
Disp:*1 * Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Relapsing Polychondritis
Resp arrest ? due to mucous plugging
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if you have any questions.
Call your pulmonologist if you develop chest pain, shortness of
breath, increased congestion.
Followup Instructions:
Call your pulmonologist for follow up.
Completed by:[**2103-6-14**]
|
[
"V55.0",
"997.3",
"733.99",
"799.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.23",
"97.37",
"31.42"
] |
icd9pcs
|
[
[
[]
]
] |
3866, 3872
|
1186, 1984
|
355, 411
|
3978, 3984
|
4224, 4294
|
795, 813
|
2223, 3843
|
3893, 3957
|
2010, 2200
|
4008, 4201
|
828, 1163
|
259, 317
|
439, 608
|
630, 689
|
705, 779
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,342
| 105,409
|
45680
|
Discharge summary
|
report
|
Admission Date: [**2113-7-27**] Discharge Date: [**2113-8-3**]
Date of Birth: [**2048-5-19**] Sex: M
Service: MEDICINE
Allergies:
Tetanus Diphtheria / Lisinopril / Mavik
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Short of breath
Major Surgical or Invasive Procedure:
ABG
History of Present Illness:
65 M with/o severe COPD and many hospialization - here with
gradually worsening shortness fof breath, at rest and worsened
with minimal exertion. No cough, chest pain, fevers. Last
discharged on [**2113-7-5**] from [**Hospital1 18**] after Rx of COPD exacerbation
and on high dose prednisone taper. He reports doing well when he
was on 60 mg --> down to 40 mg of prednisone, when he dropped
dose to 30mg / day as a part of the taper, he started getting
progressively worse in terms of breathing. Called pulmonologist
who restarted him on 60 mg prednisone. Patient noted some
improvement but still was dyspneic at rest and hence came to ER.
ROS
All other systems negative except as noted above and/or in
medical resident's note
Past Medical History:
1. Severe COPD
2. Anemia, normal C-scope
3. On home oxygen 2 liters
4. Vocal cord squamous dysplasia.
5. Hypertension.
6. Obstructive sleep apnea -->does not use CPAP.
7. Myocardial infarction diagnosed in [**2112-7-30**], as per the
patient.
8. Lower extremity venous stripping at age 28.
9. C7 neuroma.
10. History of esophageal obstruction.
11. Status post knee surgery.
12. Alcohol abuse and dependence, status post several
rehabilitation stays
13. Hospitalization [**2-4**] at [**Last Name (un) 883**] for "MRSA" --+MRSA sputum
here [**1-4**]
14. Rectus sheat hematoma
15. h/o CHF x 2 per patient with shortness of breath and leg
edema, also a/w wheezing.
Social History:
Drinks 8-10 beers per day, no history of severe withdrawals.
Smokes 2 cigarettes per day, former 80 pack year history of
smoking. He is married and lives with wife with no pets and no
drug use.
Family History:
Mother had a DVT and diabetes. Father died of coronary artery
disease at age 35.
Physical Exam:
VITALS: T 97.5, HR 90, BP 130/78, RR 20, O2 sat 95% on 2L O2
(NC)
GEN: Alert. Pleaseant man. Mildly dyspneic at rest.
Eyes: no pallor or icterus, PERRL.
ENT: Supple neck. I could not appreciate JVD, but his neck is
thick. Slight use of accessory muscles to breathe.
CV: S1, 2 - normal. No murmus/rubs or gallops.
LUNGS: Diffuse, prolonged expiratory phase with wheezing. No
crackles. Poor air entry bilaterally equal.
ABD: Obese, soft, Non-tender, non distended. Umbilical hernia.
EXT: 1+ bilateral pitting edema, periankle.
Skin - no rash/ulcer
GU - no catheter.
NEURO: Alert, oriented. Fluent speech.
Psychiatric - appropriate, [**Last Name (un) 664**]
Heme/lymph - no cervical or supra-clavicular LN.
Pertinent Results:
[**2113-7-31**] 2:51 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2113-7-31**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Preliminary):
MODERATE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. HEAVY GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
MOLD. 1 COLONY ON 1 PLATE.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- S
VANCOMYCIN------------ <=1 S
[**2113-7-27**] 7:20 pm BLOOD CULTURE VENIPUNCTURE # 2.
**FINAL REPORT [**2113-8-2**]**
AEROBIC BOTTLE (Final [**2113-8-2**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2113-8-2**]): NO GROWTH.
[**2113-7-27**] 4:35 pm BLOOD CULTURE RIGHT ARM VENIPUNCTURE.
**FINAL REPORT [**2113-8-2**]**
AEROBIC BOTTLE (Final [**2113-8-2**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2113-8-2**]): NO GROWTH.
.
CXR - No acute cardiopulmonary process including no pulmonary
edema or pneumonia
AP chest compared to [**2113-2-23**] through [**2113-7-27**] and
[**2113-7-28**].
Hyperinflation indicates COPD. There is no pneumonia or
pulmonary edema and no pleural effusion or cardiac enlargement.
[**2113-8-3**] 06:30AM BLOOD WBC-16.2* RBC-3.50* Hgb-9.6* Hct-30.0*
MCV-86 MCH-27.5 MCHC-32.1 RDW-16.7* Plt Ct-338
[**2113-7-27**] 04:35PM BLOOD WBC-10.3 RBC-3.77* Hgb-10.2* Hct-31.4*
MCV-83 MCH-27.0 MCHC-32.3 RDW-17.4* Plt Ct-533*
[**2113-7-30**] 04:40AM BLOOD WBC-20.4* RBC-3.75* Hgb-10.4* Hct-31.5*
MCV-84 MCH-27.9 MCHC-33.1 RDW-16.5* Plt Ct-437
[**2113-7-27**] 04:35PM BLOOD Neuts-92.6* Lymphs-5.0* Monos-2.2 Eos-0
Baso-0.3
[**2113-7-31**] 04:55AM BLOOD PT-11.3 PTT-23.0 INR(PT)-1.0
[**2113-8-3**] 06:30AM BLOOD Glucose-87 UreaN-24* Creat-0.9 Na-136
K-3.8 Cl-92* HCO3-40* AnGap-8
[**2113-7-27**] 04:35PM BLOOD Glucose-127* UreaN-21* Creat-0.9 Na-132*
K-4.3 Cl-92* HCO3-28 AnGap-16
[**2113-7-30**] 04:40AM BLOOD ALT-35 AST-24 LD(LDH)-261* AlkPhos-77
TotBili-0.3
[**2113-7-27**] 04:35PM BLOOD CK-MB-7 cTropnT-<0.01 proBNP-61
[**2113-8-1**] 06:35AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.8*
[**2113-7-30**] 04:40AM BLOOD calTIBC-514* Ferritn-17* TRF-395*
[**2113-7-29**] 11:09AM BLOOD Type-ART O2 Flow-2 pO2-82* pCO2-45
pH-7.41 calTCO2-30 Base XS-2 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
[**2113-8-3**] 02:13PM BLOOD Type-ART O2 Flow-2 pO2-67* pCO2-49*
pH-7.47* calTCO2-37* Base XS-10 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
[**2113-7-29**] 12:03AM URINE Hours-RANDOM Creat-119 Na-LESS THAN
[**2113-7-29**] 12:03AM URINE Osmolal-52
Brief Hospital Course:
The patient was treated for COPD exacerbation - and required [**Hospital **]
transfer to aggressive management with continous nebs. THe flare
was likely precipitated by ongoing smoking, taper of prednisone
and possible MRSA and pseudominas pneumonia vs colonization. He
was given IV steroids,Aggressive nebs, albuterol, O2. Continued
fluticasone - salmeterol, atrovent, fexofenadine, montelukast.
Evantually was changed over to prednisone. Smoking cessation
counselling was done as well. Doxycycline and levofolxacin were
started for possible lung infection. The patiet was also
diuresed in the ICU with removal of 6 liters that caused
metabolic alkalosis. The patient was advised to stop lasix and
not to resume it till seen by PCP [**Last Name (NamePattern4) **] 1 week. He likely has
Diastolic CHF and pulm HTN. Elevation of legs was recommended.
HTN was managed with verapamil at home doses.
He has iron def anemia - will defer to PCP for follow up and
furthr evaluation.
Smoking - extensively conselled about the risks of ongoing
smoking especially given that he is on home O2. He was also
advised everyone in the house should not smoke for due to fire
[**Doctor Last Name 13205**]. On buproprion. Nicotin patch was prescribed.
OSA -he is not compliant with CPAP at home. Discussed with Dr
[**Last Name (STitle) **], his pulmonologist and the plan is to see him in sleep
clinic. Dr [**Last Name (STitle) **] [**Name (STitle) **] will call patient with a pulmonary and
sleep clinics. The patient tolerated CPAP in hosp well.
DNR/ DNI as per ICU attending discussion with patient.
o not resuscitate (DNR/DNI) No shock/CPR or intubation.
Pressors/central line okay
Medications on Admission:
1. O2 tank.
2. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-31**] puff Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
3. Atrovent 0.02 % Solution Sig: 1-2 puffs Inhalation every six
(6) hours.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily). Tablet, Chewable(s)
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **].
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY
9. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID .
10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
13. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6Hours as needed for cough.
14. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Take 3 tabs daily for one week, then 2 tabs daily for
one week, then 1 tab daily after that.
15. Bupropion 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QD () as needed for smoking
cessation.
16. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY
17. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY
18. Verapamil 180 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q12H (every 12 hours)
19. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-31**] puff Inhalation
every four (4) hours.
Discharge Medications:
1. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 10 days.
[**Month/Day (2) **]:*20 Capsule(s)* Refills:*0*
2. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): for 10 days; then decrease to 55 mg PO daily for 7
days; then 50 mg po daily for 7 days; then 45 mg po daily for 7
days. Then discuss with your doctor.
[**Last Name (Titles) **]:*50 Tablet(s)* Refills:*0*
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
[**Last Name (Titles) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-31**] Sprays Nasal
TID (3 times a day) as needed.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Bupropion 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO HS (at bedtime).
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
14. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation every six (6) hours as needed for wheezing.
15. Albuterol Inhalation
16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day.
19. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Verapamil 240 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
21. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
22. Diazepam 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed for uncomfortable w/ cpap.
[**Hospital1 **]:*8 Tablet(s)* Refills:*0*
23. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
[**Hospital1 **]:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company **]
Discharge Diagnosis:
Chronic obstructive pulmonary disease exacerbation
Methicillin resistant staphylococcus and pseudomonas pneumonia
Obstructive Sleep Apnea
Congestive heart failure, diastolic; pulmonary hypertension
Metabolic alkalosis
Iron deficiency anemia
Discharge Condition:
stable
Discharge Instructions:
Return to the hospital if you notice any new symptoms of concern
to you.
Use the CPAP machine at home as instructed when you sleep.
Keep your appointments. The pulmonary doctor will call you for
an appointment with the pulmonary clinic and sleep clinic.
Take the medications as instructed.
Please discuss with your primary doctor about completely
stopping smoking.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2113-10-30**] 9:30
[**Last Name (LF) **],[**First Name3 (LF) 2946**] S. [**Telephone/Fax (1) 2205**] - [**2113-8-8**] at 11 AM.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD - ([**Telephone/Fax (1) 513**] - The doctor witll call you
with an appointment with sleep and pulmonary clinic. Please call
this number if you do not hear from them in the next 1 week.
|
[
"428.0",
"303.91",
"416.8",
"412",
"401.9",
"428.32",
"327.23",
"V09.0",
"305.1",
"276.1",
"482.1",
"276.3",
"482.41",
"280.9",
"491.21"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12005, 12050
|
6267, 7941
|
315, 320
|
12334, 12343
|
2812, 3082
|
12760, 13286
|
1990, 2072
|
9568, 11982
|
12071, 12313
|
7967, 9545
|
12367, 12737
|
2087, 2793
|
3123, 6244
|
260, 277
|
348, 1078
|
1100, 1762
|
1778, 1974
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,718
| 117,336
|
43814
|
Discharge summary
|
report
|
Admission Date: [**2119-8-21**] Discharge Date: [**2119-8-22**]
Date of Birth: [**2048-11-21**] Sex: M
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
70M who had severe headache.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This 70 year old white male is s/p aortic repair in [**2117**] and
presented to the ED with severe headache which increased with
movement of the neck. He had neck stiffness for a few days
prior to admission. When he presented to the ED his BP was
190/100.
Past Medical History:
S/p Aortic repair [**2117**] @ [**Hospital1 2025**]
?PE
Chronic AF
Gout
Hypothyroidism
^chol.
Hypothyroidism
L Rotator cuff tendonitis
s/p umbilical hernia repair
s/p appy
Social History:
Cigs: none
ETOH: none
Lives with wife.
Family History:
Unremarkable
Physical Exam:
Gen: Elderly white male in NAD
BP: 190/100, afeb, HR: 65
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+=bilat. without bruits.
Lungs: Clear to A+P
CV: IRRR without R/G, II/VI SEM
Abd: +BS, soft, nontender, no masses or hepatosplenomegaly
Ext: 2+ bil. pedal edema w/ errythema, pulses 2+=bilat.
throughout.
Neuro: nonfocal
Pertinent Results:
[**2119-8-22**] 03:28AM BLOOD WBC-9.5 Hct-33.7* Plt Ct-141*
[**2119-8-22**] 03:28AM BLOOD PT-19.4* PTT-35.9* INR(PT)-2.5
[**2119-8-21**] 05:30PM BLOOD D-Dimer-1132*
[**2119-8-22**] 03:28AM BLOOD Glucose-166* UreaN-16 Creat-1.1 Na-142
K-3.8 Cl-109* HCO3-24 AnGap-13
[**2119-8-22**] 03:28AM BLOOD CK(CPK)-30*
[**2119-8-22**] 03:28AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2119-8-22**] 03:28AM BLOOD Calcium-9.2 Phos-2.8 Mg-2.3
[**2119-8-22**] 03:33AM BLOOD Type-ART pO2-102 pCO2-37 pH-7.44
calHCO3-26 Base XS-0
RADIOLOGY Preliminary Report
CHEST (PA & LAT) [**2119-8-21**] 6:09 PM
CHEST (PA & LAT)
Reason: r/o pe
[**Hospital 93**] MEDICAL CONDITION:
70 year old man with h/a htn pmh p.e
REASON FOR THIS EXAMINATION:
r/o pe
INDICATION: 70-year-old man with headache, hypertension, and
past medical history of pulmonary embolism. Evaluate for
pulmonary embolism.
COMPARISON: None.
PA AND LATERAL VIEWS OF THE CHEST: The patient is status post
coronary artery bypass graft, with sternal wires in place. The
cardiac silhouette is slightly enlarged, with left ventricular
prominence. The aortic silhouette is extremely dilated up to 5.5
mm, concerning for aneurysm or dissection. Pulmonary vasculature
is normal. Both lungs are grossly clear, without consolidations
or effusions. The surrounding soft tissue and osseous structures
reveal degenerative changes along the thoracic spine, with mild
anterior wedging of some upper/mid thoracic vertebral bodies.
IMPRESSION: Severe dilatation of the intrathoracic aorta,
concerning for aneurysm or dissection.
These findings were called to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 7:00 p.m. on
[**2119-8-21**].
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**]
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2119-8-21**] 6:21 PM
CT HEAD W/O CONTRAST
Reason: bleed
[**Hospital 93**] MEDICAL CONDITION:
70 year old man with severe headache
REASON FOR THIS EXAMINATION:
bleed
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 70-year-old with headache.
CT OF THE BRAIN WITHOUT IV CONTRAST. No prior studies.
There is no acute intracranial hemorrhage, shift of normally
midline structures, or hydrocephalus. [**Doctor Last Name **]-white matter
differentiation appears preserved. Soft tissues and osseous
structures are unremarkable. The visualized paranasal sinuses
demonstrate minimal thickening within the ethmoid air cells.
IMPRESSION:
No acute intracranial hemorrhage.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 7853**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
DR. [**First Name (STitle) 23303**] [**Doctor Last Name **]
Approved: TUE [**2119-8-22**] 7:50 AM
RADIOLOGY Preliminary Report
CTA CHEST W&W/O C &RECONS [**2119-8-21**] 7:30 PM
CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS
Reason: R/O DISSECTION
Field of view: 41 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
70 year old man with AORTIC REPAIR AND BACK/NECK PAIN
REASON FOR THIS EXAMINATION:
R/O DISSECTION
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 70-year-old with history of prior aortic repair now
with neck and back pain.
TECHNIQUE: VCT images of the chest without IV contrast. VCT
images of the chest, abdomen, and pelvis after the
administration of IV contrast. Multiplanar reformatted images
were obtained.
No prior studies for comparison.
CT OF THE CHEST PRE- AND POST-IV CONTRAST: There are no pleural
effusions. Several small shoddy lymph nodes are seen within the
mediastinum and both axilla. No pathologically enlarged lymph
nodes are identified. Lung window images demonstrate bibasilar
atelectasis. There is also a small ill-defined nodule measuring
approximately 7 mm in the right upper lobe anteriorly. There is
no area of focal consolidation. The bronchi are patent to the
segmental level. The heart is slightly enlarged. The pericardium
is normal. Coronary calcifications are evident within the left
anterior descending and circumflex coronary arteries.
CT OF THE ABDOMEN POST-IV CONTRAST: 2 small hypodensities are
seen within the inferior most margin of the right lobe of the
liver, which are too small to characterize, but likely represent
cysts. The remainder of the liver is unremarkable. The spleen,
pancreas, adrenals are normal in appearance. Hypodensities are
seen within both kidneys consistent with cysts. The patient is
post cholecystectomy. The intraabdominal large and small bowel
are normal in appearance. A few small nonpathologically enlarged
lymph nodes are seen scattered throughout the abdomen. There is
no free air or free fluid.
CT OF THE PELVIS WITH IV CONTRAST: The upper pelvis was imaged.
There is no free fluid. The visualized portions of the distal
ureters are normal in appearance.
CT ANGIOGRAM: There is evidence of prior aortic surgery with
clips and what appears to be an anastomosis just superior to the
native aortic valve. No aortic graft is identified.
Calcification is seen throughout the intrathoracic aorta. There
is a dissection flap seen within the aorta, which begins in the
ascending aorta and continues into the abdominal aorta,
terminating just below the level of the renal arteries. Contrast
is seen to fill both the true and false lumens of the
dissection. Within the false lumen, contrast has a swirling
appearance. Note is made of dilation of the left coronary sinus.
The aortic branch vessels all originate from the true lumen, and
there is no evidence of extension of the dissection into the
branch vessels. The left common carotid is noted to be quite
tortuous at its origin. The descending thoracic aorta is
markedly narrowed in its distal portion just above the
diaphragmatic hiatus, where it measures 11 mm in transverse
diameter.
Contrast enhancement is seen within the celiac, superior
mesenteric, and renal arteries. The celiac artery is stenotic,
and there is post stenotic dilation. The superior mesenteric
artery is normal in appearance. There are 3 right-sided renal
arteries and 2 left-sided renal arteries, all of which originate
from the true lumen and demonstrate contrast enhancement. Both
iliac arteries are aneurysmal in appearance. The left iliac
artery measures 3.4 cm in greatest transverse diameter, and the
right iliac artery measures 2.1 cm in greatest transverse
diameter. Calcification is seen throughout the intraabdominal
aorta and the iliac arteries.
There is no evidence of pulmonary embolus.
The soft tissues are normal in appearance. The osseous
structures demonstrate degenerative changes throughout the
thoracic and lumbar spine. In addition, severe degenerative
changes are seen within the left shoulder joint. Bridging
osteophytes are seen around both sacroiliac joints.
Multiplanar reformatted images confirm the above findings. MPR
grade value III.
IMPRESSION:
1. There is evidence of prior aortic surgery as documented
above. No aortic graft is identified, and there is an extensive
aortic dissection beginning in the ascending aorta and extending
into the infrarenal abdominal aorta. Enhancement is seen within
both the true and false lumen. This likely represents
fenestration during prior dissection repair. It is unable to
assess the degree, and extent of the dissection without
comparison examinations. However, the branch vessels from the
aortic arch as well as the renal arteries, celiac, and superior
mesenteric arteries all originate from the true lumen and are
patent.
2. Dilation of the left sinus of Valsalva.
3. Stenosis at the origin of the celiac artery with
post-stenotic dilation.
4. Bilateral iliac artery aneurysms, left greater than right.
5. Right upper lobe ill-defined nodular density. Comparison with
prior examinations is recommended. If no examinations are
available, this nodule should be followed up.
If available, outside prior CT examinations should be obtained
for comparison.
The above findings were reviewed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the
completion of the examination.
DR. [**First Name (STitle) 7853**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**]
RADIOLOGY Preliminary Report
CTA ABD W&W/O C & RECONS [**2119-8-21**] 7:30 PM
CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS
Reason: R/O DISSECTION
Field of view: 41 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
70 year old man with AORTIC REPAIR AND BACK/NECK PAIN
REASON FOR THIS EXAMINATION:
R/O DISSECTION
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 70-year-old with history of prior aortic repair now
with neck and back pain.
TECHNIQUE: VCT images of the chest without IV contrast. VCT
images of the chest, abdomen, and pelvis after the
administration of IV contrast. Multiplanar reformatted images
were obtained.
No prior studies for comparison.
CT OF THE CHEST PRE- AND POST-IV CONTRAST: There are no pleural
effusions. Several small shoddy lymph nodes are seen within the
mediastinum and both axilla. No pathologically enlarged lymph
nodes are identified. Lung window images demonstrate bibasilar
atelectasis. There is also a small ill-defined nodule measuring
approximately 7 mm in the right upper lobe anteriorly. There is
no area of focal consolidation. The bronchi are patent to the
segmental level. The heart is slightly enlarged. The pericardium
is normal. Coronary calcifications are evident within the left
anterior descending and circumflex coronary arteries.
CT OF THE ABDOMEN POST-IV CONTRAST: 2 small hypodensities are
seen within the inferior most margin of the right lobe of the
liver, which are too small to characterize, but likely represent
cysts. The remainder of the liver is unremarkable. The spleen,
pancreas, adrenals are normal in appearance. Hypodensities are
seen within both kidneys consistent with cysts. The patient is
post cholecystectomy. The intraabdominal large and small bowel
are normal in appearance. A few small nonpathologically enlarged
lymph nodes are seen scattered throughout the abdomen. There is
no free air or free fluid.
CT OF THE PELVIS WITH IV CONTRAST: The upper pelvis was imaged.
There is no free fluid. The visualized portions of the distal
ureters are normal in appearance.
CT ANGIOGRAM: There is evidence of prior aortic surgery with
clips and what appears to be an anastomosis just superior to the
native aortic valve. No aortic graft is identified.
Calcification is seen throughout the intrathoracic aorta. There
is a dissection flap seen within the aorta, which begins in the
ascending aorta and continues into the abdominal aorta,
terminating just below the level of the renal arteries. Contrast
is seen to fill both the true and false lumens of the
dissection. Within the false lumen, contrast has a swirling
appearance. Note is made of dilation of the left coronary sinus.
The aortic branch vessels all originate from the true lumen, and
there is no evidence of extension of the dissection into the
branch vessels. The left common carotid is noted to be quite
tortuous at its origin. The descending thoracic aorta is
markedly narrowed in its distal portion just above the
diaphragmatic hiatus, where it measures 11 mm in transverse
diameter.
Contrast enhancement is seen within the celiac, superior
mesenteric, and renal arteries. The celiac artery is stenotic,
and there is post stenotic dilation. The superior mesenteric
artery is normal in appearance. There are 3 right-sided renal
arteries and 2 left-sided renal arteries, all of which originate
from the true lumen and demonstrate contrast enhancement. Both
iliac arteries are aneurysmal in appearance. The left iliac
artery measures 3.4 cm in greatest transverse diameter, and the
right iliac artery measures 2.1 cm in greatest transverse
diameter. Calcification is seen throughout the intraabdominal
aorta and the iliac arteries.
There is no evidence of pulmonary embolus.
The soft tissues are normal in appearance. The osseous
structures demonstrate degenerative changes throughout the
thoracic and lumbar spine. In addition, severe degenerative
changes are seen within the left shoulder joint. Bridging
osteophytes are seen around both sacroiliac joints.
Multiplanar reformatted images confirm the above findings. MPR
grade value III.
IMPRESSION:
1. There is evidence of prior aortic surgery as documented
above. No aortic graft is identified, and there is an extensive
aortic dissection beginning in the ascending aorta and extending
into the infrarenal abdominal aorta. Enhancement is seen within
both the true and false lumen. This likely represents
fenestration during prior dissection repair. It is unable to
assess the degree, and extent of the dissection without
comparison examinations. However, the branch vessels from the
aortic arch as well as the renal arteries, celiac, and superior
mesenteric arteries all originate from the true lumen and are
patent.
2. Dilation of the left sinus of Valsalva.
3. Stenosis at the origin of the celiac artery with
post-stenotic dilation.
4. Bilateral iliac artery aneurysms, left greater than right.
5. Right upper lobe ill-defined nodular density. Comparison with
prior examinations is recommended. If no examinations are
available, this nodule should be followed up.
If available, outside prior CT examinations should be obtained
for comparison.
The above findings were reviewed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the
completion of the examination.
DR. [**First Name (STitle) 7853**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**]
Brief Hospital Course:
This 70 year old male was admitted to the CSRU from the ED and
was evaluated by cardiac surgery, vascular surgery, and
cardiology. He was started on Labetolol and his HR blocked to
the 50's, so he was changed to Nipride and Cardene. His BP
decreased to the 120's. His films were reviewed by Dr.
[**Last Name (STitle) 1290**] and he spoke with Dr. [**Last Name (STitle) 40858**] who wanted to tx.
him to [**Hospital1 2025**].
Medications on Admission:
Coumadin
Zocor
ASA
Levoxyl
Allopurinol
Proscar
Amoxicillin (for ? leg cellulitis).
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
5. Nitroprusside Sodium 25 mg/mL Solution Sig: 0.3 mg/kg/hr
Intravenous TITRATE TO (titrate to desired clinical effect
(please specify)).
6. Nicardipine 2.5 mg/mL Solution Sig: Three (3) mg/kg/min
Intravenous INFUSION (continuous infusion).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Thorocoabdominal aortic dissection
s/p aortic repair
chronic Afib
Gout
^chol.
Hypothyroidism
L rotator cuff tendonitis
s/p umbilical hernia repair
s/p appy
Discharge Condition:
Fair.
Discharge Instructions:
Tx to acute facility.
Tx to acute facility.
Followup Instructions:
Transfer to Dr. [**Last Name (STitle) 40858**] at [**Hospital1 2025**]
Completed by:[**2119-8-22**]
|
[
"274.9",
"V45.81",
"442.2",
"244.9",
"441.03",
"401.9",
"427.31",
"272.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
16448, 16463
|
15288, 15717
|
325, 332
|
16663, 16670
|
1322, 1940
|
16762, 16864
|
886, 900
|
15850, 16425
|
9963, 10017
|
16484, 16642
|
15743, 15827
|
16694, 16739
|
915, 1303
|
257, 287
|
10046, 15265
|
360, 619
|
641, 814
|
830, 870
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,536
| 188,154
|
39316
|
Discharge summary
|
report
|
Admission Date: [**2156-6-9**] Discharge Date: [**2156-6-23**]
Date of Birth: [**2079-12-29**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Digoxin / Nitrate / Dioxyline Phosphate /
Irbesartan / Ethaverine / Nylidrin / Papaverine
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
UGI bleed
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
Picc line was placed and removed because of clot
History of Present Illness:
76 y/o F with hx of ischemic colitis with R colectomy, carotid
endarterectomy, CAD s/p CABG, COPD, and DM who presented to AJH
on [**5-21**] with abdominal pain, nausea and vomiting. Initially, she
had a CT scan on presentation which was interpreted as ischemic
colitis. Her WBC was 16. She was started on zosyn. In the ED,
she was hypotensive and admitted to the ICU where she was fluid
resuccitated and treated conservatively with TPN and bowel rest.
.
On [**5-23**], she was started on steroids for COPD exaccerbation and
with diuretics for possible CHF exaccerbation. Her breathing
improved. She was continued on the above management with zosyn
and supportive care. Her hemodynamics stabalized and she was
admitted to the floor.
.
On [**5-31**] she was noted to be more lethargic. She had a relative
bandemia and her zosyn was switched to imipenem, levaquin and
vanco. A c.diff was checked and was positive. Her antibiotics
were stopped and she was switched to IV flagyl and PO vanco. She
again stabalized on the floor.
.
On [**6-9**] She was noted to have melena. Her baseline hct of around
30 had trended down to 19.3. The trend was 31 --> 30.2 --> 28.6
--> 25.1 --> 19.3. She then had a endoscopy via GI which
revealed a duodenal clot concerning for ulcer vs. aorto-enteric
fistula. She had her hct checked again at 5 pm which was stable
at 19.5 She then received her first blood transfusion after that
hct check because she had been a hard cross-match due to
antibodies. She received a second unit while en-route here. On
arrival, she was T 98.0, BP 115/57, P 115, R 20, 98% on RA. She
denied abdominal pain, nausea, vomiting, shortness of breath,
chest pain, dizziness, lightheadedness. She felt generalized
weakness and pain in her bilateral legs all over, consistent
with arthritic pain.
Past Medical History:
Ischemic Colitis s/p R colectomy ([**2155-8-28**])
CAD s/p CABG
Afib
SVT s/p ablation
PPM
COPD
DM
Carotid Endarterectomy
PVD
HTN
Hyperlipidemia
CKD baseline Cr 1.1
Social History:
Lives in [**Location **]; quit smoking in [**2125**] after 5 pack yr history;
rarely drinks etoh.
Family History:
Pt father died of heart disease at age 42. Said he had a large
heart and not sure exact cause of death. Mother died of
meningitis (age could not remember), Both sister died - had
heart disease and DM.
Physical Exam:
Vitals: Tm -99.3, Tc 98.4, BP-127/42 (98-130/42-70), 98
(94-119), 96% RA
I/O [**Telephone/Fax (1) 86942**]
Length of stay: -1L
Physical Exam:
Gen. Patient lying in bed, lethargic, difficult to open eyes
and slow to respond
HEENT: EOMI, sclera anicteric, dried scaling lips, oral mucosa
moist, no lesions or ulcers
Neck: supple, no JVD, no LAD, skin tag at base of left neck
Lungs: rhonchi in posterior lung fields b/l with more aeration
on the left
CV: NSR auscultated, nlS1S2, no S3S4, no m/r/g
Abd: +BS, soft, tender to deep palpation in RLQ and LLQ.
Ext: Bruises on L arm, 2+ pulses in all extremities b/l, [**12-31**]+
pitting edema in lower extremities as seen when pneumo boots
removed, all extremities warm to touch.
Neuro: CN III-XII intact (did not have light to assess CN II),
senstation intact in all extremities, did not assess muscle
strength, but pt had trouble turning over for lung exam.
Pertinent Results:
[**2156-6-10**] 12:50AM BLOOD WBC-4.9 RBC-3.29* Hgb-9.1* Hct-26.8*
MCV-82 MCH-27.8 MCHC-34.1 RDW-18.8* Plt Ct-209
[**2156-6-10**] 06:36AM BLOOD Hct-24.9*
[**2156-6-10**] 08:03AM BLOOD WBC-4.4 RBC-3.27* Hgb-9.4* Hct-27.1*
MCV-83 MCH-28.6 MCHC-34.6 RDW-19.3* Plt Ct-182
[**2156-6-10**] 12:10PM BLOOD WBC-4.1 RBC-3.79* Hgb-10.3* Hct-31.2*
MCV-82 MCH-27.2 MCHC-33.0 RDW-18.8* Plt Ct-200
[**2156-6-10**] 05:42PM BLOOD WBC-4.6 RBC-3.91* Hgb-10.6* Hct-32.2*
MCV-82 MCH-27.2 MCHC-33.1 RDW-19.1* Plt Ct-204
[**2156-6-11**] 01:29AM BLOOD WBC-5.6 RBC-3.68* Hgb-10.5* Hct-30.1*
MCV-82 MCH-28.4 MCHC-34.7 RDW-19.3* Plt Ct-195
[**2156-6-12**] 04:42AM BLOOD WBC-4.0 RBC-3.18* Hgb-9.1* Hct-26.9*
MCV-85 MCH-28.6 MCHC-33.8 RDW-19.5* Plt Ct-158
[**2156-6-22**] 05:40AM BLOOD WBC-5.5 RBC-3.68* Hgb-10.3* Hct-31.4*
MCV-85 MCH-28.0 MCHC-32.8 RDW-16.3* Plt Ct-479*
[**2156-6-19**] 03:25PM BLOOD PT-13.8* PTT-27.0 INR(PT)-1.2*
[**2156-6-21**] 08:40AM BLOOD PT-16.5* PTT-58.3* INR(PT)-1.5*
[**2156-6-22**] 05:40AM BLOOD PT-19.0* PTT-90.5* INR(PT)-1.7*
[**2156-6-23**] 07:00AM BLOOD PT-22.2* PTT-133.4* INR(PT)-2.1*
[**2156-6-10**] 12:50AM BLOOD Glucose-237* UreaN-38* Creat-0.7 Na-132*
K-4.1 Cl-103 HCO3-25 AnGap-8
[**2156-6-13**] 05:25AM BLOOD Glucose-145* UreaN-20 Creat-0.5 Na-141
K-3.1* Cl-107 HCO3-24 AnGap-13
[**2156-6-16**] 06:58AM BLOOD Glucose-158* UreaN-7 Creat-0.5 Na-135
K-3.6 Cl-100 HCO3-26 AnGap-13
[**2156-6-22**] 05:40AM BLOOD Glucose-173* UreaN-9 Creat-0.7 Na-135
K-3.7 Cl-102 HCO3-25 AnGap-12
[**2156-6-10**] 12:50AM BLOOD ALT-30 AST-26 LD(LDH)-255* AlkPhos-52
TotBili-0.4
[**2156-6-21**] 08:40AM BLOOD Calcium-7.9* Phos-2.3* Mg-1.6
[**2156-6-22**] 05:40AM BLOOD VitB12-[**2079**]* Folate-17.7 Ferritn-754*
Imaging: [**5-21**] CT abd/pelvis:
Thickened colonic bowel is noted from the distal transverse
colon to the sigmoid colon with slight stranding elements along
the periphery and areas of fre fluid. A colitis from ischemic
could be in the differential. No free air.
.
[**5-25**] CT abd/pelvis:
Definite improvement in the areas of thickening of the colon in
the left hand side since [**5-21**]. It has not completely resolved.
Grafts extending from the aorta into both common iliac arteries,
unchanged.
.
[**5-27**] KUB:
Gaseous distension of small and large bowel loops diffusely with
slight dilation of the descending colon. Findings are more
likely on the basis of diffuse ileus pattern.
.
[**5-29**] KUB:
Interim placement of NGT with tip in upper to mid gastric body.
No significant change in the probable ileus.
.
[**5-31**] KUB:
No improvement in the probably ileus, s/p removal of NGT.
.
[**2156-6-2**] Colonoscopy:
Significant colitis in L side of colon, could be consistent with
ongoing ischmemic colitis now with chronic changes. Alternately
could be pseudomembranous colitis due to C.diff. There was no
black bowel or through-and-through intestingal ischemia
appreciated during this study.
.
[**6-9**] Endoscopy: (per written note)
Normal esophagus and stomach. No blood. In duodenal bulb there
was a large clot with adherent white material that was shiny and
plastic-like in appearance. On the opposite side of the
duodenal bulb, there was a non-eroded kissing lesion (not
bleeding). The endoscope was not advance, photos taken.
.
RUE U/S:
[**2156-6-14**]: Nonocclusive thrombus in the right axillary vein.
Likely
thrombus also seen in the right basilic vein.
[**2156-6-15**]:
Slight interval progression in degree of nearly occlusive
thrombus within the right axillary and basilic veins.
Of note, CT of [**5-25**] reviewed with radiologist and GI attending,
re-read as inflammation in the duodenal bulb/head of the
pancreas. The aortobifemoral graft is infrarenal and 8 cm away
from the bulb. Recommended transfer to tertiary care center.
Brief Hospital Course:
76 y/o F with hx of ischemic colitis, CAD, PVD, afib, COPD and
DM who is presenting with new UGIB concerning for possible
aorto-enteric fistula.
.
# UGIB: The pt experianced a Hct drop from 30 to 19 over the
course of 2 days at an OSH. She had melena and an endoscopy
concerning for duodenal ulcer vs. aorto-enteric fistula, less
likely tumor or impacted foreign body. Her Hct on transfer was
19.3. She was s/p 1u PRBCs at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and had 1 unit
hanging in transfer. A CTA abd was performed and did not reveal
an aorto-enteric fistula. On Admission, she was continued on a
protonix gtt and GI was consulted. On the day after admission
she recieved a EGD that revealed two duodenal ulcers and no
source of active bleeding. She was restarted on 81mg ASA and
continued on PPI for 72 hrs post procedure. Pt stabilized and
was transferred to the general medicine floor on the night of
[**2156-6-11**]. On the morning of [**2156-6-12**], pt had 2 large episodes of
melenic stool and Hct dropped from 31.9 to 26.9. The patient
was lethargic and unresponsive, tachycardic, but normotensive.
Because of symptoms and large drop in Hct, 2 units of blood were
ordered and given to the patient. Aspirin and metoprolol were
discontinued on [**2156-6-12**] secondary to bleed and metoprolol was
restarted on [**2156-6-14**]. After this episode the pt vitals and Hct
remained stable with slight fluctuations day to day, despite [**1-29**]
episodes of small amounts of melenic stool a day. The patient
tested positive for H. pylori and started treatment on [**2156-6-13**],
for a ten day course of triple therapy with pantoprazole 40mg
daily, amoxicillin 500mg Q12hrs and clarithromycin 500mg [**Hospital1 **].
Pantoprazole was switched to PO on [**2156-6-14**]. On [**2156-6-16**] the
patient passed her first brown stool since the episode of GI
bleed and she continued to pass brown stools for the rest of the
duration of her stay.
.
# DVT of RUE: Pt had PICC lline placed on [**2156-6-10**] for access in
the ICU. The PICC line was flushed with heparin on multiple
occasions each day, however, on [**2156-6-14**] pt and physicians
noticed that the pt's R arm was slightly more swollen than left.
A RUE US showed a non-occlusive thrombus in the axillary vein.
PICC was pulled and cultured, but repeat RUE U/S showed
worsening clot so pt was started on heparin drip on [**2156-6-15**].
Repeat hct after started of drip showed a drop in Hct of 3.5,
but VS were stable and so pt was not tranfused. Pt monitored
closely and remained stable. The patient began a bridge to
warfarin on [**2156-6-17**] starting at a dose of 0.5mg as per pharmacy
because of warfarin interaction with flagyl and clarithromycin.
Pt INR at time of discharge was 2.1 at a dose of 2mg daily. Pt
needs to continue heparin bridge until 48 hours after pt is
therapuetic.
# C.diff: Pt came with a positive test for C. diff and was
started on vancomycin and flagyl, but Vancomycin was
discontinued because of ileus. On transfer a repeat C. dif
toxin A and B were done and they came back negative. However,
treatment course was continued. Pt had diarrhea throughout
course of stay and on [**2156-6-22**] another C Dif assay was sent and
came back negative. Pt received flagyl throughout her stay at
the hospital and vancomycin was added for increased abd
tenderness. Pt should continue to receive flagyl and vanco
until [**2156-7-6**].
.
# Ischemic Colitis: stable symptom-wise; no abdominal pain, was
stable throughout treatment course.
.
# CAD: Pt had some episodes of SOB, w/o chest pain and some
evidence of pulmonary edema, but repeat EKG's showed no evidence
of acute episodes of ischemia. Aspirin was held initally, once
active bleeding was ruled out, aspirin was restarted at 81mg and
then held again when evidence of new bleed on [**2156-6-12**]. Aspirin
was restarted at time of discharge.
.
# Afib/flutter/tachycardia: likely from hypovolemia, appears to
be in aflutter at a rate around 100. On [**2156-6-14**] metoprolol was
restarted at 25mg [**Hospital1 **], which is half the dose; to help rate
control atrial fibrillation. Pt remained tachycardic and would
come in and out of a-fib. As she further stabilized her
metoprolol dose was increased to her original dose of 50mg [**Hospital1 **]
to rate control her a-fib.
.
# CHF: was being diuresed at OSH for mild failure. Pt was found
to have moderate mitral regurge and severe triscuspid
regurgitation on an ECHO done at [**Hospital1 **] on
[**2156-6-10**]. She had some mild lower extremity swelling upon
admission and Lasix was restarted [**2156-6-14**] at 40mg PO daily, but
patient put out over 3L in one day and so it was decreased to
20mg PO daily on [**2156-6-15**] and pt put out the desired 1-2L per
day. Pt edema resolved on that dose and the medication was
continued for maintenance of her fluid.
.
# Depression: Likely secondary to her disease process and
prolonged hospital stay, Ms. [**Known lastname **] became increasingly sad and
disheartened by her slow progress. Multiple individuals
including the nurses, aids, medical student, physicians and
chaplan spoe with her, listened to her issues and consoled her
as well as encouraged her. She has not improved at time of
discharge and psychotherapy related to chronic disease could be
beneficial in the future.
.
# COPD: stable, breathing well on room air. Was being treated
with a steroid taper at the OSH, but per nursing, had been off
for a few days. pt was started on home meds. She had episodes
of respiratory discomfort, but never had any respiratory
distress of COPD exaceerbations during her hospital stay.
.
# DM: has been hyperglycemic at OSH, unclear exactly what doses
of insulin she had been on. Her sugars were high in the unit,
but have been well controlled while on the general medicine
floor.
.
Ms. [**Known lastname **] has had a long tenuous and traumatic hospital course
complicated by many events. She has been through a lot and has
gradually improved and from a medical standpoint is ready for
discharge from this hospital in order to go to an extended care
facility for close monitoring and intensive rehab therapy.
Medications on Admission:
Diltiazem CD 120 mg daily
Furosemide 20 mg daily
KCL 20 meq daily
Simvastatin 40 mg daily
Calcium Carbonate 600 mg daily
Ferrous Sulfate 325 mg daily
Discharge Medications:
1. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
[**11-29**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
2. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for pain.
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
4. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation QID (4 times a day).
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheeze.
6. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Furosemide 20 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).
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day) as needed for hypertension.
10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: pt was originally on 5mg of warfaring, but lowered dose
because of interaction with flagyl and clarithromycin. No
longer taking clarithromycin.
11. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 14 days: Until [**2156-7-6**].
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for yeast: Apply to backside and under
breasts.
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three
times a day for 14 days.
15. Heparin Sliding Scale
Please continue patient on Heparin drip per sliding scale for at
least one day following therapeutic INR (goal [**12-31**])
Current infusion rate 250 units per hour
If PTT <40: please give 500 units Bolus, then Increase infusion
rate by 225 units/hr
If PTT 40 - 50: please give 500 units Bolus, then Increase
infusion rate by 100 units/hr
If PTT 50-80: continue rate
If PTT 81-100: Reduce infusion rate by 100 units/hr
If PTT >100: Hold 60 mins, then Reduce infusion rate by 300
units/hr
16. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Primary diagnosis
Upper Gastrointestinal bleed
Right upper extremity deep vein thrombosis
Secondary diagnosis:
Ischemic Colitis s/p R colectomy ([**2155-8-28**])
Coronary artery disease s/p Coronary Artery Bypass Graft
Atrial fibrillation
Chronic Obstructive Lung Disease
Diabetes Mellitus
Hypertension
Hyperlipidemia
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 are being discharged from the hospital because you are
medically stable. You were admitted to [**Hospital1 827**] on [**6-9**] after you were transferred from [**Hospital 39437**] hospital. You initially were admitted to the ICU and
then transferred to the general medicine floor where you
gradually improved and are now ready to be discharged to an
extended care facility in order to help you regain your
strength.
You came to the hospital because you had lost lots of blood and
they found that you had a bleed in your intestine. While you
were here, you received multiple blood transfusions because of
blood loss in the GI tract. You had an endoscopy that revealed
2 ulcers in the duodenum. Over the course of your stay you
slowly improved and your blood levels are now stable. You were
also found to have H. Pylori, a bacteria that contributes to
ulcer formation. this bacteria is common and we are currently
treating you for this with medication.
Also in the outside hospital you tested positive for a bacteria
that can cause diarrhea. We are treating you for this bacteria
and will continue to do so after your discharge from the
hospital.
During your stay, while you had the PICC line in your right arm,
we noticed your right arm was a little larger than the left arm.
Ultrasound showed that the line was clogged and we removed the
line, but repeat ultrasound showed that there was a worsening
clot and so we had to start you on blood thinners. Initially we
started you on IV blood thinners, but have since switched you to
coumadin so you can take it by mouth. We will send you home on
coumadin and you will be closely followed as there is an
increasd risk of bleeding while on this medication.
While you were here there were some changes to your medication
as a result of the bleed.
The following meds were changed:
warfarin 5mg --> warfain 2mg daily
The following meds are new:
Vancomycin Oral Liquid 125 mg PO/NG Q6H (until [**2156-7-6**])
MetRONIDAZOLE (FLagyl) 500 mg PO/NG TID (until [**2156-7-6**])
Acetaminophen 650 mg PO/NG Q6H:PRN
Miconazole Powder 2% 1 Appl TP QID:PRN
Pantoprazole 40 mg PO Q12H
Heparin drip at 250units per hour
The following meds were not changed:
Albuterol Inhaler 2 PUFF IH Q4H:PRN
Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
Furosemide 20 mg PO/NG DAILY
Metoprolol Tartrate 50 mg PO/NG [**Hospital1 **]
Rosuvastatin Calcium 40 mg PO DAILY
Aspirin 81mg daily
You will be sent to a Long Term Acute Care facility. Please
make and appt with your Primary Care provider at your earliest
convenience once you leave this facility as they will not
transport you to your PCP office while there.
Followup Instructions:
You will be sent to a Long Term Acute Care facility. Please
make and appt with your Primary Care provider at your earliest
convenience once you leave this facility as they will not
transport you to your PCP office while there. They will make
sure you make it to the appt below.
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2156-7-6**] at 4:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22561**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
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16621, 16621
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482, 2283
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16391, 16600
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16636, 16773
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2305, 2470
|
2486, 2585
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,067
| 112,784
|
7912
|
Discharge summary
|
report
|
Admission Date: [**2104-3-29**] Discharge Date: [**2104-5-2**]
Date of Birth: [**2043-11-1**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Vicodin / Percocet / Compazine / Percodan / Tigan /
Latex / Betadine Viscous Gauze / Protonix / Surgical Lubricant
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
"severe all over body pain"
Major Surgical or Invasive Procedure:
- Esophagogastroduodenoscopy
History of Present Illness:
60-year-old female with history of EtOH/NASH cirrhosis
complicated by ascites and encephalopathy (no known varices or
history of SBP) who presents with "severe all over body pain".
.
The patient was recently admitted for hypotension and
hyponatremia where she was found to have ESBL UTI and treated
with tobramycin/tetracycline. She was discharged to a nursing
home on [**2104-3-25**]. At the nursing home, the patient states that she
has not been taking her lactulose and has not had bowel
movements. She is confused and states she has "all over body
pain" although she is unable to describe it and unsure of if it
is different or more severe than her baseline chronic pain. She
presents to [**Hospital1 18**] for further evaluation.
.
Upon presentation to the EW, intial vitals were: T 98.2, HR 86,
BP 130/80, RR 18, SaO2 97% RA. Labs show INR 1.6, Hct 27 (near
recent baseline), LFTs okay. She is confused and has asterixis
on exam. She denies rectal. CXR with question of focal
infiltrate. KUB with dilated loops of small bowel likely
secondary to ileus (although cannot rule out obstruction).
Ultrasound with difficult anatomy and not enough ascites to
safely do diagnostic paracentesis at bedside. Recommend
ultrasound guided paracentesis. She received lactulose and was
admitted for hepatic encephalopathy treatment.
.
Currently, patient confused. Yelling at nurses and very slow
with movement. She notes chills, nausea, right upper quadrant
discomfort and diffuse pain. She is unsure if this is different
than baseline. She is unsure of her last bowel movement and is
unsure if she is taking lactulose. She denies or does not know
about other ROS.
Past Medical History:
1. Cirrhosis: thought to be secondary to EtOH use and fatty
liver disease
2. H/o pancreatitis
3. ETOH abuse
4. Cholelithiasis
5. Obesity
6. Hypothyroidism
7. Venous Insuffuciency
8. Chronic Lower extremity edema
9. Spinal Stenosis
10. Reflex Sympathetic Dystrophy
11. Hypokalemia
12. Mitral regurgitation
13. Neuropathy
14. Bilateral Hand weakness
15. Osteoporosis
16. Macrocytic anemia
17. Thrombocytopenia
18. Uterine fibroids
19. Chronic renal insufficiency
20. "tummy tuck"
21. Chronic pain: on narcotics
Social History:
Lives with her roomate. Is a former constable and volunteer
police officer. Drinks 3-4 beers/day x 12 yrs. No h/o withdrawl
szs. No tobacco or illicit drug use. Estranged from family. No
HCP, though patient believes that father or [**Name2 (NI) 8317**] [**Name (NI) **] could
be HCP.
Family History:
Aunt with cirrhosis. Mother with alcoholism.
Physical Exam:
VS: T 98.2, BP 104/66, HR 86, RR 16, SaO2 94% RA
GENERAL: yelling at nurses - "no - I want to do it my own way",
no apparent distress
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK: supple
LUNGS: limited lung volumes, bibasilar crackles, no cough,
wheezes.
HEART: RR, nl rate, I/VI murmur
ABDOMEN: obese, soft, diffuse tenderness no rebound or guarding,
decreased bowel sounds
EXTREMITIES: Warm, LE edema 2+
SKIN: Stasis dermatitis bilateral lower extremities, multiple
ecchymotic lesions, rash right forearm
NEURO - awake, A&Ox2 (name and hospital, wrong day, month,
unsure of year) unwilling to participate in neuro examination,
very upset when asked to participate, emotionally labile. +
asterixis.
Pertinent Results:
Labs on Admission:
[**2104-3-29**] 06:54PM COMMENTS-GREEN TOP
[**2104-3-29**] 06:54PM GLUCOSE-89 LACTATE-1.4 NA+-131* K+-3.5
CL--97* TCO2-26
[**2104-3-29**] 06:50PM UREA N-10 CREAT-1.0
[**2104-3-29**] 06:50PM estGFR-Using this
[**2104-3-29**] 06:50PM ALT(SGPT)-15 AST(SGOT)-22 LD(LDH)-227 ALK
PHOS-61 TOT BILI-1.9*
[**2104-3-29**] 06:50PM LIPASE-14
[**2104-3-29**] 06:50PM CALCIUM-9.3 PHOSPHATE-3.9# MAGNESIUM-1.5*
[**2104-3-29**] 06:50PM WBC-5.7 RBC-2.43* HGB-9.1* HCT-27.0* MCV-111*
MCH-37.7* MCHC-33.9 RDW-16.1*
[**2104-3-29**] 06:50PM NEUTS-62.6 LYMPHS-23.1 MONOS-8.5 EOS-4.9*
BASOS-0.9
[**2104-3-29**] 06:50PM PLT COUNT-148*
[**2104-3-29**] 06:50PM PT-17.8* PTT-37.0* INR(PT)-1.6*
Labs on Discharge:
131 95 5
------------<98
3.1 31 0.8
Microbiology:
[**2104-3-30**] 10:57 am URINE Source: CVS.
**FINAL REPORT [**2104-3-31**]**
URINE CULTURE (Final [**2104-3-31**]):
YEAST. >100,000 ORGANISMS/ML..
[**2104-4-3**] 3:23 pm URINE Source: CVS.
**FINAL REPORT [**2104-4-6**]**
URINE CULTURE (Final [**2104-4-6**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
YEAST. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 1 S
NITROFURANTOIN-------- 64 I
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
[**2104-4-17**] 11:03 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2104-4-22**]**
GRAM STAIN (Final [**2104-4-17**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2104-4-22**]):
Commensal Respiratory Flora Absent.
ESCHERICHIA COLI. RARE GROWTH.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
YEAST. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
[**2104-4-29**] 9:39 am URINE NO GROWTH.
Imaging:
- CHEST (PA & LAT) Study Date of [**2104-3-29**] 7:11 PM
IMPRESSION: Markedly limited study. Question increased density
at the medial right lung base. This could represent
superimposition of normal structures crowded by significant
volume loss, however focal infiltrates cannot be entirely
excluded.
- PORTABLE ABDOMEN Study Date of [**2104-3-30**] 9:07 AM
IMPRESSION: Two frontal views of the supine abdomen show
disproportionate
dilatation of the stomach and proximal small bowel with respect
to relatively mild gaseous dilatation of the colon, probably the
transverse. Appearance is similar to [**3-29**]; small-bowel
obstruction must still be considered. No nasogastric tube is
seen despite severe gaseous distention of the stomach.
Right lung base is elevated, probably a combination of
subpulmonic pleural
effusion and upward displacement of the diaphragm.
- CT ABD & PELVIS WITH CONTRAST Study Date of [**2104-3-30**] 2:56 PM
IMPRESSION:
1. Proximal small bowel dilatation measuring up to 3.6 cm with a
point of transition in the right lower quadrant. Imaging
findings are consistent with partial versus complete obstruction
likely on the basis of adhesions.
2. Findings of hepatic cirrhosis as on prior exams.
3. Anterior abdominal wall hernia containing mesenteric fat and
fluid.
- LUNG SCAN Study Date of [**2104-3-31**]
IMPRESSION: Underventilated triple match V/Q defect with low
probability of PE.
- UNILAT UP EXT VEINS US Study Date of [**2104-4-3**] 9:53 AM
IMPRESSION: No evidence of deep vein thrombosis in the right
arm.
- CT ABD & PELVIS WITH CONTRAST Study Date of [**2104-4-5**] 2:58 PM
IMPRESSION:
1. Stable mild dilatation of the proximal small bowel loops,
maximally measuring 3.6 cm. Distal loops appear less distended,
with possible transition point in the right lower quadrant,
likely representing mild/partial small-bowel obstruction.
2. Cirrhosis with moderate amount of abdominal and pelvic
ascites.
- CT HEAD W/O CONTRAST Study Date of [**2104-4-16**] 6:30 PM
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect. If there is
continued
concern for parenchymal abnormalities, consider MR head if not
contra-indicated.
2. Mild diffuse volume loss increased from [**2096**] CT Head study.
- PORTABLE ABDOMEN Study Date of [**2104-4-20**] 9:38 PM
IMPRESSION:
In comparison to [**2104-4-17**] exam, there is mild improvement of
ileus without
complete resolution.
- CHEST (PORTABLE AP) Study Date of [**2104-4-25**] 8:38 AM
FINDINGS: In comparison with the study of [**4-23**], the degree of
pulmonary
vascular congestion may have slightly improved. Extensive
bilateral
atelectatic changes are again seen with blunting of the
costophrenic angles
consistent with pleural fluid. Area of increased opacification
in the right
mid zone may merely represent atelectasis, though in the
appropriate clinical setting the possibility of pneumonia would
have to be considered.
Brief Hospital Course:
Summary Statement:
Ms. [**Known lastname 28445**] is a 60 year old female with a provisional diagnosis
of ETOH cirrhosis who presented from rehab after a brief
hospitalization for an MDR E.coli UTI, new diagnosis of
cirrhosis, and hyponatremia with chronic pain who was found to
have an narcotic ileus who required TPN and then was transferred
to the MICU for concern for prolonged epistaxis from presumably
NGT trauma who has remained encephalopathic with decompensated
cirrhosis, persistent ileus from administration from narcotics,
volume overload and hypoxia secondary to pulmonary edema and
atelectasis
Prior to transfer to the MICU:
1) Narcotic Ilues: Prior to admission she presented with diffuse
abdominal pain, and dilated small loops of bowl on KUB.
Subsequent Abdominal CT scans reveal potential transistion
points and partial small bowel obstruction. She also developed
non-bloody bilious emesis necessitating NGT placement and small
bowel decompression. Surgery was consulted and a small bowel
follow through revealed and an ileus that was secondary to
prolonged narcotic use for a presumed diagnosis of RSD. Her
narcotics were then stopped, but her ileus persisted which
necessitated starting TPN, and subsequently her ileus resolved
after methalynaloxone was administered. Her pain from RSD was
subsequently controlled with non-opioid analgesia including
tramadol and lyrica. Radiographs of the abdomin showed passing
of contrast from the small bowel to the colon and her nutrition
was transitioned from TPN to PO. She was tolerating PO prior to
her transfer to the MICU for epistaxis
2) Decompensated Cirrhosis: She presented with peripherial
edema ascities without evidence of encephalopathy. However, she
became mildly encephalopathic (grade I) with mild asterixis and
disorientation (date) as her ileus persisted. She was given
lactulose enemas which helped resolve her confusion. There was
also concern that she may have SBP, although she was never
febrile, and a a diagnostic paracentesis was negative.
Subsequently however, she underwent a therapeutic paracentesis
to help remove ascites (3L removed) to improve her respiratory
mechanics in addition to her ileus. She remained mildly
encephalopathic until her transfer to the MICU.
2) Volume Overload: She developed volume overload secondary to
decompensated cirrhosis and portal hypertension, ascities, and
the administration TPN in addition to IV medications and
antibiotics. She was given albumin and PRBC to maintain her MAP
to help diuresis with aldactone and lasix. Due to her UTI, and
concern for delerium, a foley was note placed to monitor UOP.
Her weights were followed to monitor her fluid balance.
3) Nutrition: Due to her inability to tolerate PO and narcotic
ileus. She was started on TPN for several days. She also
required additional potassium repletion due to diuresis for
volume overload.
4) Hyponatremia: She developed hypervolemic hyponatremia due to
decompensated cirrhosis. Her hyponatremia resolved after the
administration of diurectics and free water restriction.
5) Enterococcus/Yeast UTI. Upon admission she was noted to have
inflammation on her UA in addition to persistent yeast in her
urine and VRE. She was treated empirically for seven days for a
complicated UTI with linezolid and fluconazole. Subsequent
urine cultures were negative for persisent yeast or VRE.
6) MDR E.coli UTI: Upon admission she was completing a course of
tobramycin for an ESBL UTI, please see previous Discharge
Summary for sensitivities.
7) Anemia: The patient remained anemic on presentation and
required multiple PRBC transfusions for volume due to
hypotension secondary to decreased intravascular volume. Prior
to her transfer to the MICU she did not have evidence of active
bleeding.
MICU Course: Patient transferred to MICU given concern for
hematemesis and upper GI bleed. Was electively intubated for
EGD on [**4-16**]. EGD did not reveal presence of varices, but did
show Barrett's and gastropathy. Patient continued on famotidine
for GI ppx. There was no recurrence of hematemesis, and HCT
remained stable. Patient did develop hypotension while
intubated, likely multifactorial secondary to her underlying
cirrhosis and to sedating medications. Was briefly on pressors,
but quickly weaned off once extubated. Was successfully
extubated [**2104-4-17**]. Patient developed recurrent ileus while in
ICU; NGT kept to continuous low wall suction and patient kept
NPO. Course notable for persistent AMS, and patient was given
lactulose enemas while NPO. No evidence of infection, as
patient afebrile without leukocytosis. Diagnostic para [**4-16**]
negative for SBP.
Post MICU course
# Encephalopathy: The patient's encephalopathy continued after
she was transferred from the MICU to the floor. She was AAO x 1
with asterixis. She was treated heavily with Lactulose PO/PR,
and began to put out an appropriate amount of stool, but without
resolution of her encephalopathy. An infectious work-up with
blood, urine, and chest x-ray was negative. Opioid medications,
which were given to her in the ICU, were avoided on the floor.
The patient's encephalopathy cleared on [**2104-4-24**], when she was
AAOx3, and was following commands, but with occasional
asterixis. She no longer required restraints, and had not been
using the olanzapine which was written for her PRN for
agitation. Her encephalopathy was felt likely secondary to
lingering opioid medication, and not to hepatic encephalopathy
given her appropriate output of stool.
# Epistaxis: Upon transfer back from the ICU, the patient did
not have any signs of epistaxis, and did not require any
transfusion.
# Ileus: The patient had an ileus that was noted on abdominal
X-ray upon return from the ICU, which was felt likely secondary
to opioid medication. The patient was made NPO, and started on
metoclopromide. A few days later the patient's GI motility
started to return, and her diet was gradually advanced, and her
medications were returned to PO. Opioid medication was again
thought to play the largest role in the patient's ileus.
Metoclopromide was discontinued on patient's discharge.
# Tachypnea: The patient was noted on the floor for tachypnea
during her stay, with a normal ABG and normal O2 sats. Her
tachypnea was felt to be secondary to abdominal ascities with
ateletasis and an element of volume overload. She was treated on
the floor with IV lasix, and ultimately her O2 requirements were
removed. The patient was started on a dose of 40 mg Lasix PO BID
and her home dose of Spironolactone (50 mg Daily). She was
discharged on her home dose of 40 mg Lasix Daily and a new dose
of 100 mg Spironolactone daily without tachypnea.
# Decompensated Cirrhosis: Underlying EtOH cirrhosis. No history
of varices or SBP; EGD from [**4-16**] confirmed patient does not have
varices, and diagnostic para [**4-16**] not suggestive of SBP. The
patient was continued on Lactulose and rifaximin.
# Hypernatremia/Hyponatremia: The patient transiently became
hypernatemic with Na of 154 after diuresis, which resolved with
free water administration. On discharge she was hyponatremic
without end organ signs likely secondary to diuresis.
# Nutrition: Given resolving ileus and multiple BM, the patient
was discharged on regular diet low salt/heart healthy diet
# Pain: The patient's chronic leg and back pain had previously
been treated with opiod medication, but her hospital course was
complicated by several adverse events secondary to opioid
medication (ileus, encephalopathy). Her morphine doses were
discontinued, and the patient was started in house on standing
Tylenol for pain control.
# History of restless legs: The patient previously had been on
mirapex 1mg qhs for restless legs. This was stopped while in
the hospital, but may be restarted as needed.
Medications on Admission:
1. alendronate 70 mg PO qweekly
2. morphine 30 mg PO q12H
3. morphine 15 mg PO Q6H prn
4. omeprazole 20 mg PO DAILY
5. potassium chloride 20 mEq PO BID
6. Mirapex 1 mg PO qHS
7. trazodone 300 mg PO qHS
8. hydroxyzine HCl 25 mg PO q6H prn
9. lactulose 30ml PO TID
10. phenazopyridine 100 mg PO TID prn
11. triamcinolone acetonide 0.1 % Cream Topical [**Hospital1 **]
12. lidocaine 5 %(700 mg/patch) Adhesive Patch DAILY
13. Zofran 8 mg PO QID prn
14. Calcium Citrate + D 630-400 mg-unit PO BID
15. Vitamin D-3 1,000 unit PO DAILY
16. cyanocobalamin (vitamin B-12) 1,000 mcg PO DAILY
17. docusate sodium 100 mg PO BID
18. Centrum Silver PO DAILY
19. furosemide 40 mg PO DAILY
20. spironolactone 50 mg PO DAILY
21. rifaximin 550 mg PO BID
22. tetracycline 500 mg PO QID last day [**2104-3-31**]
23. azithromycin 250mg daily (started at rehab)
24. albuterol nebulizer (started at rehab)
Discharge Medications:
1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. potassium chloride 10 mEq Capsule, Extended Release Sig: Two
(2) Capsule, Extended Release PO twice a day.
4. trazodone 300 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
5. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for itching.
6. lactulose 10 gram/15 mL Solution Sig: Thirty (30) mL PO three
times a day.
7. phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for pain.
8. triamcinolone acetonide 0.1 % Cream Sig: One (1) application
to affected areas Topical twice a day.
9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical once a day.
10. Zofran 8 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for nausea.
11. Calcium 600 with Vitamin D3 600 mg(1,500mg) -400 unit
Capsule Sig: One (1) Capsule PO twice a day.
12. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
13. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a day.
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
15. Centrum Silver Tablet Sig: One (1) Tablet PO once a day.
16. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
17. rifaximin 550 mg Tablet Sig: One (1) Tablet PO twice a day.
18. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) puff Inhalation every 4-6 hours as
needed for shortness of breath or wheezing.
19. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: One (1) puff Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*3*
20. acetaminophen 500 mg Capsule Sig: One (1) Capsule PO every
six (6) hours.
Disp:*120 Capsule(s)* Refills:*0*
21. Artificial Tears(glycerin-peg) 1-0.3 % Drops Sig: One (1)
drop to both eyes Ophthalmic PRN as needed for dry eye.
Disp:*1 tube* Refills:*0*
22. spironolactone 100 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary Diagnosis:
- [**Female First Name (un) 564**] and VRE Cystitis
- Opioid-induced ileus
- Hepatic encephalopathy
Secondary Diagnosis:
- EtOH Cirrhosis
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:
Ms. [**Known lastname 28445**], it was a pleasure taking care of you in the
hospital. You were admitted to the hospital with diffuse body
pain. You were found to have an infection in your bladder, and
we treated you with the appropriate antibiotics. However, your
hospital course was complicated by a slow moving GI tract that
likely happened because of the high dose of narcotics which you
normally take. We confirmed that you did not have an obstruction
in your abdomen, and gave you some medications to help your gut
move along. During that time when you were not eating, we were
giving your nutrition through your veins. Also during your
hospital stay, you had started vomiting some blood; we took you
to the ICU were we put a breathing tube down your throat and
also looked at your stomach lining, where we did not see any
bleeding. We believe that your vomiting of blood may have been
blood which dripped into your stomach from your nose.
Unfortunately, when you were intubated, we needed to give you
more doses of narcotics, which caused your GI tract to slow down
again. Your gut motility improved, but you still remained a
little bit confused, which improved once the narcotics had
worked their way out of your system.
When you leave the hospital:
- STOP Morphine 30 mg every 12 hours
- STOP Morphine 15 mg every 6 hours as needed for pain
- STOP Tetracycline 500 mg four times a day
- STOP Azithromycin 250 mg every day
- STOP Mirapex 1mg before bedtime
- START Ipratropium bromide inhaler 1 puff inhalation every four
(4) hours as needed for shortness of breath or wheezing
- START Acetaminophen 500 mg every 6 hours
- START Artificial Tears(glycerin-peg) 1-0.3 % Drops: Use One
(1) drop to both eyes as needed for dry eyes
- INCREASE your dose of Spironolactone to 100 mg Daily
(previously you had been taking 50 mg Daily)
We did not make any other changes to your medications, so please
continue to take them as you normally have been.
Followup Instructions:
When you leave the hospital, please have your rehab facility
make the following appointments for you:
- Make an appointment to see your primary care doctor, Dr. [**First Name (STitle) 1022**],
one week after your discharge from rehab by calling [**Telephone/Fax (1) 250**]
Department: LIVER CENTER
When: WEDNESDAY [**2104-5-7**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"733.00",
"303.91",
"348.39",
"E937.9",
"724.5",
"285.29",
"276.1",
"530.85",
"V58.69",
"E935.2",
"278.00",
"041.04",
"595.9",
"V09.80",
"560.1",
"V85.41",
"338.29",
"572.3",
"789.59",
"537.89",
"578.0",
"799.02",
"337.20",
"729.5",
"459.81",
"E849.8",
"V64.2",
"112.2",
"571.2",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"96.71",
"38.91",
"54.91",
"96.04",
"45.13",
"38.93",
"38.97",
"00.14"
] |
icd9pcs
|
[
[
[]
]
] |
20623, 20695
|
9634, 17491
|
412, 443
|
20896, 20896
|
3780, 3785
|
23056, 23640
|
2979, 3025
|
18424, 20600
|
20716, 20716
|
17517, 18401
|
21079, 23033
|
3040, 3761
|
344, 374
|
4508, 9611
|
471, 2128
|
20856, 20875
|
20735, 20835
|
3799, 4489
|
20911, 21055
|
2150, 2661
|
2677, 2963
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,981
| 148,690
|
4746
|
Discharge summary
|
report
|
Admission Date: [**2130-7-27**] Discharge Date: [**2130-8-1**]
Date of Birth: [**2072-12-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
Pericardiectomy [**7-27**]
History of Present Illness:
57 y/o female with h/o esophageal and colon cancer s/p resection
and adjuvant therapy who was in her usual state of health until
she began to experience dyspnea on exertion in [**2127**]. Work-up
last year was notable for constrictive vs. restrictive
pericarditis.
Past Medical History:
Esophageal Cancer s/p Esophagectomy and Chemo/Rad [**2116**], Colon
Cancer s/p Colectomy and Chemo [**2119**], Pleural Effusions s/p
Thoracentesis, Esophagitis/Gastritis, Anemia, TIA [**2120**],
Pancreatitis, s/p Appendectomy
Social History:
Construction contractor. Denies ETOH use. Social ETOH use.
Family History:
No pre-mature CAD history, h/o Cancer.
Physical Exam:
Gen: A&O x 3, NAD
Skin: Unremarkable
HEENT: EOMI, PERRLA, NCAT
Neck: Supple, FROM w/ well-healed scar
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND +BS w/ well-healed scar
Ext: Warm, well-perfused 1+ edema, superficial spider veins
Neuro: Grossly intact
Pertinent Results:
[**2130-8-1**] 05:27AM BLOOD Hct-37.3 Plt Ct-308
[**2130-7-30**] 03:56AM BLOOD WBC-12.4* RBC-4.03* Hgb-11.7* Hct-35.8*
MCV-89 MCH-29.1 MCHC-32.7 RDW-15.3 Plt Ct-231
[**2130-8-1**] 05:27AM BLOOD Glucose-83 UreaN-27* Creat-0.9 Na-133
K-3.7 Cl-97 HCO3-29 AnGap-11
Radiology Report CHEST (PORTABLE AP) Study Date of [**2130-8-1**] 8:29
AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2130-8-1**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 19943**]
Reason: ptx
[**Hospital 93**] MEDICAL CONDITION:
57 year old woman s/p pericardial stripping
REASON FOR THIS EXAMINATION:
ptx
Final Report
CHEST RADIOGRAPH
INDICATION: Followup.
COMPARISON: [**2130-7-31**].
FINDINGS: As compared to the previous radiograph, the extent of
the bilateral
pneumothoraces is unchanged. There are no obvious signs of
tension. In
unchanged manner, a right-sided chest tube, whereas no chest
tube is seen in
the left hemithorax. Unchanged position of the central venous
access line,
unchanged size of the cardiac silhouette.
Brief Hospital Course:
Ms. [**Known lastname **] was a same day admit after undergoing pre-operative
work-up as an outpatient. On day of surgery she was brought to
the operating room where she underwent a pericardiectomy. Please
see operative report for surgical details. Following surgery she
was transferred to the CVICU for invasive monitoring in stable
condition. Within 24 hours she was weaned from sedation, awoke
neurologically intact and extubated. On post-op day two she was
transferred to the telemetry floor for further care. Her chest
tubes were planned to be removed but chest x-ray showed
bilateral apical pneumothoraces. They were eventually removed on
post-op day four. She worked with physical therapy for strength
and mobility. She slowly recovered and was eventually discharged
home with VNA services and the appropriate follow-up
appointments.
Medications on Admission:
Evista, Protonix, Simvastatin, Lasix, Aspirin
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. 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*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*1*
6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed.
Disp:*40 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 6136**] Home Care Services
Discharge Diagnosis:
Constrictive Pericarditis s/p Pericardiectomy
Malnutrition
PMH: Esophageal Cancer s/p Esophagectomy and Chemo/Rad [**2116**],
Colon Cancer s/p Colectomy and Chemo [**2119**], Pleural Effusions s/p
Thoracentesis, Esophagitis/Gastritis, Anemia, TIA [**2120**],
Pancreatitis, s/p Appendectomy
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain. In the event that you have drainage
from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Plavix to be taken for 3 months.
8) Call with any questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks
Dr. [**Last Name (STitle) 19944**] in [**2-26**] weeks
Dr. [**Last Name (STitle) **] in [**1-25**] weeks
Completed by:[**2130-8-1**]
|
[
"V10.05",
"263.9",
"423.2",
"E878.8",
"V10.03",
"512.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.31"
] |
icd9pcs
|
[
[
[]
]
] |
4561, 4631
|
2436, 3278
|
294, 322
|
4964, 4970
|
1296, 1862
|
5742, 5920
|
957, 997
|
3374, 4538
|
1902, 1946
|
4652, 4943
|
3304, 3351
|
4994, 5719
|
1012, 1277
|
235, 256
|
1978, 2413
|
350, 616
|
638, 865
|
881, 941
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,840
| 120,507
|
5191
|
Discharge summary
|
report
|
Admission Date: [**2157-4-5**] Discharge Date: [**2157-4-12**]
Date of Birth: [**2093-3-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
Melena, Chest Pain
Major Surgical or Invasive Procedure:
EGD [**2157-4-6**]
Bare metal stenting of proximal LAD w/ 2.75x15 vision.
History of Present Illness:
Mr. [**Known lastname 21218**] is a 64 year old male with medical history
including hypertension and GERD who was in his usual state of
health until 2 days ago. he reports sunday night that he feeled
some sensation of increasing restlessness and difficulty
sleeping although this is not that atypical for him. Monday
afternoon he had decreased appetitie but attempted to eat some
pineapple and strawberries. He felt nauseous later in the
afternoon and vomited this food up, denies identifiying blood in
his vomitus at that time. The following morning he again felt
increasingly fatigued but went to work per usual. That morning
he felt lightheaded and then had a sense of a need to pass
stool. He reports a sensation of diarrhea but saw that he had
passd what is described as black stool with halo of maroon
around it. He had two additional episodes of passing black stool
that same day with decreased volume. The patient sought care
with his PCP who confirmed guaiac positive stool and sent the
patient to [**Hospital **] hospital for further evaluation. On arrival
he reports sensation at the bottom of his sternal of
burning/pressure that was similar to episodes of what he thought
was reflux, but much more intense. He denies radiation,
nausea/diaphoresis or dyspnea with these symptoms. The patient
reports that at baseline his functional activity is limited
secondary to arthritis and obesity although he recently had an
exercise stress test with imaging that was normal per his verbal
report.
For his symptoms the patient was evaluated at an OSH with Hct of
29. NG lavage at the outside hospital was negative for bright
blood. At [**Location (un) **] he was treated with SL Nitro and Morphine and
subsequently developed hypotension which resolved wiht fluid
bolus. An ECG at the outside hospital was concerning for lateral
ST depressions although enzymes at that time were flat. The
patient was transferred to [**Hospital1 18**] for further care.
.
ED Course: In the ED the patient had vitals of 98.9 132/59 70 16
97% RA. The patient had repeat Hct which was 28 compared to 29
at OSH. Received 2U PRBCs in ED. He was given protonix IV.
Repeat cardiac enzymes now reveal elevated CK and Troponin
312/.30. The patient was seen by cardiology with impression that
he likely has a fixed circ lesion and his current NSTEMI is
secondary to demand ischemia in setting of GI bleed. The patient
reports he does not take ASA daily. He has been taking Ibuprofen
400mg daily for couple weeks for left shoulder discomfort. He
does not actively smoke or drink.
.
MICU COURSE:
.
Pt is a 64 y/o M w/ Hx of GERD, HTN, Peripheral Edema,
Obstructive Sleep apnea, COPD, w/ 20 pack year history, quit
smoking 30 years ago, who was transferred to [**Hospital1 18**] MICU for
melena/BRBPR which began on [**4-5**]. At OSH patient had "Chest
Pressure" [**8-21**], epigastric, w/ reported ST depressions on
lateral leads, but flat troponins. OSH hct 29. In MICU patient
received 3 units of packed RBCS, HCT 28=>32=>30 with the 3 units
of blood. GI has been consulted. EGD is planned for AM.
.
No more episodes of CP while in the unit. Pt is NOT on ASA,
plavix or heparin. [**4-6**] ECG, concerning for v3-v6 ST depressions
and TWI, 1mm V1 st elevation, I/AVL ST 1mm ST depressions and
TWI.
.
Patient now ruled in for an NSTEMI. See below.
[**4-5**] 9pm CK: 312 MB: 57 MBI: 18.3 Trop-T: 0.30
[**4-6**] 8am CK: 581 MB: 108 MBI: 18.6 Trop-T: 0.61
[**4-6**] 430pm CK: 678 MB: 142 MBI: 20.9 Trop-T: 0.98
.
Patients Vitals in MICU were T 97.9, HR 102 (68-107), BP
140/92(131/71-140/94), RR 12, 99% on 3L.
.
Patient arrived on the floor, and developed [**5-21**] SSCP,
nonradiating, ECG w/ and w/o pain were done, patient was given
SL NTG 0.4mg x3 relieved pain down to zero. HR 60 and BP 150/70
w/ [**5-21**] CP. CP developed after patient had repeat melanotic
stool.
Past Medical History:
#. Hypertension
#. Sleep Apnea
#. Reactive Airway Disease
#. GERD
#. OA
Social History:
The patient is employed in the security department providing
computer passwords [**Street Address(1) 17131**] Bank. He currently lives
with his wife and 27 year old son in [**Name (NI) **].
Tobacco: 50 pk-yr, quit > 30 years ago
ETOH: [**1-12**] beer/month
Illict: None
Family History:
Mother: Passed from breast CA
Father: Died age 70 from likely CAD
Physical Exam:
Vitals: 97.8 132/77 70 12 98% 2L
General: Patient is a pleasant male, obese, in NAD
HEENT: NCAT, EOMI, sclera anicteric, conjunctiva pale. OP: MMM,
no lesions
Neck: Obese, JVP not easily visualzied
Chest: Fair air movement, no rhonchi, wheezes or rales
Cor: RRR, normal S1/S2. No M/R/G
Abd: Obese, distended, soft, non-tender. + BS
Ext: trace pitting edema at ankles bilaterally
Pertinent Results:
ADMISSION LABS:
.
[**2157-4-5**] 09:45PM BLOOD WBC-12.7* RBC-3.43* Hgb-9.7* Hct-28.0*
MCV-82 MCH-28.2 MCHC-34.5 RDW-15.7* Plt Ct-207
[**2157-4-5**] 09:45PM BLOOD Neuts-82.3* Lymphs-14.7* Monos-2.8
Eos-0.1 Baso-0.1
[**2157-4-5**] 09:45PM BLOOD PT-13.3 PTT-26.0 INR(PT)-1.1
[**2157-4-5**] 09:45PM BLOOD Glucose-165* UreaN-54* Creat-1.3* Na-139
K-4.3 Cl-107 HCO3-22 AnGap-14
[**2157-4-5**] 09:45PM BLOOD CK(CPK)-312*
[**2157-4-6**] 07:53AM BLOOD ALT-20 AST-98* LD(LDH)-318* CK(CPK)-581*
AlkPhos-49 Amylase-58 TotBili-0.6
[**2157-4-6**] 07:53AM BLOOD Lipase-44
[**2157-4-5**] 09:45PM BLOOD Calcium-8.4 Phos-3.4 Mg-1.9
[**2157-4-6**] 08:20AM BLOOD Type-[**Last Name (un) **] Temp-36.1 pH-7.42
[**2157-4-6**] 08:20AM BLOOD Lactate-1.3
[**2157-4-6**] 08:20AM BLOOD freeCa-1.12
CARDIAC ENZYMES:
.
[**2157-4-5**] 09:45PM BLOOD CK-MB-57* MB Indx-18.3* cTropnT-0.30*
[**2157-4-6**] 07:53AM BLOOD CK-MB-108* MB Indx-18.6* cTropnT-0.61*
[**2157-4-6**] 04:36PM BLOOD CK-MB-142* MB Indx-20.9* cTropnT-0.98*
[**2157-4-6**] 09:49PM BLOOD CK-MB-129* MB Indx-17.5* cTropnT-1.75*
[**2157-4-7**] 05:35AM BLOOD CK-MB-92* MB Indx-16.0* cTropnT-1.78*
[**2157-4-7**] 03:20PM BLOOD CK-MB-60* MB Indx-11.0* cTropnT-2.62*
[**2157-4-9**] 05:55PM BLOOD CK-MB-6 cTropnT-2.27*
[**2157-4-11**] 05:45PM BLOOD CK-MB-4 cTropnT-1.46*
[**2157-4-12**] 07:40AM BLOOD CK-MB-4 cTropnT-1.07*
HCTs:
.
[**2157-4-5**] 09:45PM Hct-28.0*
[**2157-4-6**] 12:59AM Hct-27.7*
[**2157-4-6**] 07:53AM Hct-32.1*
[**2157-4-6**] 12:17PM Hct-32.1*
[**2157-4-6**] 04:36PM Hct-30.7*
[**2157-4-6**] 09:49PM Hct-31.5*
[**2157-4-7**] 05:35AM Hct-32.9*
[**2157-4-7**] 03:20PM Hct-33.2*
[**2157-4-7**] 09:50PM Hct-31.8*
[**2157-4-8**] 06:50AM Hct-32.6*
[**2157-4-8**] 03:05PM Hct-33.4*
[**2157-4-9**] 06:34AM Hct-32.3*
[**2157-4-9**] 05:55PM Hct-35.6*
[**2157-4-9**] 05:55PM Hct-35.6*
[**2157-4-11**] 05:45PM Hct-35.0*
[**2157-4-12**] 07:40AM Hct-33.0*
[**4-6**] CXR
.
FINDINGS: Single frontal chest radiograph examination,showing an
area of increased opacity seen projected over the right heart
border. The pulmonary vasculature is mildly prominent. The heart
size is mildly enlarged. No pleural effusion is seen.
.
IMPRESSION:
1. A focal opacity is seen projected over the right heart border
most likely in the right lung base secondary to either
atelectasis and/or aspiration however pneumonia cannot be
completely excluded since we do not have any prior
studies.Follow up exam in not less than three weeks with a
dedicated PA and lateral chest radiographs.
2. The pulmonary vasculature is mildly prominent, indicating
volume overload however no edema is noted.
[**4-6**] ECHO
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is mildly dilated.
There is mild to moderate regional left ventricular systolic
dysfunction with hypokinesis of the mid to distal antero-septum,
anterior wall and apex. There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The aortic arch is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
[**2157-4-12**] CARDIAC CATH
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed single vessel coronary artery disease. The LMCA had no
angiographically apparent flow-limiting disease. The LAD had a
90% proximal lesion and an 80% lesion of D1. The LCX and RCA
had no angiographically apparent flow-limiting stenoses.
2. Limited resting hemodynamics revealed normal systemic
arterial
pressure of 136/78 mm Hg.
3. Successful PTCA and stenting of the proximal LAD with a 2.75
x 15 mm Vision BMS which was postdilated to 3.25 at high
pressure. Final
angiography revealed no residual stenosis in the [**Month/Day/Year **], no
dissection
and TIMI III flow ([**Name (NI) **] PTCA comments)
4. Right femoral arteriotomy site was closed with a 6 French
Angioseal
device.
FINAL DIAGNOSIS:
1. Single vessel coronary artery disease.
2. Successful stenting of the proximal LAD.
[**2157-4-7**] EGD
[**2093-3-5**] (64 years) Instrument: GIF 180
ID#: [**Numeric Identifier 21219**] ASA Class: P2
Medications: Fentanyl 75 micrograms
Midazolam 2mg
Indications: Melena
GI bleed
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. The
physical exam was performed. The patient was administered
conscious sedation. The patient was placed in the left lateral
decubitus position and an endoscope was introduced through the
mouth and advanced under direct visualization until the second
part of the duodenum was reached. Careful visualization of the
upper GI tract was performed. The procedure was not difficult.
The patient tolerated the procedure well. There were no
complications.
Findings: Esophagus:
Other There were 2 sub-mucosal lesions noted in the lower third
of the esophagus, each measuring 2cm in length and were bluish-
cystic in appeareance( not classic for varices, did not extend
from GE junction and did not flatten with inflation).
Stomach:
Excavated Lesions Multiple non-bleeding erosions were noted in
the stomach body and antrum.There was no active bleeding noted.
Duodenum:
Excavated Lesions Multiple non-bleeding erosions were seen in
the duodenal bulb.
Impression: There were 2 sub-mucosal lesions, each measuring 2cm
in length and were bluish- cystic in appeareance( not classic
for varices, did not extend from GE junction and did not flatten
with inflation).These are located in the lower third of the
esophagus.
Erosions in the stomach body and antrum
Erosions in the duodenal bulb
Otherwise normal EGD to second part of the duodenum
Recommendations: 1. Continue PPI po daily
2. If ASA needs to be started for cardiac issues by tomorrow,
would add 2 weeks of Carafate 1gm po QID.
3. Avoid NSAID's.
PTCA COMMENTS: Initial angiography revealed a 90% proximal
LAD
stenosis and an 80% ostial diagonal. We planned to treat the LAD
with
PTCA and stenting. A 6 French XB LAD 3.5 guide provided good
support for
the procedure. Angiomax was used as anticoagulation. A prowater
wire
crossed the lesion with minimal difficulty. The lesion was
predilated
with a 2.0 x 12 mm Voyager balloon at 12 ATMs. A 2.75 x 15 mm
VISION BMS
was deployed in the proximal LAD at 16 ATMs. The [**Numeric Identifier **] was post
dilated
with a 3.25 x 13 mm Highsail balloon at 16 ATM three times.
Final
angiography revealed no residual stenosis in the [**Last Name (LF) **], [**First Name3 (LF) **]
unchanged
diagonal stenosis with improved flow, no dissection and TIMI III
flow.
The right femoral arteriotomy site was closed with a 6 French
Angioseal
device.
Brief Hospital Course:
Mr. [**Known lastname 21218**] is a 64 y/o M w/ a hx of GERD, OSA, CODP, who was
transferred to [**Hospital1 18**] MICU from OSH for Melena, Chest Pain and
ECG changes. Felt that GI bleed was secondary to over use of
NSAIDS (aleve). Patient was admitted to the MICU with a HCT of
28. Patient was noted to still be having melena on arrival, but
normotensive through out hospital stay. Patient was transfused 4
units of packed RBCs during his hospital stay. Patients final
hct at discharge was 33. Patient was started on IV PPI, and high
dose statin. He was transferred to general medical floor where
he developed SSCP, which resolved with sublingual NTG. Patient
ruled in for an MI during his hospital stay, felt to be a type 2
MI, MI in setting of demand ischemia. Patients hct remained
stable, he had EGD which showed erosions in esophagus, stomach,
and duodenum, no active bleeding. Patient was started on aspirin
and Sucralfate 1gm QID. He was then taken for cardiac cath where
he was found to have angiography revealing a 90% proximal LAD
stenosis and an 80% ostial diagonal. Patient received dilation
of the LAD stenosis and placement of Vision BMS. Diagonal lesion
was not approached for intervention.
.
#GI Bleed - Patient was admitted with melena. On EGD patient
noted to have multiple erosion. Hpylori was negative. Felt that
erosions were due to overzealous NSAID use. Indicated to patient
to minimize NSAID intake in the future. Patient was given
sulcralfate to take qid for 2 weeks to aid in the restoration of
his gastric mucosal lining. Patient was discharged on
pantoprazole 40mg [**Hospital1 **]. Patient informed that being on aspirin
and plavix puts him at risk of repeat GI bleed. Patient was
warned of signs and symptoms that might indicate a GI bleed.
.
#Anemia [**2-12**] GI bleed: Hct stable at 33 on day of dicharge. Pt
received 4 units of pRBCs this admission. Admission hct was 28.
.
#Type 2 MI: (Actually not ACS, likely non-thrombotic, event
rather, demand ischemia in setting of low hct, and probable CAD)
- Trop 0.30=>0.61=>0.98=>1.75=>1.78, CK 312=>581=>678=>574, MBI
20=>17=>16. Patient had lateral ST depressions on ECG prior to
cath. Patient was continued on aspirin, plavix, toprol-xl 100mg
daily and 80mg lipitor.
.
#Angina: Related to NSTEMI, TIMI score 2, Patient had episode of
SSCP [**5-21**] when he hit the floor. Patient responded to 0.4mg
SLNTG x3. No chest pain after cardiac intervention. Patient
discharged with SL NTG.
.
#Acute Systolic CHF: Depressed EF 40-45%, hypokinesis of ant
wall and septum. New wall motion abnormalities in the setting of
recent MI. Patient will need follow up TTE in [**6-20**] months.
Discharged on toprol-xl 100mg daily, lisinopril 20mg daily,
lasix 20mg daily.
.
#Reactive Airway Disease.: Patient was discharged on home
Advair.
.
#Osteoarthritis: Patient was given oxycodone for pain control.
.
#. Communication: Wife [**Name (NI) **] [**Name (NI) 21220**]
Home: [**Telephone/Fax (1) 21221**]
Cell: [**Telephone/Fax (1) 21222**]
Medications on Admission:
Atenolol 50mg daily
Lasix 20mg daily
Advair 250/50 [**Hospital1 **]
Albuterol PRN
Flomax 0.4mg
.
Allergies: NKDA
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): You must continue to take this medicaton to keep your
cardiac [**Hospital1 **] open.
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
7. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: As directed for
CP Tablet, Sublingual Sublingual As directed below for 6 doses:
Please take one pill every 5 min for chest pain for a maximum of
3 pills. Call 911 if you have chest pain. Refill after 6 months.
Disp:*6 Tablet, Sublingual(s)* Refills:*1*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. 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*
10. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 14 days: Please take for 2 weeks starting [**2157-4-12**].
Disp:*56 Tablet(s)* Refills:*0*
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed: Due not take more than 4gm per day. .
Disp:*50 Tablet(s)* Refills:*0*
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for 20 doses.
Disp:*20 Tablet(s)* Refills:*0*
14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: Take
daily.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Upper GI bleed (gastro and duodenal lesions)
2. Anemia
3. NSTEMI (in setting of demand ischemia)
4. Coronary Artery disease (LAD 90% proximal, 80% origin of
first diag. Bare metal stenting of proximal LAD w/ 2.75x15
vision, first diagnonal not approached done [**2157-4-11**]
.
Secondary
1. Hypertension
2. Sleep Apnea
3. Reactive Airway Disease
4. GERD
5. Osteoarthritis
6. Hx of Septic Arthritis L knee.
Discharge Condition:
stable, hct 33, Chest pain free.
Discharge Instructions:
Mr. [**Known lastname 21218**] you were transferred to [**Hospital1 18**] out of concern for
your dropping red blood cell counts, gastrointestinal bleeding
as well as for your chest pain and ECG changes.
.
You were monitored initially in the medical ICU. During your
hospital stay you received a blood transfusion of 4 units pRBCs.
Your blood counts were stable at discharge. You were seen by the
gastroenterologists, who completed an upper endoscopy on you.
The endoscopy showed erosions, in your esophagus, stomach and
duodenum. The GI doctors think that your lesions are from taking
to much aleve. Please do not take any more aleve or ibuprofen
for pain control. We suggest you take tylenol for pain control,
no more than 4gm per day. We have also written you for some
oxycodone for pain control. You can not drive or operate heavy
machinery if you take oxycodone. Please take every 8 hours as
needed.
You were started on a protonix and 1gm of Sucralfate 4 times a
day for 2 weeks to help protect your stomach.
.
During your hospitalization you were noted to have an Non-ST
elevation myocardial infarction. You had elevated cardiac
markers or troponins that supported this diagnosis. You had a
cardiac cath that showed to lesions in one of your cororonary
arteries The LAD had a 90% proximal stenosis and the first
Diagnonal had an 80% stenosis at the origin.
.
You had a bare metal vision [**Hospital1 **] placed in the LAD. The
cardiologists did not approach the other narrowing at this time.
You need to follow up with cardiology as below. You will need to
continue to take aspirin 162mg daily. You will also have to take
your plavix 75mg daily for at least the next 3 months probably
longer. It is essential that you continue to take this
medication. If you stop taking this medication you could form a
clot in your [**Hospital1 **] and have another heart attack.
.
You had an abnormal echocardiogram where your LV ejection
fraction was reported to be 40-45%, this is abnormal but may
recover in the future. You will need to follow up with your
cardiologist for a repeat echocardiogram in the future.
.
You were started on some other medication during your
hospitalization. You have several new medications that you
should continue to take lisinopril 20mg daily, toprol-xl 100mg
daily, and atorvastatin 80mg daily, plavix 75mg daily, aspirin
162mg daily, colace 100mg twice a day(for constipation), senna 1
tab twice daily (for constipation), 20mg PO lasix daily.
.
You are on blood thinners aspirin and plavix, in the setting of
a recent GI bleed, you are at high risk of bleeding again. It is
important that you watch for signs of bleeding, meaning looking
for black-tarry stools, bloody stools or any vomiting of blood.
.
You have been given nitroglycerin tablets. If you develop chest
pain place one of the pills under your tongue. Continue to do
this for
Please call 911 or go to the emergency room if you develop any
of the above symptoms, chest pain, shortness of breath or any
other worsening of your overall condition.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] [**Telephone/Fax (1) 13350**] in the next two weeks.
.
Please follow up with Dr. [**Last Name (STitle) **] from the department of
Cardiology at [**Hospital1 18**] pH# [**Telephone/Fax (1) 5003**] You are scheduled for an
appointment on [**2157-4-26**] at 11 am on the [**Location (un) 436**] of the
[**Hospital Ward Name 516**] [**Hospital1 18**] [**Hospital Ward Name **] building.
|
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27,423
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11113
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Discharge summary
|
report
|
Admission Date: [**2150-4-21**] Discharge Date: [**2150-4-29**]
Date of Birth: [**2092-7-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2150-4-21**] Mitral Valve Repair(30mm [**Doctor Last Name 405**] Band) and Three Vessel
Coronary Artery Bypass Grafting utilizing the LIMA to LAD, and
saphenous vein grafts to OM and PDA.
History of Present Illness:
Mr. [**Known lastname 15582**] is a 57 year old male with known coronary artery
disease. He had recent complaints of increasing dyspnea on
exertion and chest discomfort. Recent stress echo was "abnormal"
showing an LVEF of 30% with anteroapical and inferobasal
hypokinesis along with moderate to severe mitral regurgitation.
He subsequently underwent cardiac catheterization which revealed
worsening three vessel coronary artery disease. Based upon the
above, he underwent routine preoperative evaluation and was
eventually cleared for cardiac surgical intervention.
Past Medical History:
Ischemic Cardiomyopathy
Coronary Artery Disease, History of MI
Prior PCI/Stenting - BMS to LCX in [**2143**], DES to LAD [**2148**]
History of Brachytherapy in [**2144**]
Mitral Regurgitation
Hypertension
Elevated Cholesterol
Type II Diabetes Mellitus
Gout
History of Rheumatic Fever as child
Vasectomy
Tonsillectomy
Prior Abdominal Surgery/Hernia Repair
Social History:
Approximate 20 pack year history of tobacco, quit 14 years ago.
Admits to [**3-1**] ETOH drinks per day. Married and works as an
electrical engineer.
Family History:
Mother suffered MI at age 51
Physical Exam:
PREOP EXAM
Vitals: 120/85, 100, 16
General: WDWN male in no acute distress
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD
Lungs: CTA bilaterally
Heart: Regular rate and rhythm, normal s1s2, no murmur or rub
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema
Pulses: 2+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2150-4-21**] Intraop TEE:
PRE CPB - The left atrium is dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium/left
atrial appendage or the body of the right atrium/right atrial
appendage. A patent foramen ovale is present. The left
ventricular cavity is moderately dilated. There is severe global
left ventricular hypokinesis (LVEF = 20-25 %). There is some
septal hypokinesis and the anterior wall is close to being
akinetic. Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the ascending aorta.
There are simple atheroma in the aortic arch. There are focal
calcifications 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 moderately
thickened. Moderate to severe (3+) mitral regurgitation is seen.
It is centrally directed and likely due to mitral annular
dilitation.
POST CPB - The patient is receiving epinephrine, norepinephrine,
and milrinone by infusion. An intra-aortic balloon pump has been
placed with its tip 2 cm below the distal aortic arch. There is
normal right ventricular systolic function. The right ventricle,
initially, appears underfilled. The left ventricle displays more
septal dyskinesis than in the pre-CPB study. There is inferior
and inferolateral severe hypokinesis. The anterior wall function
is improved. Overall EF is still about 20-25%. A mitral valve
annuloplasty ring is in situ. It appears well seated. There is
trivial mitral regurgitation. The peak gradient across the
mitral valve is 11.5 mm Hg with a mean of 8 mm Hg.
CHEST (PA & LAT) [**2150-4-29**] 9:33 AM
CHEST (PA & LAT)
Reason: ? infiltrate
[**Hospital 93**] MEDICAL CONDITION:
57 year old man with s/p cabg mv repair
REASON FOR THIS EXAMINATION:
? infiltrate
HISTORY: CABG and MV repair.
FINDINGS: In comparison with the study of [**4-27**], the right IJ
catheter has been removed. Again there is enlargement of the
cardiac silhouette and intact multiple midline sternotomy wires.
Mild blunting of the left costophrenic angle persists.
[**2150-4-28**] 04:34AM BLOOD WBC-7.5 RBC-3.09* Hgb-8.7* Hct-25.8*
MCV-84 MCH-28.3 MCHC-33.8 RDW-14.1 Plt Ct-249
[**2150-4-29**] 05:30AM BLOOD PT-17.0* INR(PT)-1.5*
[**2150-4-28**] 04:34AM BLOOD PT-14.8* PTT-24.7 INR(PT)-1.3*
[**2150-4-29**] 05:30AM BLOOD UreaN-22* Creat-0.7 K-4.1
Brief Hospital Course:
Mr. [**Known lastname 15582**] was admitted and taken directly to the operating
room where Dr. [**Last Name (STitle) 1290**] performed coronary artery bypass
grafting and a mitral valve repair. Operative course was notable
for prophylactic placement of an IABP given his very poor
ejection fraction and severe mitral regurgitation. In addition,
he required multiple inotropes to wean from cardiopulmonary
bypass. For additional surgical details, please see seperate
dictated operative note. Following the operation, he was brought
to the CVICU in critical condition.
He remained pressor dependent and remained intubated for several
days. He maintained good urine output while on a Lasix drip.
Around postoperative day 2 to 3, developed atrial fibrillation
for which he was started on Amiodarone. Also started on broad
spectrum antibiotics for postoperative fevers associated with
copious, yellow respiratory secretions. He continued to
experience paroxysmal atrial fibrillation, but over several
days, his heart rate and hemodynamics improved. The IABP was
eventually removed without complication and pressors were
gradually weaned. Once off all inotropic support, he was
extubated on postoperative five. Sputum cultures eventually grew
out Moraxella catarrhalis for which antibiotics were titrated
accordingly. He was also noted to have a lower extremity
cellulitis and started on warm compresses. He will need a 7 day
course of ciprofloxacin for both.
He transferred to the SDU on postoperative day six. Given
postoperative atrial fibrillation, he was started on Warfarin
anticoagulation.
He did well and was ready for discharge home on POD #8.
Medications on Admission:
Aspirin 81 qd, Crestor 40 qd, Diovan 160 qd, Glucophage 1000
[**Hospital1 **], Plavix 75 qd(stopped 1 week prior), Zetia 10 qd, Lasix 20
[**Hospital1 **]
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Outpatient [**Name (NI) **] Work
PT/INR for coumadin dosing goal INR 2-2.5 for atrial
fibrillation
first draw [**5-1**] with results to Dr [**Last Name (STitle) 6955**] office # [**Telephone/Fax (1) 22629**]
fax # [**Telephone/Fax (1) 35844**]
7. 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:*0*
8. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): take 400mg twice a day for 5 days then decrease to 400mg
daily for 7 days, then decrease to 200mg daily and follow up
with Dr [**Last Name (STitle) 11493**].
Disp:*90 Tablet(s)* Refills:*0*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks: follow up with Dr [**Last Name (STitle) 11493**] prior to completing lasix.
Disp:*14 Tablet(s)* Refills:*0*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
13. 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*
14. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for
2 doses: please take 4mg daily [**4-29**] and [**4-30**] with INR check [**5-1**]
with further dosing by Dr [**Last Name (STitle) 6955**] .
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 976**] VNA Inc
Discharge Diagnosis:
Chronic Systolic Congestive Heart Failure/Ischemic
Cardiomyopathy
Mitral Regurgitation
Coronary Artery Disease, History of MI
Hypertension
Elevated Cholesterol
Type II Diabetes Mellitus
Postoperative Atrial Fibrillation
Postoperative Ventilator Associated Bacterial
Pneumonia(Moraxella)
Postoperative Lower Extremity Cellulitis
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month
Followup Instructions:
Dr. [**Last Name (STitle) 1290**] in [**5-2**] weeks, call for appt
Dr. [**Last Name (STitle) 11493**] in [**3-1**] weeks, call for appt
Dr. [**Last Name (STitle) 6955**] in [**3-1**] weeks, call for appt
PT/INR for coumadin dosing goal INR 2-2.5 for atrial
fibrillation
first draw [**5-1**] with results to Dr [**Last Name (STitle) 6955**] office # [**Telephone/Fax (1) 22629**]
fax # [**Telephone/Fax (1) 35844**]
Completed by:[**2150-4-29**]
|
[
"427.31",
"998.0",
"250.00",
"272.0",
"682.6",
"428.23",
"999.9",
"E878.2",
"428.0",
"424.0",
"401.9",
"482.83",
"414.01",
"998.59",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.61",
"96.04",
"96.71",
"35.22",
"37.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
8727, 8789
|
4605, 6258
|
298, 491
|
9162, 9169
|
2097, 3900
|
9503, 9951
|
1649, 1679
|
6462, 8704
|
3937, 3977
|
8810, 9141
|
6284, 6439
|
9193, 9480
|
1694, 2078
|
239, 260
|
4006, 4582
|
519, 1087
|
1109, 1466
|
1482, 1633
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,871
| 117,488
|
50866+59290
|
Discharge summary
|
report+addendum
|
Admission Date: [**2185-4-9**] Discharge Date: [**2185-4-21**]
Date of Birth: [**2099-4-27**] Sex: F
Service: SURGERY
Allergies:
Shellfish
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
[**2185-4-9**]: Exploratory laparotomy with duodenal [**Location (un) **] patch,
Hepatorrhaphy, Placement of jejunal feeding tube, Temporary
abdominal closure.
[**2185-4-11**]: Abdominal washout, temporary closure.
[**2185-4-14**]: Exploratory laparotomy, washout, and closure of abdomen
with internal drainage.
History of Present Illness:
Ms. [**Known lastname 105753**] is an 85F with chronic CLL, bladder cancer
s/p TURB, and retroperitoneal non-hodgkins lymphoma who presents
with abdominal pain s/p fall this afternoon. Patient was
recently admitted in early may with hyponatremia and dehydration
related to poor po intake, diuretic use, and possible RLL
pneumonia. At that time, CT showed interval increase in her RP
mass and she was
started on rituximab. Recent CT from [**2185-4-7**] showed a decrease
in the size of her mass and increased pleural effusions. Since
her CT, she has been at her baseline with continued poor po
intake. Today, she attempted to rise from a chair and fell over,
striking her abdomen on the coffee table. She did not hit her
head and denies LOC. She complained of severe abdominal pain
therafter
with 2 episodes of emesis. Since arrival in the ED, she has had
increasing tachypnea and hypoxia. A non-rebreather mask and
foley were placed. Her pain has worsened and she reports feeling
confused and overwhelmed
Past Medical History:
-Transitional cell bladder CA s/p TURB ([**2185-3-15**]), anticipating
radiation
-Non-hogkins retroperitoneal lymphoma on rituximab
-Chronic CLL
-Depression
-Anxiety
-Hypothyroidism
-Dyspepsia
-Herpes zoster
-Right bundle-branch block.
-HTN
-Hyperlipidemia
Past Surgical History:
-Lobular breast CA s/p resection [**2182**]
-Mechanical fall requiring R arm hardware
-Two spinal surgeries for scoliosis, s/p hysterectomy for
fibroid
Social History:
The patient is a widow from her first husband back in the [**2152**]
and married to her second husband for about 24 years. No
siblings. never smoked. denies drinking any alcohol. Denies any
illicit drug use.
Family History:
Denies any known family history of any blood disorders or cancer
that she is aware of
Physical Exam:
On admission:
Vital Signs: 97.8 90 154/69 16 98% 2L Nasal Cannula
General Appearance: Cahectic, appears uncomfortable with labored
breathing
Cardiovascular: RRR
Respiratory: Diminished breath sounds bilaterally, L>R, crackles
at b/l bases, wheezes intermittently, using accessory muscles
for
breathing
Abdomen: Soft, markedly distended, severely tender to palpation
and percussion throughout with rebound tenderness and guarding/
Extremities: Warm, thin, no edema
On discharge:
Vital Signs: T 98.0 BP 130/78 P 68 R 20 O2sat 97% RA
GEN: A&O, NAD
CV: RRR
PULM: Crackles to bilateral lung bases on auscultation, no use
of accessory muscles.
GI: Soft, appropriately tender at incision site, minimally
distended. Abdominal midline surgical incision well-approximated
with staples intact, no drainage, minimal errythema. RLQ old
drain sites with small amount serosang drainage. J tube site
c/d/i.
EXTR: 2+ edema to all 4 extremties. Warm, pink, well-perfused.
Pertinent Results:
[**2185-4-9**] 02:00PM BLOOD WBC-12.3* RBC-3.87* Hgb-11.9* Hct-38.3
MCV-99* MCH-30.7 MCHC-31.0 RDW-18.8* Plt Ct-668*
[**2185-4-9**] 02:00PM BLOOD Glucose-146* UreaN-36* Creat-1.0 Na-138
K-4.0 Cl-100 HCO3-29 AnGap-13
CT abdomen/pelvis:
1. New pneumoperitoneum and complex free fluid. In the absence
of recent
intervention, findings are highly concerning for a bowel
perforation, and
given the distribution and mechanism of injury, a duodenal
perforation is
suspected.
2. New heterogeneous hepatic hypodensities within segment IVb
of the liver concerning for hepatic lacerations and hematoma.
3. Ill-defined pancreatic head hypodensity is concerning for
additional
injury.
4. Cholelithiasis with gallbladder wall edema likely secondary
to the
intra-abdominal fluid.
5. Flattened IVC suggest a degree of volume depletion.
6. Unchanged appearance of extensive retroperitoneal mass
compatible with lymphoma.
7. Unchanged right moderate hydronephrosis.
8. Bladder mass at the right UVJ is not well delineated on the
current exam.
Labs at discharge:
[**2185-4-19**] 06:17AM BLOOD WBC-11.7* RBC-4.21 Hgb-12.7 Hct-40.9
MCV-97 MCH-30.1 MCHC-31.0 RDW-17.3* Plt Ct-391
[**2185-4-19**] 06:17AM BLOOD Glucose-149* UreaN-30* Creat-0.6 Na-144
K-4.1 Cl-104 HCO3-28 AnGap-16
[**2185-4-19**] 06:17AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.0
Brief Hospital Course:
After long discussions with the patient, her husband, her son,
her PCP, [**Name10 (NameIs) **] her oncologist, the consensus was to proceed with
surgery. Patient was taken emergently to the OR on [**2185-4-9**]. Due
to severe bowel distension, her abdomen could not be closed and
she was brought to the ICU intubated and sedated.
ICU Course:
Patient was initially hypotensive and required neosinephrine for
pressor support. She was resuscitated with crystalloid and PRBC
with improvement. She was taken back to the OR on [**4-11**] for wash
out and attempted closure, however her colon was still too
distended and came back to ICU intubated and sedated. A rectal
tube was placed for decompression with good effect. Tube feeds
were started via her Jtube. She was treated with vanco, cipro,
and flagyl for 48 hours postop. Once improved, she was diuresed
with a lasix drip. On [**4-14**], she returned to the OR for
definitive closure which she tolerated well. She was extubated
postop. On the night of [**4-14**], she developed afib with RVR
requiring an amio drip for rate control. She converted to sinus
rhythym within 12 hours. Her tube feeds were advanced to goal
and her amiodarone converted to po. She was transferred to the
floor on [**2185-4-15**].
Floor course:
On the floor her vital signs were routinely monitored and
remained stable. She was monitored on telemetry and remained in
NSR with occasional PVC's on the PO amiodarone. Diuresis was
continued with intermittent IV lasix. Her electrolytes were
monitored and repleted as needed. Tube feeds were continued at
goal via the J tube. She was kept NPO with an NG tube in place
until [**4-17**] when the NG tube was removed. Speech and swallow was
consulted on [**4-18**] to evaluate for dysphagia. She had difficulty
swallowing but ultimately the decision was made to keep her NPO
with tubefeeds for 10 more days after discharge to allow the
site of perforation time to heal. Plan was to re-evaluate
swallowing at rehab 10 days from discharge and advance diet if
appropriate at that time. A foley catheter had been placed on
admission and was removed on [**4-18**] at which time she was able to
void adequate amounts of urine without difficulty. She remained
on SC heparin for DVT prophylaxis.
Physical therapy was consulted to evaluate the patient's
mobility who recommended rehab when patient was medically
cleared.
The patient's oncologist Dr. [**Last Name (STitle) 105754**] was notified of her
hospitalization. The oncology service evaluated the patient and
agreed with the plan of care. Plan was to hold off on any
radiotherapeutic treatment of her bladder cancer until she has
recovered and reevaluate after the patient has recovered.
On [**4-20**] she remains afebrile and hemodynamically stable. She is
tolerating tube feeds at goal via J tube and diuresing
appropriately with lasix prn. She is being discharged to acute
rehab to continue her recovery.
Medications on Admission:
Acyclovir 400 mg TID, Amlodipine 5mg daily, Atorvastatin 10 mg
daily, Duloxetine 60 mg daily, Levothyroxine 100 mcg daily,
Lorazepam prn, Mirtazapine 7.5 mg qhs, Olmesartan 20mg daily,
Sertraline 20mg daily, Spironolocatone-HCTZ 25 mg daily, Aspirin
81mg daily, Calcium 250 mg daily, Vitamine D3 1000 U daily,
Colace 100 mg TID, Multivitamin
Discharge Medications:
1. mirtazapine 15 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO HS (at bedtime).
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).
3. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
5. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. olmesartan 20 mg Tablet Sig: One (1) Tablet PO daily ().
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
13. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
14. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. sertraline 20 mg/mL Concentrate Sig: Five (5) mL PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
s/p fall
1. Hepatic laceration.
2. Traumatic perforation of duodenum.
3. sepsis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after a fall and a perforation
in a portion of your gastrointestinal tract called your
duodenum. Your required an operation to fix the area of
perforation and a feeding tube was placed into the portion of
your small bowel below the area of perforation called the
jejunum. You are now receiving tubefeeds through the tube. You
should not eat or drink anything by mouth until your swallowing
has been re-evaluated at the rehab facility 10-14 days from now.
Please follow up in the Acute Care Surgery clinic at the
appointment scheduled for you below.
Because of the surgery, plans for any radiotherapeutic treatment
of your bladder cancer have been put on hold for now. Please
follow up with Dr. [**Last Name (STitle) 105754**] after you have left rehab to discuss
future treatment.
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
With Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: TUESDAY [**2185-5-10**] at 1:30 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2185-4-20**] Name: [**Known lastname **] [**Known lastname 8739**],[**Known firstname 1073**] B Unit No: [**Numeric Identifier 17207**]
Admission Date: [**2185-4-9**] Discharge Date: [**2185-4-21**]
Date of Birth: [**2099-4-27**] Sex: F
Service: SURGERY
Allergies:
Shellfish
Attending:[**First Name3 (LF) 4216**]
Addendum:
This addendum is to note that the patient's listed diagnosis of
"sepsis" should read "resolving sepsis".
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1502**]
[**First Name11 (Name Pattern1) 499**] [**Last Name (NamePattern4) 4218**] MD [**MD Number(2) 4219**]
Completed by:[**2185-4-27**]
|
[
"038.9",
"188.9",
"204.10",
"251.2",
"202.83",
"568.89",
"V10.3",
"995.91",
"300.00",
"864.02",
"272.4",
"311",
"244.9",
"458.9",
"863.21",
"426.4",
"285.8",
"V58.69",
"401.9",
"E885.9",
"569.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.71",
"38.93",
"50.61",
"54.11",
"54.12",
"46.39",
"96.72",
"96.6",
"54.63",
"54.25"
] |
icd9pcs
|
[
[
[]
]
] |
11444, 11698
|
4747, 7677
|
273, 586
|
9513, 9513
|
3397, 4431
|
10537, 11421
|
2318, 2407
|
8069, 9272
|
9410, 9492
|
7703, 8046
|
9696, 10514
|
1923, 2076
|
2422, 2422
|
2901, 3378
|
229, 235
|
4451, 4724
|
614, 1620
|
2436, 2887
|
9528, 9672
|
1642, 1900
|
2092, 2302
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,520
| 148,964
|
22262
|
Discharge summary
|
report
|
Admission Date: [**2152-10-2**] Discharge Date: [**2152-11-8**]
Date of Birth: [**2094-3-1**] Sex: F
Service: VSURG
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Chest Pain with Radiation to the Back
Major Surgical or Invasive Procedure:
[**2152-10-3**] Central Venous Line Placement
[**2152-10-5**] Repair of aortic dissection with 32 mm Dacron graft and
partial cardiopulmonary bypass
[**2152-10-6**] Fiberoptic bronchoscopy
[**2152-10-10**] Bronchoscopy with BAL and therapeutic aspiration of
retained secretions.
[**2152-10-25**] Percutaneous tracheostomy tube placement.
History of Present Illness:
This is a 58 year old female with a past medical history
significant for HTN, asthma, obesity who is a long time smoker.
She started experienceing chest pain at approximately 10:20 am
on the date of admission. The pain was described as tearing,
constant substernal pain with radiation to head and the back.
She also reported SOB. She therefore presented to an OSH and
received IV lopressor and Toradol which improved the pain. She
underwent a CT scan which showed a type B aortic dissection
starting distal to the subclavian artery and extending to the
right iliac. The takeoff of the celiac/ SMA/ and bilateral renal
vessels came off the true lumen, however the [**Female First Name (un) 899**] came off of the
true lumen. She present to the [**Hospital1 18**] for further evaluation and
treatment.
Past Medical History:
1) Poorly controlled hypertension
2) Ashtma
3) Obesity
Social History:
Active smoker; 15 pk years. No Etoh, No Drugs.
Family History:
Negative for aortic dissection; negative for CAD.
Physical Exam:
VS: P 60, BP 96/60 R-20 98%4L
Gem: A+Ox3
HEENT: PERRLA EOMI
Neck: No Carotid Bruits
Heart: Distant, RRR w/o M
Chest: Bilateral Rhonchi, wheezes l>r
ABD: SNTND. No rebound
Vasc: Radial Femoral DP PT
R A-Line 2+ 2+ 2+
L 2+ 2+ 2+ 1+
Pertinent Results:
[**2152-10-2**] 11:42PM HCT-30.5*
[**2152-10-2**] 07:47PM TYPE-ART PO2-71* PCO2-40 PH-7.32* TOTAL
CO2-22 BASE XS--5
[**2152-10-2**] 07:47PM LACTATE-1.5
[**2152-10-2**] 07:47PM O2 SAT-93
[**2152-10-2**] 07:47PM freeCa-1.18
[**2152-10-2**] 07:11PM POTASSIUM-4.2
[**2152-10-2**] 07:11PM WBC-10.6 RBC-4.06* HGB-11.2* HCT-32.3*
MCV-80* MCH-27.6 MCHC-34.7 RDW-14.8
[**2152-10-2**] 07:11PM CALCIUM-8.6 PHOSPHATE-4.9* MAGNESIUM-2.0
[**2152-10-2**] 07:11PM PLT COUNT-213
[**2152-10-2**] 03:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2152-10-2**] 03:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2152-10-2**] 03:20PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2152-10-2**] 02:40PM GLUCOSE-118* UREA N-15 CREAT-0.8 SODIUM-143
POTASSIUM-4.1 CHLORIDE-109* TOTAL CO2-24 ANION GAP-14
[**2152-10-2**] 02:40PM WBC-12.1* RBC-4.34 HGB-11.8* HCT-33.6*
MCV-77* MCH-27.3 MCHC-35.3* RDW-14.7
[**2152-10-2**] 02:40PM NEUTS-84.1* LYMPHS-12.7* MONOS-2.7 EOS-0.2
BASOS-0.2
[**2152-10-2**] 02:40PM MICROCYT-1+
[**2152-10-2**] 02:40PM PLT COUNT-217
[**2152-10-2**] 02:40PM PT-13.4 PTT-22.9 INR(PT)-1.1
Brief Hospital Course:
The patient was admitted to the surgical intensive care unit for
tight blood pressure control. The patient had no visceral or
lower extremity ischemia, however, over the last two days the
aneurysm has been seen to be enlarging on CT scan and there was
some suggestion of blood in the left chest suggesting contained
rupture. For that reason, she was taken to the operating room
on [**2152-10-5**] at which time she underwent a repair of the aortic
dissection with 32 mm Dacron graft and partial cardiopulmonary
bypass. Postoperatively admitted to the SICU and remained in
critical condition requiring pressor support. She was seen in
consult with neurology and pulmonary medicine. She was noted to
develop a right sided parietal hemmorrhage on [**2152-10-5**], and then
developed a new left frontal lobe ischemic infarct which was
visualized in CT scan on [**2152-10-10**]. Additionally, she was found
to have anterior mediastinal and left retroperitoneal hematoma
(10x9cm) on [**10-17**]. Over the ensuing two weeks, she gradually
improved, but it became apparent given her respiratory failure
that she would benefit from a tracheostomy. She therefore
underwent placement of a percutaneous trach on [**2152-10-25**]. Over
the following two weeks she weened to trach mask trials and
eventually to trach collar. She was deemed to be appropriate to
transfer to rehab on [**2152-11-7**] where she will continue her
recuperation.
Medications on Admission:
HCTZ
Lisinopril
Discharge Medications:
Docusate Sodium (Liquid) 100 mg NG [**Hospital1 **]
Insulin SC (per Insulin Flowsheet)
Breakfast/ Bedtime NPH 10 Units
Insulin SC Sliding Scale Q6H
Regular
Glucose Insulin Dose
0-60 mg/dL [**2-11**] amp D50
61-120 mg/dL 0 Units
121-140 mg/dL 2 Units
141-160 mg/dL 4 Units
161-180 mg/dL 6 Units
181-200 mg/dL 8 Units
201-220 mg/dL 10 Units
221-240 mg/dL 12 Units
> 240 mg/dL Notify M.D.
Insulin NPH 10u sc qam and qhs
Potassium Chloride 40 mEq NG [**Hospital1 **]; Hold for K > 4
Nystatin Oral Suspension 5 ml PO prn
Lorazepam 1 mg PO BID
Albuterol-Ipratropium [**2-11**] PUFF IH Q6H:PRN
Heparin 5000 UNIT SC TID
Amiodarone HCl 400 mg PO QD
Furosemide 40 mg IV BID
Albuterol Neb Soln 1 NEB IH Q6H
Miconazole Powder 2% 1 Appl TP TID:PRN
Metoprolol 50 mg PO BID
Bisacodyl 10 mg PR HS:PRN
Milk of Magnesia 30 ml PO Q6H:PRN
Amlodipine 10 mg PO QD
Oxycodone-Acetaminophen [**6-19**] ml PO
Lansoprazole Oral Suspension 30 mg NG
Aspirin 325 mg PO QD
Artificial Tears 1-2 DROP OU PRN
Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Type B aortic dissection starting distal to the subclavian
artery and extending to the right iliac
Type A intramural hematoma involving the entire ascending aorta
from the aortic valve level with penetreting ulcer in left
lateral aspect of the distal ascending aorta (proximal to the
brachicephalic artery).
Right Parietal lobe hemorrhage ([**2152-10-5**])
Left Frontal Lobe Ischemic Infarct ([**2152-10-10**])
HTN
Asthma
Respiratory Failure
Retained Secretions
Retroperitoneal hematoma
Hypokalemia
Atrial Fibrilation
Blood Loss Anemia
Discharge Condition:
Good
Discharge Instructions:
The patient should return to the hospital for evaluation if she
develops fever, chills, or redness around the wound sites.
Followup Instructions:
The patient should follow-up with Drs. [**Last Name (STitle) **] and [**First Name4 (NamePattern1) **] [**Last Name (Prefixes) **], M.D.
|
[
"998.2",
"423.0",
"518.5",
"997.02",
"441.03",
"285.1",
"998.12",
"785.59",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.59",
"03.90",
"39.32",
"39.61",
"38.44",
"96.72",
"37.12",
"38.45",
"33.24",
"38.93",
"96.6",
"33.22",
"31.1",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
5881, 5936
|
3284, 4723
|
349, 689
|
6515, 6521
|
2041, 3261
|
6692, 6832
|
1681, 1732
|
4789, 5858
|
5957, 6494
|
4749, 4766
|
6545, 6669
|
1747, 2022
|
272, 311
|
717, 1522
|
1544, 1601
|
1617, 1665
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,416
| 190,786
|
1470
|
Discharge summary
|
report
|
Admission Date: [**2148-5-29**] Discharge Date: [**2148-6-13**]
Date of Birth: [**2092-11-29**] Sex: M
Service: CARDIOTHOR
CHIEF COMPLAINT: The patient is a 54 year old man, a
patient of Dr. [**Last Name (STitle) **] and [**Doctor Last Name 8712**], referred for outpatient cardiac
catheterization due to worsening exertional chest pain.
HISTORY OF PRESENT ILLNESS: The patient is a 54 year old man
with known coronary artery disease, totally occluded right
coronary artery in [**2136**], hypertension and renal cell cancer,
status post bilateral nephrectomies, who was admitted in
[**2146-12-16**] with unstable angina. Since that time, he
has had stable exertional angina. During a recent ETT to
evaluate his anginal symptoms, he exercised for nine minutes
at a modified [**Doctor First Name **] protocol, during which time he
experienced typical exertional chest pain. MIBI images at
that time revealed partially reversible inferior and
inferolateral perfusion defects and he is now referred for
cardiac catheterization.
PAST MEDICAL HISTORY:
1. Gout.
2. Renal failure on hemodialysis Monday, Wednesday and
Friday.
3. Renal cell carcinoma.
4. Coronary artery disease status post stenting of
circumflex and obtuse marginal in [**2147-5-16**].
5. Hepatitis C.
6. Remote intravenous drug use.
7. Esophagitis.
8. Herniated disc L4 through 5.
9. Right peroneal palsy.
PAST SURGICAL HISTORY:
1. Bilateral nephrectomies.
2. Remote broken ankle.
ALLERGIES: He has no known allergies.
MEDICATIONS PRIOR TO ADMISSION:
1. Aspirin 325 mg q. day.
2. Lopressor 50 twice a day.
3. Nephrocaps one q. day.
4. Isorbid 40 twice a day or three times a day, unclear.
5. Allopurinol 100 mg q. day.
6. Zestril 20 mg q. day.
7. Remegel 800 mg three times a day.
8. Coumadin 6 mg on Saturdays, 5 mg on all other days.
9. Clonidine patch q. week.
10. Norvasc 5 mg q. day.
LABORATORY: Prior to admission, white blood cell count 7.6,
hematocrit 36.1, platelets 243. Sodium 138, potassium 4.5,
chloride 102, CO2 22, BUN 39, creatinine 14.7, glucose 94,
INR 1.9.
SOCIAL HISTORY: Lives with girlfriend. [**Name (NI) 1403**] part time
delivering medical supplies.
PHYSICAL EXAMINATION: At the time of admission, vital signs
were heart rate 58 and sinus rhythm; blood pressure 171/79;
respiratory rate 20; O2 saturation 88% on room air. Neck
with questionable bruits versus radiating murmur. Lungs are
clear to auscultation. Heart: S1, S2, regular rate and
rhythm with a III/VI systolic ejection murmur best heard at
the lower right sternal border. Abdomen is soft, nontender,
nondistended. Right hemodialysis graft with a positive
thrill; no oozing.
HOSPITAL COURSE: As stated previously, the patient was
admitted and underwent cardiac catheterization. Please see
the Catheterization Report for full details. In summary, the
patient was found to have left main 60 to 70% mid-distal
stenosis, left anterior descending diffuse disease
throughout, circumflex with a 90% ostial stenosis, right
coronary artery recanalized mid-70% followed by a total
occlusion with extensive bridging to right collaterals.
Ejection fraction of 47%.
Following catheterization, Cardiothoracic Surgery was
consulted. The patient was seen and accepted for coronary
artery bypass grafting. On the morning of [**5-30**], the
patient was brought to the Operating Room. Please see the
Operative Report for full details. In summary, the patient
had a coronary artery bypass graft times three with a left
internal mammary artery to the left anterior descending, a
saphenous vein graft to the obtuse marginal and a saphenous
vein graft to the distal right coronary artery. He
tolerated the procedure well and was transferred from the
Operating Room to the Cardiothoracic Intensive Care Unit.
The patient did well in the immediate postoperative period,
however, he was somewhat acidotic and therefore, he remained
intubated overnight. In the morning of postoperative day
one, the plan was to dialyze the patient and then wean to
extubate.
Following dialysis, the patient remained somewhat acidotic
with a pH of 7.26, therefore, the ET tube was kept in place
and he remained on CPAP overnight. In the morning of
postoperative day two, the patient was again weaned to CPAP
of 5 and 5 and was successfully extubated. At that time, his
chest tubes were also removed. Following extubation, the
patient developed an episode of rapid atrial fibrillation
with a ventricular response rate in the 140s. He was started
on an Amiodarone drip and was treated with intravenous
Lopressor for rate control.
Unfortunately, at that time, the patient also became
tachypneic and desaturated requiring re-intubation.
Postoperative day three, the patient developed a fever to
103.8 F. At that time, he had a white blood cell count of
6.5. He was fully cultured. The sputum culture revealed
Pseudomonas and Klebsiella and he was begun on Ceftazidime
and Levaquin at that time.
Over the next several days, the patient remained intubated on
pressure support ventilation. He was slowly weaned from
pressure support ventilation as his secretions diminished.
On postoperative day seven, the patient was successfully
extubated which he tolerated well. The patient remained in
the Intensive Care Unit for several more days in order to
closely monitor his respiratory status and provide vigorous
chest Physical Therapy.
On postoperative day 12, he was transferred from the
Intensive Care Unit to Fahr 6 for continuing postoperative
care and cardiac rehabilitation. Once on the Floor, the
patient remained hemodynamically stable. His activity level
was slowly increased with the assistance of Physical Therapy
and the nursing staff. He continued to be followed by the
Renal Service, being dialyzed as needed.
Postoperative day 14, it was decided that the patient was
stable and ready to be transferred to a rehabilitation center
for continuing postoperative care and cardiac rehabilitation.
At the time of transfer, the patient's physical examination
was as follows: Vital signs with temperature 97.0 F.; heart
rate 58, sinus rhythm; blood pressure 152/81; respiratory
rate 18; O2 saturation 95% on three liters nasal prongs. His
weight preoperatively was 84 kilograms; at discharge it is 80
kilograms.
Laboratory data on [**6-12**], white blood cell count 9.1,
hematocrit 32.9, platelets 430. Sodium 132, potassium 4.8,
chloride 92, CO2 23, BUN 72, creatinine 12, glucose 84.
On physical, alert and oriented times three. Moves all
extremities, follows commands. Respiratory: Clear to
auscultation bilaterally. Heart sounds regular rate and
rhythm, S1 and S2 with a III/VI systolic ejection murmur,
sternum is stable. Incisions open to air, clean and dry with
Steri-Strips intact. Abdomen soft, nontender, nondistended,
with positive bowel sounds. Extremities are warm and well
perfused with no edema. Right leg incision with Steri-Strips
open to air; clean and dry.
DISCHARGE MEDICATIONS:
1. Pantoprazole 40 mg p.o. q. day.
2. Amiodarone 400 mg p.o. q. day through [**6-19**], then 200
mg q. day.
3. Lisinopril 30 mg q. day.
4. Norvasc 10 mg p.o. q. day.
5. Metoprolol 50 mg twice a day.
6. Clonidine patch TTS-2, q. week.
7. Remegel 800 mg three times a day.
8. Nephrocaps one q. day.
9. Enteric coated aspirin 325 mg q. day.
10. Percocet 5/325 one to two tablets q. four hours p.r.n.
11. Levofloxacin 250 mg q.o.d. through [**6-16**].
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery
bypass grafting times three with a left internal mammary
artery to the left anterior descending, a saphenous vein
graft to obtuse marginal and a saphenous vein graft to the
distal right coronary artery.
2. Hypertension.
3. Status post bilateral nephrectomies.
4. Renal cell carcinoma.
5. Gout.
6. Hepatitis C.
7. Esophagitis.
8. Herniated disc, L4 through 5.
9. Right peroneal nerve palsy.
DISPOSITION: The patient is to be discharged to
rehabilitation.
DISCHARGE INSTRUCTIONS:
1. He is to follow-up with the Renal Service to continue his
hemodialysis.
2. He is to follow-up with Dr. [**Last Name (STitle) 1537**] in one month.
3. He is to follow-up with is primary care provider in three
to four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2148-6-12**] 14:22
T: [**2148-6-12**] 14:31
JOB#: [**Job Number 8713**]
|
[
"997.1",
"427.31",
"998.59",
"V10.52",
"518.5",
"070.54",
"585",
"411.1",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.71",
"39.95",
"96.04",
"37.23",
"36.15",
"88.57",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7488, 8010
|
7009, 7467
|
2708, 6986
|
8034, 8529
|
1428, 1524
|
1556, 2094
|
2219, 2690
|
163, 362
|
391, 1053
|
1075, 1405
|
2111, 2196
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,146
| 111,849
|
48942
|
Discharge summary
|
report
|
Admission Date: [**2184-2-9**] Discharge Date: [**2184-2-18**]
Service: SURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
R chest wall pain
Major Surgical or Invasive Procedure:
[**2184-2-9**] exploratory laparotomy, right thoracotomy with packing
[**2184-2-11**]
1. Unpack packed abdomen with abdominal washout and closure.
2. [**Doctor Last Name **] gastropexy with feeding gastrostomy.
3. Unpack packed right hemithorax.
4. Internal fixation of multiple (#4) ribs.
History of Present Illness:
86F transferred from referring institution after falling down 10
stairs onto her right side. Now with rib fractures along her
entire right side.
Past Medical History:
alzheimer's dementia, HTN, OP, Gerd, ^chol
Social History:
nc
Family History:
nc
Physical Exam:
deceased
Pertinent Results:
[**2184-2-9**] 02:45AM PT-12.7 PTT-23.3 INR(PT)-1.1
[**2184-2-9**] 02:45AM WBC-8.4 RBC-3.53* HGB-10.7* HCT-31.0* MCV-88
MCH-30.2 MCHC-34.4 RDW-13.6
[**2184-2-9**] 02:45AM cTropnT-<0.01
[**2184-2-9**] 02:45AM CK(CPK)-73
[**2184-2-9**] 02:45AM GLUCOSE-182* UREA N-34* CREAT-1.3* SODIUM-144
POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-25 ANION GAP-13
CXR [**2184-2-9**] 8:19 AM
Increased right pleural effusion (likely hemothorax) with
increasing right basilar opacity, which likely reflects
atelectasis. No evidence of pneumothorax.
KUB [**2184-2-9**] 2:06 AM
No radiographic evidence of intraperitoneal air. Large hiatal
hernia.
Right rib [**6-27**] fractures
Brief Hospital Course:
Briefly, Mrs. [**Known lastname **] was transferred to [**Hospital1 18**] from a referring
institution on [**2184-2-9**] after she fell down 10 steps onto her R
side with no LOC sustaining severe R 8-10th rib fractures. Per
referring institution reports, her head CT and spine CT were
negative. CT here showed no active bleeding into any cavity but
there was concern for liver herniation through a diphragmatic
injury versus an eventrated diaphragm on the right. While in the
ED on the early AM of [**2-9**] the patient became hypotensive.
Surgery was called. Fluids were begun and the patient was moved
the patient to the TSICU. Shortly thereafter she coded with PEA
arrest x25 min. During the code a chest tube was placed with no
air gush but 700cc blood emptied immediate into the pleurovac.
This bleeding persisted. A TEE during the code showed a type B
thoracic aortic dissection, probably due to CPR and previously
undiagnosed critical aortic stenosis (valve 0.8 cm) which likely
cause the PEA arrest. She was resuscitated regaining normal
pulses and relatively normotension on pressors. Since she was
continuing to bleed from the chest she was taken to OR.
Initially an exploratory laparotomy was performed but the liver
and diaphragm were uninjured. A thoracotomy was then done
showing massive hemorrhage into the chest from multiple broken
ribs - probably related to the CPR. Multiple belledrs were
ligated, packing was placed, and she received 12 units RBC, 4
units FFP, 2 units PLT, 1 unit cryoprecipitate and 25 mcg/Kg
Factor 7a before being controlled. She was closely monitored in
the TSICU post-operatively.
On [**2-11**] pt returned to OR for unpacking, washout and wound
closure of the chest and abdomen. All sites were dry. 2 chest
tubes remained in place.
She was followed by APS for analgesia, nephrology for ischemic
ATN and oliguria in the setting of hemorrhagic PEA arrest,
neurology was asked to evaluate for possible anoxic brain
injury.
Neurologic eval was remarkable for minimal cortical function on
EEG, c/w anoxic brain injury. On [**2-13**] the palliative care team
met with patient's family. Another family meeting was held on
[**2184-2-16**], and it was decided that she would be extubated and made
CMO with her family present on [**2184-2-17**]. She expired peacefully
at 4:45am this morning with her family present at the bedside.
Medications on Admission:
aripirazole 20'', amlodipine 5', Aricept 10', Lisinoril 10',
Lipitor 20', Mirtazapine 15', colace, vit d, MVI
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
multiple right rib fractures s/p fall
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
n/a
|
[
"862.0",
"441.01",
"568.0",
"881.00",
"511.9",
"807.03",
"331.0",
"901.0",
"958.4",
"860.2",
"276.2",
"584.5",
"434.91",
"348.30",
"799.1",
"424.1",
"958.99",
"272.0",
"E880.9",
"427.5",
"733.00",
"458.9",
"286.9",
"294.10",
"530.81",
"348.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.09",
"99.04",
"43.19",
"79.39",
"54.11",
"99.06",
"96.72",
"54.59",
"53.7",
"34.02",
"99.60",
"88.72",
"99.05",
"38.91",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
4101, 4110
|
1538, 3912
|
231, 524
|
4192, 4203
|
849, 1515
|
4260, 4267
|
801, 805
|
4072, 4078
|
4131, 4171
|
3938, 4049
|
4227, 4237
|
820, 830
|
174, 193
|
552, 699
|
721, 765
|
781, 785
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,422
| 124,583
|
37928
|
Discharge summary
|
report
|
Admission Date: [**2153-10-1**] Discharge Date: [**2153-10-11**]
Date of Birth: [**2128-1-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Nasogastric tube placement
PICC placement
History of Present Illness:
[**Known firstname **] [**Known lastname 84781**] is a 25 yo male with severe cerebral palsy,
non-verbal at baseline who was transferred from [**Hospital3 **]
where he was being evaluated for Left foot swelling and
incidentally found to have Hct of 20. There was concern that his
stools were melanotic. He was given 2 units of PRBC, a PPI and
transferred for further evaluation.
.
In the emergency department, initial vitals: 100.0 110 117/84 18
98% ra. He spiked a fever to 102 and had a leukocytosis of 33.
He was given vancomycin 1 gm x1, Levofloxacin 750mg X1, Flagyl
500mg IV x1 to empirically cover both HAP and [**First Name8 (NamePattern2) **] [**Last Name (un) 5487**]
abdominal process. He was also give NS 1L and ativan. For
evaluation of his GIB, his NG lavage was negative, stool dark &
guiaic positive but not obvious melena. His abdomen was rigid on
exam so general surgery was conulted and a CT of the abd/pelvis
was performed which showed a large mass in the right proximal
colon and possilby a partial bowel obstruction. GI felt that
surgery was not necessary urgently and requested that the
patient have either a barium enema or a colonoscopy. The mass
was noted to be obstructing the ureter and causing
hydronephrosis in the right kidney. Urology was consulted and
will see the patient this morning. He will likely need
percutaneous nephrostomy tube placed by IR. His vital signs
prior to transfer as as follows: 98.4 110 108/79 20 100% ra.
.
In conversation with his caregiver he had a change in behavior
approximately 3 months ago when his mood seemed to become more
labile. He was crying frequently and often reporting abdominal
pain. He was admitted at [**Hospital3 **] and spent 3-4 weeks
there. Per [**Hospital3 4107**] ED notes, he had 2 abd CT scans there
without acute change, a bone marrow bx w/o myeloproliferative
findings and pan cultures were persistently negative. The
caregiver knows that he required blood transfusions but does not
know of any diagnosis. He developed diarrhea 2-3 weeks ago. He
has had a significant weight loss over the past few months
despite a good appetite. He vomited (foodstuff; non-bloody) once
yesterday and this is a new symptom for him. He is able to sign
yes or no when asked questions. He currently reports pain in his
right foot and his belly. He has had intermittent fevers for the
past few weeks.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain, headache, visual changes, lightheadedness, syncope, sinus
tenderness, rhinorrhea, nasal congestion, cough, shortness of
breath, wheeze, chest pain or tightness, palpitations,
orthopnea, PND, abdominal pain nausea, vomiting, diarrhea,
constipation, dark tarry stools, BRBPR, changes in bowel or
bladder habits, dysuria, hematuria, increased frequency,
arthralgias, myalgias or rash.
Past Medical History:
# Severe Cerebral Palsy - non-verbal at baseline.
non-ambulatory. Able to get OOB-> chair.
# GERD
# development delay
# Leukocytosis - The patient was found to have a chronic
leukocytosis of unknown baseline at this time is currently being
evaluated for hematologic malignancy. Workup began at [**Hospital1 10551**]. Including bone marrow bx which was reportedly
negative.
PAST SURGICAL HISTORY: Surgery on R and L leg for contractures
Social History:
FAMILY HISTORY: unknown
Family History:
SOCIAL HISTORY: The patient's 2 parents are involved in his
care. He has several siblings as well. He lives in a group home
called "Human Services Options" in [**Last Name (un) 21037**] MA. He has 24hr
caregivers. [**Name (NI) **] gets OOB to chair and is able to communicate
answers to yes/no questions with hand movements. Yes = shake
fist, No=will wave index & middle fingers.
Physical Exam:
VS: 98. 127/90 100 24 98% ra
GENERAL: cachectic young man. appears uncomfortable but NAD.
HEENT: NCAT No scleral icterus. PERRLA/EOMI. MMM. OP clear.
NECK: Supple, No LAD.
CARDIAC: RRR. Normal S1, S2. No m/r/g.
LUNGS: CTAB, no w/w/r. no dullness to percussion.
ABDOMEN: NABS. rigid abdomen with contracted abdominal muscles.
ND, unable to discern if tender. no masses appreciated.
EXTREMITIES: LLE 2+ pedal edema. no RLE edema wwp.
NEURO: alert responds with hand communications to yes/no
questions appropriately at times. responds to pain. contracted
posturing.
BACK: with sacral ulceration. dressing c-d-i
Pertinent Results:
On admission:
WBC 33.3
Hct 31.4
Plts 569
PT 13.7 PTT 28.3 INR 1.2
Chem on admission Gluc 69 BUN/Cr 11/0.6 rest of chems normal
LDH 447 <-- 337
Urate 3.5
CEA 4.7 (0-4)
Lactate 1.4
UA small blood, +nitrite, 30 prot, neg glucose, tr ketones, neg
bili, tr LE, [**5-30**] RBC's, [**11-9**] WBC's, few bact
[**2153-10-4**] O&P
BLASTOCYSTIS HOMINIS. MODERATE.
Cdiff negative x2
[**2153-10-1**] UCx
STREPTOCOCCUS SPECIES. ~3000/ML.
[**2153-10-1**] EKG
Sinus tachycardia. Otherwise, normal tracing for age. No
previous tracing
available for comparison.
[**2153-10-1**] L foot plain film
FINDINGS: AP, lateral, oblique views of the left foot are
obtained. There is
no fracture or dislocation. Marked soft tissue swelling is seen
without soft
tissue gas or foreign body. No significant degenerative changes
are present.
Joint appeared articulate normally.
IMPRESSION:
Soft tissue swelling, without evidence of underlying bony
injury.
[**2153-10-1**] CXR
FINDINGS: AP portable semi-upright view of the chest is
obtained. An NG tube
is seen with its tip in the left upper quadrant. The lungs are
clear
bilaterally. Cardiomediastinal silhouette is normal. Bones
appear intact.
Gas distended loops of bowel are noted in the upper abdomen.
IMPRESSION: No evidence of pneumonia. NG tube in appropriate
position.
[**2153-10-1**] CT abdomen pelvis with contrast
CT ABDOMEN WITH IV CONTRAST: Dependent atelectatic changes are
noted in the
lung bases. No pleural or pericardial effusion is seen. There is
dilation of
the distal esophagus which is filled with oral contrast. A
nasogastric tube
is in place, terminating in the stomach.
Orally administered contrast has progressed to mid loops of
small bowel which
are dilated to approximately 3.9 cm (301B:14). Fecalized
material is noted
within what appears to be the cecum or distended terminal ileum.
There is
marked abnormality within the proximal right colon, extending
from the cecum
to the mid-ascending colon. Within the mid-ascending colon,
there is a large
mass with circumferential involvement of the ascending colon
with enhancement
and frond- like projections extending into the lumen. Findings
are best seen
on coronal views (301B:19-21) and are highly concerning for
tumor. Distal to
this, the hepatic flexure and transverse colon contain gas and
fluid. The
descending colon as well as the rectosigmoid colon is collapsed.
Overall,
findings are concerning for tumor in the proximal right colon,
causing with
proximal bowel obstruction. There is also hydronephrosis of the
right kidney
with dilatation of the ureter to the level of the right colonic
mass. There
is hypoenhancement of the right kidney compared to the left,
with delayed
excretion.
The liver, gallbladder, spleen, pancreas, adrenal glands, and
left kidney
appear unremarkable. The abdominal aorta demonstrates normal
caliber. The
venous structures are suboptimally assessed; however, note is
made of a small
12-mm filling defect within the IVC, at the level of the right
renal hilum
(301B:23, 2:33). The right renal vein is not well visualized.
Multiple prominent mesenteric nodes are noted, measuring up to
11 mm in short
axis (301B:17). Ill-defined lesion is noted along the right
paracolic gutter,
inferior to the liver tip, measuring approximately 1.5 x 3.1 x
2.7 cm (2:38,
301B:25). This lesion has apparent linear densities extending to
the right
colonic mass region. While its etiology is not clear, findings
are suspicious
for peritoneal deposit. No definite free air is noted within the
abdomen.
Assessment for ascites is very limited due to increased density
of this
cachetic patient's subcutaneous and mesenteric fat.
CT PELVIS WITH IV CONTRAST: Evaluation of the pelvis is
suboptimal due to the
patient's overlying right leg, due to contractures. Gas can be
seen within
the urinary bladder which contains a Foley catheter. Aside from
bowel
findings mentioned above, no free air or adenopathy is
definitely noted in the
pelvis. The left common femoral and external iliac veins appear
patent;
however, the right common femoral vein and external iliac veins
are not well
assessed.
OSSEOUS STRUCTURES: There is S-shaped scoliosis of the
thoracolumbar spine.
It is noted that the right eleventh rib appears diffusely more
sclerotic
compared to other ribs, of uncertain clinical significance.
IMPRESSIONS:
1. Findings concerning for tumor in the ascending colon with
associated small
bowel obstruction and obstruction of the right ureter, with
right
hydronephrosis. If the patient does not require surgery for
bowel obstruction,
further assessment by colonoscopy would be recommended.
2. Multiple borderline enlarged mesenteric nodes. Indeterminate
lesion along
right paracolic gutter, inferior to liver tip, suspicious for
peritoneal
metastasis.
3. Small filling defect in the IVC, at the level of the right
renal hilum,
consistent with thrombus.
4. Dilated distal esophagus, filled with oral contrast.
[**2153-10-2**] LENI
FINDINGS: Grayscale, color and Doppler son[**Name (NI) 1417**] of the left
common femoral,
superficial femoral, popliteal and tibial veins were performed.
There is
normal flow, compression and augmentation seen in all of the
vessels.
IMPRESSION: No evidence of deep vein thrombosis in the left leg.
[**2153-10-2**] Abdomen plain film
IMPRESSION: Dilated small bowel loops consistent with
small-bowel
obstruction. No free air or extraluminal contrast.
.
[**10-7**]
IMPRESSION:
1. Findings concerning for a mass in the ascending colon with
associated
small-bowel obstruction which has slightly increased since the
prior
examination as described above.
2. Stable right hydroureteronephrosis with involvement of the
right ureter by this tumor.
3. No evidence of a pulmonary embolism.
4. Soft tissue/secretions within the distal left main bronchus
as well as
left upper and lower lobe bronchi may represent aspiration.
Scattered ground- glass opacities in both lungs may represent
infection, inflammation or sequelae of aspiration.
5. Compared to the priod study the filling defect in the IVC has
resolved.
Brief Hospital Course:
Abdominal mass - Treated initially with broad spectrum
antibiotics for possible ruptured appendix with periappendiceal
abscess formation. Subsequent CT scan showed progressive
enlargement of the mass with worsening obstruction. Endoscopic
biopsy was deferred due to the risk of perforation. Given his
poor nutritional status, and that surgery was unlikely to be
curative if the mass were malignant, operative therapy was
deferred. GI bleeding signified likely colonic invasion with a
poor prognosis. After a family meeting with the medical team,
social work, and palliative care, the patient was made comfort
measures only, and expired on [**2153-10-11**] at approximately 2 AM.
.
Aspiration pneumonia - Treated with broad-spectrum antibiotics,
as above, and oxygen therapy.
.
IVC thrombus - Treated with heparin IV until recurrent GI
bleeding led to its discontinuation.
.
Right hydroureteronephrosis - The consulting IR and urology
teams did not recommend percutaneous nephrostomy due to a poor
overall prognosis.
Medications on Admission:
MEDICATIONS AT HOME:
Colace 100 mg Cap Oral 1 Capsule(s) Once Daily PRN
Ensure Plus Oral Liquid Oral 1 Liquid(s) Twice Daily
Loratadine 10 mg Tab Oral 1 Tablet(s) Once Daily
Omeprazole 20 mg Tab, Delayed Release Oral 1 Tablet, Delayed
Release (E.C.)(s) Once Daily
Baclofen 10 mg Tab Oral 0.5mg Tablet(s) Three times daily
Tylenol 325 mg Tab Oral 2 Tablet(s) Every 4-6 hrs, as needed
Ferrous Sulfate 325mg PO BID
Artificial tears
Chromolyn Optho 4% 1 drop OU [**Hospital1 **]
Multivitamin
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Abdominal mass with large bowel obstruction and colonic
invasion
2. Aspiration pneumonia
3. Right hydroureteronephrosis
4. IVC thrombus
Discharge Condition:
Expired.
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2153-10-11**]
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icd9cm
|
[
[
[]
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[
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"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
12481, 12490
|
10896, 11914
|
323, 367
|
12673, 12683
|
4788, 4788
|
12735, 12770
|
3763, 3763
|
12453, 12458
|
12511, 12652
|
11940, 11940
|
12707, 12712
|
11961, 12430
|
3664, 3706
|
4159, 4769
|
2782, 3246
|
275, 285
|
395, 2763
|
4802, 10873
|
3268, 3641
|
3779, 4144
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,212
| 172,169
|
18489
|
Discharge summary
|
report
|
Admission Date: [**2101-7-31**] Discharge Date: [**2101-7-31**]
Service: [**Location (un) **] MICU
HISTORY OF PRESENT ILLNESS: An 82-year-old male with history
of atrial fibrillation on [**Hospital 197**] transferred from outside
hospital status post unwitnessed fall, presumably from
standing position at approximately 10 a.m. on day of
admission. Patient was reportedly conscious at the scene,
oriented x2 without recollection of event. Patient had
progressive deterioration of mental status at the outside
hospital with vomiting (bright read hematemesis). INR was
5.2 at the outside hospital; patient received 2 units of FFP.
Patient was intubated for airway protection and transferred
to [**Hospital1 69**].
CT there showed a 2.8 cm left subdural hematoma, several
intraparenchymal hemorrhages in the frontal lobes, pontine
hemorrhage with hypodensity of brain stem. Midline shift
with ablation of left lateral ventricle and entrapment of the
right lateral ventricle, tonsillar herniation were noted.
Patient was evaluated by Trauma, Neurosurgery, and Neurology
services. The extent of the neurologic injury was felt to
preclude surgical intervention at this time. Patient had
bright red blood on nasogastric lavage in the Emergency
Department.
PAST MEDICAL HISTORY:
1. CVA and TIA at unknown times.
2. COPD.
3. CAD status post a bypass in [**2080**].
4. Anemia.
5. Chronic renal insufficiency.
6. Atrial fibrillation.
MEDICATIONS ON ADMISSION:
1. Coumadin 2.5 mg p.o. q.d.
2. Zestril.
3. Vitamin E.
4. Digoxin 0.125 mg p.o. q.d.
5. Vitamin B12.
ALLERGIES: No known drug allergies.
PHYSICAL EXAM ON ADMISSION: Vital signs: Temperature 96.4,
pulse 82, blood pressure 167/72, respirations 20. Patient
was on FIMV with pressure support, tidal volume of 600, rate
14, pressure support 5, PEEP 5, FIO2 100. General: Patient
intubated, unresponsive. HEENT: Left periauricular
hematoma, head laceration with overlying gauze, blood soaked.
Pupils at 7 mm, equal, nonreactive to light. No corneal
reflex noted. Neck brace in place. No lymphadenopathy.
Cardiac: Regular, rate, and rhythm, normal S1, S2, with a
2/6 systolic murmur at the apex. Pulmonary: Coarse breath
sounds bilaterally with no wheezes, rubs, or crackles noted.
Abdomen: Normoactive bowel sounds, concave, soft, no masses.
Extremities: Cool with no cyanosis and no edema.
Neurologic: No response to voice. No response to sternal
rub or pain in upper extremities bilaterally. Pupils 7 mm,
equal, and fixed, with no reaction to light. No gag
elicited. No spontaneous movement. Trouble flexion of legs
bilaterally and response to stimulation of legs. Toes are
upgoing bilaterally.
LABORATORY STUDIES ON ADMISSION: White blood cell count
25.5, polys 91.8, bands 0, lymphocytes 4.3, monocytes 3.7,
eosinophils 0.1, basos 0.1, hematocrit 25.3. Platelets 267.
Sodium 140, potassium 3.0, chloride 108, bicarbonate 21, BUN
22, creatinine 0.9, glucose 285. Alkaline phosphatase 129,
calcium 7.1, phosphorus 3.5, magnesium 1.8. CK 85 with a
troponin of less than 0.01. PT 17.7, INR 2.0, PTT 34.6.
Chest x-ray: Nasogastric tube at the GE junction, ET in good
position. No focal consolidations, CHF, or fractures noted.
AP pelvis: Degenerative changes in the lower lumbar spine
with osteopenic osseous structures.
EKG: Normal sinus rhythm at 71 beats per minute with normal
axis. QRS 0.13 seconds, P-R 0.142 seconds, QTc 0.443,
sloping [**Street Address(2) 4793**] depressions in II, III, and aVF, and T-wave
inversions in V1 through V3, and [**Street Address(2) 4793**] depressions in V4
through V6.
SUMMARY OF HOSPITAL COURSE: As this male had evidence of
intracranial hemorrhage with herniation status post fall, his
health care proxy was [**Name (NI) 653**]. She requested that he
receive comfort oriented care until the family arrived from
[**State 531**] City. She stated that she wanted no pressors,
cardiac resuscitation, or invasive procedures. She
understood that the patient might not survive until she
arrived.
The patient was continued on the ventilator at the settings
given above until the family arrived from [**State 531**] City.
Shortly after arrival, the [**Hospital 228**] health care proxy along
with the rest of her family decided to withdrawal ventilatory
support. Approximately 15 minutes after extubation, patient
went into asystole. His pupils remained fixed at 7 mm and
nonreactive, he was unresponsive to sternal rub. There was
no spontaneous ventilation and no heart sounds were heard
while auscultating for five minutes.
Time of death: 11:45 p.m. [**2101-7-31**]. Case was reported to
the medical examiner's office, who accepted the case. Family
was present at time of death and was informed regarding the
forthcoming medical examiner's autopsy.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 14605**]
MEDQUIST36
D: [**2101-10-12**] 13:53
T: [**2101-10-13**] 07:45
JOB#: [**Job Number 50844**]
|
[
"518.81",
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"E888.9",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
1470, 1624
|
3640, 5073
|
138, 1269
|
2721, 3611
|
1291, 1444
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,338
| 198,762
|
44257
|
Discharge summary
|
report
|
Admission Date: [**2162-10-8**] Discharge Date: [**2162-10-26**]
Date of Birth: [**2089-8-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5129**]
Chief Complaint:
transferred from OSH for altered mental status and bilateral
pleural effusions with right-sided loculated hydropneumothorax
Major Surgical or Invasive Procedure:
3 chest tubes placed in left, right anterior, and right
posterior chest.
Bronchoscopy x 2.
History of Present Illness:
73M with history of ESRD, PEG tube, CVA, DMII, CAD s/p CABG,
initially admitted to an OSH for altered mental status. There,
he had a chest X-ray showing bilateral pleural effusions. The
effusions were tapped and he developed a pneumothorax.
Subsequently, he developed abdominal pain, had a KUB showed free
air under the diaphragm, and CT scan was consistent with air
around the G-tube. At this time, he was transferred to [**Hospital1 18**].
Past Medical History:
-CABG [**1-19**] after MI (at [**Hospital1 2177**]: LIMA to LAD, SVG to OM1, SVG to
PDA)
-Post-operative R.MCA CVA ~1wk after CABG-Pt with resultant
hemiplegia, aphasia, dsyphagia.
-Post-op large RUE DVT
-Status-post respiratory failure from CVA, now weaned of vent.
-Hypertension
-Peripheral vascular disease, status-post left
popliteal-dorsalis pedis bypass with saphenous vein graft
-Status-post sepsis at [**Hospital1 **] in [**Month (only) 958**]
-Diabetes mellitus, Type II. Diagnosed 40 years ago,
complicated by nephropathy, neuropathy (sensory and autonomic
leading to urinary retention) and retinopathy (s/p bilat
vitrectomies, L eye blindness).
-ESRD secondary to diabetic nephropathy + chronic allograft
insufficiency s/p R cadaveric kidney transplant, complicated by
postinfectious GN (negative [**Doctor First Name **], ANCA, low complemt), signs of
chronic rejection (sclerotic glomeruli, interstitial fibrosis
3/[**2158**]). On dialysis starting [**2148**]. Tu/Th/sat
-Anemia
-Neurogenic bladder
-BPH status-post TURP [**2157**].
-Chronic osteomyelitis of C-spine and bilateral feet, s/p
bilateral transmetatarsal amputations (R foot [**2145**], L foot
[**2157**]).
-HSV stomatitis/genital
-Recurrent UTI
-blindness in R.eye
- Adrenal insufficiently diagnosed this year.
- ICD for mobitz type II
Social History:
Immigrated from [**Country **] in [**2141**]. Retired civil engineer.
Retired at age 47 because of health issues. Currently lives at
home with his wife and 38 year old daughter. Daughter, [**Name2 (NI) 4457**],
provides most of his care. Denies alcohol, tobacco, drug use.
Family History:
Mother and brother with DM Type 2.
Physical Exam:
T: 95.0 BP: 131/79 HR:79 RR:20 O2Sat: 100(3L)
GENERAL: NAD, talking to daughter
[**Name (NI) 4459**]: L cataract, poor vision, poor dentition, no cervical LAD,
no JVD
CARDIAC: RRR, nl S1S2, 2/6 systolic murmur at left sternal
border
PULM: left CTA, unable to auscultate right lung
ABD: firm, NT/ND, G-tube in place, BS+
EXT: warm, stumps C/D/I, no C/C/E
NEURO: left hemiparesis
SKIN: sacral decub ulcer, stage 2
....
On discharge, exam was unchanged except for the following:
PULM: Improvement of breath sounds in the right lung, though
still diminshed compared to left. No crackles/wheezes/rhonchi.
Pertinent Results:
Admission labs:
[**2162-10-9**] 02:50PM BLOOD WBC-6.2 RBC-3.46* Hgb-9.9* Hct-30.6*
MCV-89 MCH-28.7 MCHC-32.4 RDW-19.0* Plt Ct-185
[**2162-10-9**] 02:50PM BLOOD PT-14.0* PTT-37.2* INR(PT)-1.2*
[**2162-10-9**] 02:50PM BLOOD Fibrino-664*#
[**2162-10-9**] 02:50PM BLOOD FDP-10-40*
[**2162-10-9**] 02:50PM BLOOD Glucose-113* UreaN-25* Creat-4.1* Na-141
K-4.1 Cl-98 HCO3-34* AnGap-13
[**2162-10-9**] 02:50PM BLOOD ALT-19 AST-22 CK(CPK)-19* AlkPhos-111
TotBili-0.5
[**2162-10-9**] 02:50PM BLOOD Lipase-10
[**2162-10-9**] 02:50PM BLOOD CK-MB-NotDone cTropnT-0.33*
[**2162-10-9**] 02:50PM BLOOD Calcium-9.8 Phos-3.4 Mg-2.4 Iron-29*
[**2162-10-9**] 02:50PM BLOOD calTIBC-140* VitB12-GREATER TH
Folate-17.7 Ferritn-743* TRF-108*
Labs prior to transfer to MICU:
[**2162-10-14**] 12:18PM BLOOD WBC-18.4* RBC-3.22* Hgb-9.6* Hct-29.1*
MCV-91 MCH-29.7 MCHC-32.8 RDW-19.7* Plt Ct-272
[**2162-10-14**] 12:18PM BLOOD Glucose-197* UreaN-37* Creat-4.4* Na-139
K-4.2 Cl-100 HCO3-29 AnGap-14
[**2162-10-14**] 12:18PM BLOOD ALT-11 AST-17 AlkPhos-108 Amylase-209*
TotBili-0.5
[**2162-10-14**] 12:18PM BLOOD Calcium-9.5 Phos-3.2 Mg-2.1
[**2162-10-14**] 09:07PM BLOOD Glucose-253* Lactate-1.8 Na-141 K-3.4*
Cl-98*
[**2162-10-14**] 09:07PM BLOOD Type-ART pO2-80* pCO2-46* pH-7.46*
calTCO2-34* Base XS-7
Repeat Blood Gas MICU day 1:
[**2162-10-15**] 08:22AM BLOOD Type-ART pO2-102 pCO2-42 pH-7.48*
calTCO2-32* Base XS-6
Discharge labs:
[**2162-10-26**] 08:10AM BLOOD WBC-12.3 Hgb-9.1 Hct-27.4 MCV-91 Plt
Ct-333
[**2162-10-26**] 08:10AM BLOOD Glucose-202 UreaN-63 Creat-4.7 Na-139
K-3.4 Cl-103 HCO3-27 Ca 9.3 Mg 2.0 P 3.5
Radiology:
CXR [**10-9**]:
1. Interval development of large right hydropneumothorax.
2. Malpositioned right PICC tip projects over the subclavian
vein at the
upper lateral right chest. Repositioning is recommended.
CT [**10-9**]:
1. Large right hydropneumothorax. Predominantly loculated
posteriorly, with
smaller anterior component with layering fluid. Right lung
mostly collapsed,
except for a small portion of the right upper lobe.
2. Moderate left pleural effusion, with related compressive
atelectasis.
3. No free air in the abdomen.
G-tube study [**10-9**]:
G-tube in appropriate position within the stomach, without
evidence of contrast extravasation.
Cytology on [**10-11**] and [**10-17**]:
NEGATIVE FOR MALIGNANT CELLS
Head CT [**10-14**]:
IMPRESSION:
1. No evidence of hemorrhage or recent infarction.
2. Chronic right MCA territory infarction.
3. Periventricular white matter disease and findings consistent
with age-
related atrophy.
4. Sinus mucosal disease.
5. No significant change from [**2162-10-6**].
CXR [**10-14**] prior to MICU transfer:
1. Bilateral hydropneumothoraces, not significantly changed from
previous
radiograph.
LENI [**10-16**]:
IMPRESSION:
1. No lower extremity DVT.
2. Small amount of subcutaneous edema bilaterally.
CTA [**10-16**]:
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Bilateral hydropneumothorax, with hemothorax on the right.
The size of
the pneumothorax component on the left has slightly decreased.
3. Bibasilar atelectasis, unchanged. The possibility of
superimposed
consolidation is difficult to exclude.
CXR [**10-21**]:
IMPRESSION: No significant change in moderate right-sided
hydropneumothorax
and small left apical pneumothorax.
Brief Hospital Course:
This is a 73M with history of ESRD, COPD, CAD, CVA transferred
from an outside hospital with bilateral pleural effusions and
right loculated hemopneumothorax.
Question of perforated G-tube:
On admission to the [**Hospital1 **], a G-tube check indicated proper
placement of the G-tube with no extravasation of contrast,
indicating that a perforation was not present. Repeat CT
indicated no free air in the abdomen.
Hemopneumothorax:
A CXR for PICC placement on admission showed worsening
hemopneumothorax. CT scan showed large right hydropneumothorax,
which is predominantly loculated posteriorly, with smaller
anterior component with layering fluid. Right lung was mostly
collapsed, except for a small portion of the right upper lobe.
There was also moderate left pleural effusion, with related
compressive atelectasis. Large, round perihilar lymph nodes were
also noted. IP and thoracics were consulted the patient had 3
chest tubes placed on HD2: left, right anterior, and right
posterior. The chest tubes drained serosanguinous fluid that was
exudative by Light's criteria. No malignant cells were noted on
cytology. On HD3, the patient received a bronchoscopy that ruled
out endotrachial tumors and cleared secretions. Two chest tubes
were taken out on HD9 and HD10, but the left posterior tube was
left in place. Repeat chest CTA on HD11 showed the size of right
hemopneumothorax had decreased, but was still loculated, the L
lung had re-expanded, although there was still a persistent
apical pneumothorax. Patient was further evaluated by thoracic
surgery and interventional pulmonology, and both teams decided
that chest tubes would be of no further benefit to the patient.
A surgical operation would be necessary to re-expand the
patient's right lung, but the patient was not a surgical
candidate due to his multiple co-morbidities. On HD13, the last
chest tube was also taken out. On HD15, patient received
another therapeutic bronchoscopy that was only signficant for
secretions.
Pneumonia:
The patient developed a pseudomonas pneumonia on HD7 and was
initially treated with Zosyn. The pseudomonas was eventually
found to be pan-sensitive and the patient was started on
Ceftazidime 1g IV qHD, which is the dose for ESRD on HD. He was
continued on this regimen until discharge. He will receive one
more dose of Ceftazidime at HD after discharge, after which he
will have completed a 14 day course.
Mental status:
The patient was alert and oriented x 3 upon transfer to the [**Hospital1 **].
However, his mental status began to wax and wane. On HD5, he
became somnolent, but was still arousable. His mental status
deteriorated over the next day, and on HD7, when his white blood
cell count climbed to 18.5, he became difficult to arouse. He
triggered for tachypnea and nursing concern for somnolence.
Head CT was negative for bleed/ischemia. He was transferred to
the MICU with a blood gas of 7.46/46/80. In the MICU, CTA was
negative for PE. Lumbar puncture showed no PMN or
micro-organisms on gram stain and no growth was noted on
culture. His respiratory culture speciated while in the MICU,
and he began Ceftazidime for pseudomonas pneumonia at this time.
HD11, his oxygenation had improved and his WBC count had
decreased to 11.2, and the patient was transferred back to
floor. On the floor, his mental status continued to improve
with intermittent periods of somnolence. On the day of
discharge, his mental status was back to his baseline. He was
alert and oriented x 3 (aware of his name, that he was at [**Hospital1 18**],
and that it was [**Month (only) 359**]).
Diarrhea/Rectal Bleeding:
On HD15, the patient developed loose stools and diarrhea and a
rectal tube was inserted. Bloody diarrhea was then noticed in
the rectal tube, and it was discontinued. The patient was
started on PO vancomycin to cover for C. diff. He was found to
be C. diff negative x 2, and stool culture, ova and parasite
were negative as well. PO vancomycin was discontinued. On HD18,
the day of discharge, the patient's abdominal pain and
distension had resolved, and he was no longer having diarrhea.
DMII:
The patient's DMII was managed with a Humalog sliding scale. He
was also started back on Lantus, which he was on at home. At
time of discharge, the patient was receiving 9U of Lantus at
noon as well as the sliding scale.
ESRD:
He received dialysis every Tuesday, Thursday, Saturday, and also
received Epo and antibiotics at HD. He was always diuresed to
his dry weight, or as much as possible while still maintaining
his SBP above 90mmHg.
Coronary Artery Disease (s/p MI and CABG in [**1-19**]) and
Hypertension were stable throughout the hospital course. He was
managed on his home medications.
Medications on Admission:
Zocor 10mg QHS
Prednisone 10 mg QD
Aspirin 81 mg PO DAILY
Metoclopramide 5 mg/5 mL Five (5) ml PO TID via g-tube.
Therapeutic Multivitamin DAILY via g-tube
Simethicone 40 mg/0.6 mL Drops via g-tube.
Robitussin 200mg Q6H PRN
Vicodin 5mg Q4H PRN
Prevacid 30mg [**Hospital1 **]
Regular Insulin SS
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ceftazidime 1 gram Recon Soln Sig: One (1) Recon Soln
Intravenous QHD (each hemodialysis) for 1 doses: At dialysis on
[**2162-10-28**].
Disp:*1 gram* Refills:*0*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
5. Metoclopramide 5 mg/5 mL Solution Sig: One (1) PO three
times a day.
6. Simethicone 40 mg/0.6 mL Drops, Suspension Sig: One (1) PO
once a day.
7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Lantus 100 unit/mL Cartridge Sig: Nine (9) Units Subcutaneous
once a day: Please give at 12:00pm.
Disp:*1 cartridge* Refills:*2*
9. Insulin Sliding Scale
Resume previous home sliding scale.
10. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary Diagnoses:
Bilateraly hemopneumothorax
Pseudomonas pneumonia
Secondary Diagnoses:
Coronary artery disease
Right-sided Cerebral Vascular Accident
Hypertension
Peripheral Vascular Disease
Diabetes Mellitus Type II with diabetic nephropathy and diabetic
neuropathy and diabetic retinopathy
Post-infectious glomerulonephropathy
Anemia
Neurogenic bladder
Benign Prostatic Hypertrophy
Mobitz II with pacemaker/ICD
Adrenal Insufficiency
End Stage Renal Disease on Hemodialysis
Discharge Condition:
stable, good oxygenation on room air
Discharge Instructions:
You were admitted because you had difficulty with breathing due
to large, bilateral hemopneumothoraces (blood and air around
your lungs). You had three chest tubes placed in your chest to
help drain the fluid.
You also developed a pneumonia while in the hospital that you
are being treated for with antibiotics.
Please continue to take the medications provided to you at the
time of this discharge. We have made the following changes to
your medications.
1. Antibiotics: You should receive one more dose of Ceftazipime
1mg IV at hemodialysis on Thursday [**2162-10-28**].
2. Insulin: Please take Lantus 9 units once daily; continue your
insulin sliding scale.
3. Your prednisone has been decreased to 5 mg daily.
.
Please follow up with your Primary Care Physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], after discharge as listed below. You should have a
colonoscopy as an outpatient; Dr [**Last Name (STitle) **] will help you arrange
this.
Please follow up with Pulmonology for continued work up of your
lung issues, including the hemopneumothoraces and enlarged hilar
lymph nodes.
.
Please come back to the Emergency Room if you experience nausea,
vomiting, diarrhea, bleeding from your rectum, shortness of
breath, chest pain, change in mental status, difficulty or
intolerance of tube feeds, or fever to 101F.
Followup Instructions:
Please follow up on these appointments, which are already
scheduled:
PULMONOLOGY (DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1112**]/Dr [**Last Name (STitle) **]): [**2162-11-3**] 1:00 PM
([**Hospital Ward Name 23**] 7). Call [**Telephone/Fax (1) 612**] with questions.
PRIMARY CARE (DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **])
[**2162-11-26**]. 3:30pm. [**Hospital6 733**] - [**Location (un) 8661**]
Atrium at [**Hospital1 69**] [**Hospital Ward Name 516**]. You
will need a colonoscopy in the near future; Dr [**Last Name (STitle) **] will help
you arrange this.
Completed by:[**2162-10-27**]
|
[
"533.90",
"V45.81",
"438.82",
"438.20",
"482.1",
"275.3",
"996.81",
"357.2",
"585.6",
"412",
"780.09",
"276.8",
"788.20",
"511.89",
"250.62",
"414.00",
"578.1",
"707.22",
"276.0",
"285.21",
"438.11",
"255.41",
"707.03",
"276.50",
"789.00",
"787.20",
"E935.4",
"403.91",
"998.11",
"337.1",
"362.01",
"E915",
"E878.0",
"E879.4",
"934.8",
"511.9",
"787.91",
"596.54",
"250.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.09",
"96.6",
"99.10",
"33.24",
"03.31",
"39.95",
"96.05",
"88.73",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
12669, 12724
|
6648, 9067
|
440, 533
|
13247, 13286
|
3325, 3325
|
14713, 15364
|
2651, 2687
|
11721, 12646
|
12745, 12815
|
11403, 11698
|
13310, 14690
|
4735, 6625
|
2702, 3306
|
12836, 13226
|
277, 402
|
561, 1004
|
3341, 4719
|
9082, 11377
|
1026, 2340
|
2356, 2635
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,293
| 142,265
|
42371
|
Discharge summary
|
report
|
Admission Date: [**2138-2-14**] Discharge Date: [**2138-2-19**]
Date of Birth: [**2059-11-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest tightness; shortness of breath
Major Surgical or Invasive Procedure:
[**2138-2-14**] Aortic valve replacement (23 St. [**Male First Name (un) 923**] tissue),
Coronary artery bypass graft x1 (Left internal mammary artery to
left anterior descending)
History of Present Illness:
78 year old male with a history of aortic stenosis who has been
followed with serial echocardiograms. He reports exertional neck
and shoulder pain when carrying laundry up stairs. This is
occasionally associated with "tightness" in his chest and mild
shortness of breath that resolves after resting 30-60 seconds.
He also describes 1-2 episodes of lone mild chest tightness at
rest while [**Location (un) 1131**] a book lasting 5-10 seconds which resolved
spontaneously. He was referred for right and left heart
catheterization for evaluation for possible future aortic valve
replacement surgery. He was found to have coronary artery
disease and severe aortic stenosis on catheterization and is now
admitted for aortic valve replacement and revascularization.
Past Medical History:
Aortic stenosis
Prostate cancer and prostatectomy [**2129**]
Heme positive stool
Depression
Basal cell lesions removed
History of anemia
Hip abscess as a child
s/p Cholecystectomy
s/p Herniorrhaphy
s/p Prostatectomy
Social History:
Race:Caucasian
Last Dental Exam:5 months ago, he will call dentist to have
dental clearance faxed
Lives with: Wife
Contact: [**Name (NI) 622**] (wife) #[**Telephone/Fax (1) 91763**]
Occupation: Retired construction superintendant and estimator
Cigarettes: Smoked no [x] yes []
Other Tobacco use: denies
ETOH: [**1-13**] scotch or rye daily
Illicit drug use: denies
Family History:
Premature coronary artery disease- Uncle with CAD
Physical Exam:
Pulse:68 Resp:18 O2 sat:100/RA
B/P Right:135/75 Left:127/81
Height:5'6" Weight:171 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade SEM III/VI
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: None [x], multiple spider veins
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 referred murmur to carotids
Pertinent Results:
[**2138-2-14**] Echo: PRE-BYPASS: No spontaneous echo contrast is seen in
the body of the left atrium or left atrial appendage. 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. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The ascending aorta is
mildly dilated. There are simple atheroma in the aortic arch.
There are simple atheroma in the descending thoracic aorta.
There appear to be three aortic valve leaflets with almost
complete fusion of the left and right coronary cusps. The aortic
valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Mild (1+)
aortic regurgitation is seen. The anterior mitral valve leaflet
is moderately thickened. The posterior mitral leaflet is very
calcified and mobility is significantly restricted. Mild (1+)
mitral regurgitation is seen. There is no mitral stenosis. There
is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person
of the results in the operating room.
POSTBYPASS: There is a bioprosthetic valve in the aortic
position. The valve appears well-seated with normal leaflet
mobility. There are no apparent paravalvular leaks. There is no
AI. The peak gradient across the aortic valve is , and the mean
gradient is , with a cardiac output of 4.5L/min. The left
ventricle appears small, consistent with hypovolemic state. The
left ventricular systolic function appears normal, EF>55%. Other
valvular function remains unchanged.
Admission labs:
[**2138-2-14**] 07:44AM HGB-11.5* calcHCT-35
[**2138-2-14**] 07:44AM GLUCOSE-106* LACTATE-1.4 NA+-138 K+-4.4
CL--108
Discharge labs:
[**2138-2-17**] 04:50AM BLOOD WBC-11.0 RBC-3.17* Hgb-9.4* Hct-27.7*
MCV-88 MCH-29.5 MCHC-33.8 RDW-14.8 Plt Ct-143*
[**2138-2-17**] 04:50AM BLOOD Plt Ct-143*
[**2138-2-17**] 04:50AM BLOOD Glucose-126* UreaN-26* Creat-1.0 Na-141
K-3.9 Cl-102 HCO3-32 AnGap-11
[**2138-2-16**] 05:25AM BLOOD Mg-2.0
Radiology Report CHEST (PORTABLE AP) Study Date of [**2138-2-16**]
12:18 PM
Final Report CHEST ON [**2-16**]
FINDINGS: The endotracheal tube, Swan-Ganz catheter, NG tube
have all been
removed. Left-sided chest tube has been removed. There is a
small left
apical pneumothorax. There is a small left pleural effusion.
DR. [**First Name (STitle) **] [**Doctor Last Name **]
[**2138-2-19**] 04:50AM BLOOD PT-10.9 INR(PT)-1.0
Brief Hospital Course:
Mr. [**Known lastname **] was a same day admission to the operating room where
he underwent an aortic valve replacement and coronary artery
bypass graft x1 on [**2-14**] by Dr [**Last Name (STitle) **]. Please see operative note
for surgical details in summary he had:
1. Aortic valve replacement, 23-mm Biocor Epic porcine valve.
2. Coronary artery bypass grafting x1 with the left internal
mammary artery graft to left anterior descending artery.
His cardiopulmonary bypass time was 101 minutes with a
crossclamp time of 82 minutes. He tolerated the surgery well and
post-operatively was transferred to the CVICU for invasive
monitoring in stable condition. Within 24 hours he was weaned
from sedation, awoke neurologically intact and extubated. He
remained hemodynamically stable and on POD1 was started on ASA,
Bblockers, statin and diuretics. Additionally he was transferred
to the stepdown floor for further post-operative care. All tubes
lines and drains were removed per cardiac suregry protocol.
Once on the stepdown floor he worked with nursing and physical
therapy to improve his strength and endurance. On POD# 4 he had
several episodes of rapid Atrial Fibrillation. He was given an
Amio bolus and placed on oral meds. In addition, he was started
on anticoagulation with Coumadin. He converted to normal sinus
rhythm. He continued to progress post-operatively and on POD #5
was discharged home with visiting nurses. He is to follow up in
wound clinic in 1 week and with Dr [**Last Name (STitle) **] in 4 weeks.First INR
check tomorrow with results to Dr. [**Last Name (STitle) **]. Target INR 2.0-2.5 .
Medications on Admission:
FLUOXETINE 20 mg Daily
LEUPROLIDE 1 injection every 6 months (for prostate)
SIMVASTATIN 20 mg Daily
ASCORBIC ACID [VITAMIN C] Dosage uncertain
ASPIRIN 81 mg Daily
MULTIVITAMIN WITH MIN-FA-LYCOPENE [ONE-A-DAY MEN'S] Dosage
uncertain
VITAMIN E 400 unit Daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*1*
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
3. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
4. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
9. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 1 weeks.
Disp:*14 Tablet Extended Release(s)* Refills:*0*
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
11. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
12. 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*
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
14. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
15. warfarin 1 mg Tablet Sig: MD to order daily dosing Tablet PO
Once Daily at 4 PM: dose today 5 mg [**2-19**] only; all further daily
dosing per Dr. [**Last Name (STitle) **]; target INR 2.0-2.5 for A Fib.
Disp:*75 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 3765**] Hospice Program
Discharge Diagnosis:
Aortic stenosis s/p Aortic valve replacement
Coronary artery disease s/p Coronary artery bypass graft x 1
postop atrial fibrillation
Past medical history:
Prostate cancer and prostatectomy [**2129**]
Heme positive stool
Depression
Basal cell lesions removed
History of anemia
Hip abscess as a child
s/p Cholecystectomy
s/p Herniorrhaphy
s/p Prostatectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Incision-N/A
Edema: 1+ bilat
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
[**Hospital 409**] Clinic: [**2138-2-25**] at 10:30a [**Telephone/Fax (1) 1504**]
Surgeon: Dr. [**Last Name (STitle) **] [**2138-3-19**] at 1:00p [**Telephone/Fax (1) 1504**]
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7756**] [**2138-3-10**] at 2:00p
Please call to schedule appointment with your
Primary Care Dr. [**First Name (STitle) 2530**] [**Name (STitle) **] in [**4-17**] weeks [**Telephone/Fax (1) 71053**]
**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:[**2138-2-19**]
|
[
"V45.79",
"E878.2",
"V10.46",
"285.9",
"311",
"414.01",
"V10.83",
"997.1",
"V45.77",
"427.31",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9133, 9200
|
5263, 6879
|
348, 530
|
9598, 9789
|
2720, 4369
|
10591, 11289
|
1957, 2008
|
7187, 9110
|
9221, 9354
|
6905, 7164
|
9813, 10568
|
4522, 5240
|
2023, 2701
|
272, 310
|
558, 1319
|
4385, 4506
|
9376, 9577
|
1574, 1941
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,724
| 183,435
|
24675
|
Discharge summary
|
report
|
Admission Date: [**2138-6-5**] Discharge Date: [**2138-6-7**]
Date of Birth: [**2090-3-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Neck discomfort.
Major Surgical or Invasive Procedure:
Fiberoptic endoscopy [**2138-6-5**].
History of Present Illness:
Mr. [**Known lastname 62275**] is a 48 year-old male with PMH significant for
GERD and asthma, status post left shoulder AC joint
reconstruction by Dr. [**Last Name (STitle) 62276**] on the day of admission. He was
discharged from the PACU after an uncomplicated surgery.
Per discussion with anesthesia, intubation was not complicated
but placement of the OG tube required force. At home, Mr.
[**Known lastname 62275**] reported that he felt sinus congestion and fullness in
his in right ear. He then pinched his nose and did a valsalva
maneuver to clear the congestion. Seconds later, he found that
his right neck, cheek and periauricular area puffed out with
air. He subsequently presented to the pre-op holding area, where
a STAT CXR and neck X-ray showed pneumomediastinum and SQ
empyshema in neck, no pleural effusion.
ENT was consulted. A fiberoptic scope did not demonstrate
air/damage in upper pharynx. He was admitted to the [**Hospital Unit Name 153**] for
closer monitoring. Of note, he says the swelling is actually
getting better.
Past Medical History:
Exercise-induced asthma
Status post left shoulder reconstruction for AC separation
Gastroesophageal reflux disease
Social History:
He denies tobacco or EtOH intake.
Family History:
Non-contributory.
Physical Exam:
Physical examination on admission:
VITALS: AF, 92, 130/61, 12, 100% 2L
Gen: Flattened affect but not in extremis
HEENT: NCAT, oropharynx clear
Neck: Supple, +SQ emphysema around neck (B) extending to R>L
check, around platysmus and extending to upper chest area
CVS: RRR, no mrg
Lungs: CTA except rales at R base
Abd: Soft, NABS, NT/ND
Extremities: No edema, L extremity in sling, 2+ pulses
Pertinent Results:
Relevant laboratory data on admission ([**2138-6-5**]):
CBC:
WBC-15.4*# RBC-4.83 HGB-13.7* HCT-39.5* MCV-82 MCH-28.4
MCHC-34.7 RDW-13.1 PLT SMR-NORMAL PLT COUNT-303
NEUTS-88* BANDS-2 LYMPHS-10* MONOS-0 EOS-0 BASOS-0 ATYPS-0
METAS-0 MYELOS-0
Chemistry:
GLUCOSE-136* UREA N-13 CREAT-1.1 SODIUM-139 POTASSIUM-4.8
CHLORIDE-102 TOTAL CO2-25 ANION GAP-17
CALCIUM-9.6 PHOSPHATE-1.2* MAGNESIUM-2.0
LACTATE-3.7*
Relevant imaging data:
[**2138-6-5**] CXR: Lucency along the left cardiac silhouette and
along the left trachea represents mediastinal air. There is no
evidence for PTX, though the upper most apices are not imaged.
The left costophrenic angle is not imaged. The lungs are clear
given these limitations, the pleurae are normal. The heart is
top normal. The mediastinal contours are normal besides presence
of mediastinal emphysema.
[**2138-6-5**] NECK X-RAY: Moderate subcutaneous emphysema is seen
tracking within the soft tissues of the neck. Lung apices are
unremarkable.
[**2138-6-5**] CT NECK: There is extensive pneumomediastinum extending
into the
parapharyngeal spaces as well as subcutaneous soft tissues of
the neck. There is no definite evidence of disruption of the
trachea or esophagus. Oral contrast is noted in the esophagus
and there is no extravasation of oral contrast into the
mediastinum. On lung windows, there is minimal atelectasis in
the LLL.
[**2138-6-6**] CXR: There is persistent mediastinal emphysema
extending into the soft tissues of the neck bilaterally. No
definite pneumothorax. The lungs remain clear and there are no
definite pleural effusions in this single view.
[**2138-6-7**] CXR: Single portable radiograph of the chest again
demonstrates air within the superior mediastinum and soft
tissues of the neck. The cardiac silhouette is unremarkable.
The hila are unremarkable. The lungs are clear. Trachea is
midline.
Brief Hospital Course:
48 year-old male with a history of asthma, status post
uncomplicated left AC joint reconstruction, presenting with
subcutaneous emphysema and pneumomediastinum following a
Valsalva maneuver. His brief hospital course will be reviewed by
problems.
1) Subcutaneous emphysema and pneumomediastinum: As noted above,
a CXR and neck X-ray were remarkable for subcutaneous emphysema
and pneumomediastinum. A CT neck was subsequently obtained which
confirmed the above findings. No definite evidence for tracheal
injury was found (although not fully excluded by CT), and there
was no evidence of contrast extravasation from the esophagus. As
noted above, ENT was consulted, and a fiberoptic endoscopy
showed a normal pharynx/larynx. Thoracic surgery was consulted,
with recommendation to manage conservatively. Serial CXRs showed
stable findings, and Mr. [**Known lastname 62275**] remained clinically stable.
He was placed on empiric antibiotic coverage with Clindamycin,
initially IV then oral. A mouth care regimen was also initiated
with chlorhexidine and nystatin, and he was placed on stool
softeners to prevent straining.
Given radiographic stability and clinical improvement, he was
discharged home directly from the ICU on hospital day #3. He
will complete a 7-day course of Clindamycin as an out-patient
(last doses on [**2138-6-12**]). He was instructed to use his mouthcare
regimen, and stool softeners, and emphasis was placed on
avoidance of lifting or straining. He will contact Dr.[**Name2 (NI) 1816**]
office on Monday [**6-9**] and schedule a follow-up appointment to
be seen in [**6-23**] days.
2) Status post left shoulder AC reconstruction: He was followed
by the Orthopedics service while in the hospital. His left arm
was kept in a sling, non weight bearing. Pain control was
achieved with Percocet as needed. He has a scheduled follow-up
appointment with Dr. [**Last Name (STitle) 2719**] on [**2138-6-18**].
Medications on Admission:
Prilosec OTC 20 mg PO QD
Rhinocort
Discharge Medications:
1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) for 10 days.
Disp:*qs qs* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*20 Capsule(s)* Refills:*0*
3. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every
six (6) hours for 6 days: Last doses on [**2138-6-12**].
Disp:*24 Capsule(s)* Refills:*0*
4. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day) for 10 days: After
brushing, rinse for 30 seconds, then spit.
Disp:*qs qs* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
6. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Mediastinal emphysema
Status post left shoulder reconstruction
Discharge Condition:
Patient discharged home in stable condition.
Discharge Instructions:
Please call your PCP or return to the hospital if you notice
increased neck or facial swelling, or if you develop increased
shortness of breath, chest pain or fever.
We have prescribed an antibiotic called Clindamycin. Please take
1 tablet every 6 hours for an additional 6 days (last doses on
[**2138-6-12**]).
Please AVOID ALL STRAINING. We have started stool softeners.
Please take Colace twice daily as prescribed for at least 10
days. Please also use the mouth care regimen prescribed for the
next 10 days. NO LIFTING.
Please keep your left arm in a sling as instructed by
Orthopedics until follow-up with Dr. [**Last Name (STitle) 2719**].
Please call Dr.[**Name (NI) 1816**] office on Monday [**Telephone/Fax (1) 170**] (Thoracic
surgery) and schedule an appointment to be seen in [**6-23**] days.
Followup Instructions:
1. You have a scheduled appointment with Dr. [**Last Name (STitle) 2719**] on [**6-18**]. Please see below for details.
- Provider: [**Name10 (NameIs) 8741**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2138-6-18**] 2:20.
2. Please call Dr.[**Name (NI) 1816**] office on Monday [**Telephone/Fax (1) 170**]
(Thoracic surgery) and schedule an appointment to be seen in
[**6-23**] days.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2138-6-7**]
|
[
"E826.1",
"493.81",
"530.81",
"831.04",
"998.81",
"998.2",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.83"
] |
icd9pcs
|
[
[
[]
]
] |
6827, 6833
|
3990, 5919
|
336, 375
|
6940, 6987
|
2101, 3967
|
7844, 8425
|
1655, 1674
|
6005, 6804
|
6854, 6919
|
5945, 5982
|
7011, 7821
|
1689, 1710
|
280, 298
|
403, 1450
|
1724, 2082
|
1472, 1588
|
1604, 1639
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,945
| 169,507
|
10092
|
Discharge summary
|
report
|
Admission Date: [**2181-3-23**] Discharge Date: [**2181-4-9**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Presented to OSH with c/o SOB x several days
Major Surgical or Invasive Procedure:
Aortic valve replacement [**2181-4-2**] with 23 mm CE Magna pericardial
tissue valve.
History of Present Illness:
This is an 80 yo female who presented to OSH [**3-20**] with
compliants of shortness of breath. Treated for CHF with
diuresis and CPAP and heart rate controlled with beta blockers.
At OSH, cath revealed severe aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of
0.3-0.4 cm2, with echo confirming this and showing an EF of 50%.
She was transferred to the [**Hospital1 18**] for eval for AVR.
Past Medical History:
Diabetes type 2
Hypothyroidism
Hypertension
Hyperlipidimia
Anemia/ GIB
Atrial fibrillation
Inflammatory breast CA s/p XRT/chemo
Hypertrophic cardiomyopathy
Bilateral knee replacement
Chronic obstructive pulmonary disease
Social History:
Lives alone in [**Hospital3 **]. Denies history of ETOH or
tobacco use.
Pertinent Results:
[**2181-4-4**] 06:05AM BLOOD WBC-11.7* RBC-3.32* Hgb-8.7* Hct-26.8*
MCV-81* MCH-26.2* MCHC-32.4 RDW-19.3* Plt Ct-134*
[**2181-4-9**] 05:50AM BLOOD PT-14.0* PTT-26.1 INR(PT)-1.3
[**2181-4-5**] 05:50AM BLOOD Glucose-82 UreaN-24* Creat-0.8 Na-136
K-3.9 Cl-103 HCO3-26 AnGap-11
[**2181-4-1**] 06:25AM BLOOD ALT-11 AST-19 LD(LDH)-224 AlkPhos-95
Amylase-23 TotBili-0.4
[**2181-4-5**] 05:50AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.0
Brief Hospital Course:
Mrs. [**Known lastname 33705**] was admitted from an OSH on [**2181-3-23**] with aortic
stenosis for evaluation for aortic valve replacement. Because
of her history of GIB a GI consult was obtained with
recommendations for upper an lower endoscopy. On [**3-26**] she
underwent endoscopy showing external hemorrhoids, diverticulosis
of the sigmoid colon and descending, polyp in the transverse
colon, polyp in the mid-ascending colon (biopsy), and mass in
the proximal ascending colon (biopsy). Recs were then made to
await biopsy results as well as obtain CT scan of abdomen and to
start IV portonix. A pancreatic mass was detected for which a
general surgery consult was obtained; no recommendations for
surgical intervention were made. In this same time period Mrs.
[**Known lastname 33705**] began experinecing nose bleeds for which an ENT consult
was obtained.
After thorough pre-op workup, it was decided that Mrs. [**Known lastname 33705**]
would continue on the the OR for AVR.
On [**2181-4-2**] she proceeded to the OR with Dr. [**Last Name (STitle) **] for an
aortic valve replacement with a 23 mm CE magna pericardial
tissue valve. Please see op note for full details. On her
operative evening she was slow to wake up and was unable to
extubate. She was successfully weened and extubated in POD one
and was transferred to the inpatient floor for further
management and rehabilitation.
On POD two her chest tubes were discontinued and physical
therapy was initiated. On POD three her carduac pacing wires
were discontinued and she continued to progress. On POD three
she also experienced runs of afib rising to a rate in the 150s.
Over the next several days she continued to progress well with
ongoing physical therapy and electrolyte repletion. She was
also started on warfarin for her pre-op diagnosis of atrial
fibrillation.
On POD seven it was decided that hse was stable for transfer to
a rehabilitation facility but was not yet cleared by physical
tharapy and it was decided that she was safe for transfer to
rehab.
Medications on Admission:
Metformin, Avandia, Hyzaar, Aricept, Arimidex, Lipitor,
Coumadin, Digoxin, Atenolol, Aspirin, Levoxyl, Potassium
chloride, Niferex, Protonix.
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. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7
days. Tab Sust.Rel. Particle/Crystal(s)
10. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO ONCE
(once) for 1 doses: Dose daily per INR.
11. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
12. Aricept 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] - [**Location 4288**]
Discharge Diagnosis:
Aortic stenosis.
Diabetes type 2.
Congestive heart failure.
Atrial fibrillation.
Discharge Condition:
Stable.
Discharge Instructions:
Shower daily and wash incisions with soap and water. Rinse
well. Pat dry. Do not apply any creams, lotions, powders, or
ointments.
No lifting greater than 10 pounds.
No driving x 6 weeks.
[**Last Name (NamePattern4) 2138**]p Instructions:
Call to schedule appointment with Dr. [**Last Name (Prefixes) **] in 4 weeks.
Call to schedule appointment with Dr. [**Last Name (STitle) 8840**] in 2 weeks.
Call to schedule appointment with cardiologist in 2 weeks.
Completed by:[**2181-4-9**]
|
[
"577.9",
"V43.65",
"496",
"562.10",
"272.0",
"398.91",
"250.00",
"427.31",
"401.9",
"V15.3",
"V10.3",
"396.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"45.25",
"88.72",
"45.16",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5010, 5075
|
1649, 3692
|
312, 400
|
5200, 5209
|
1205, 1626
|
3884, 4987
|
5096, 5179
|
3718, 3861
|
5233, 5425
|
5476, 5723
|
228, 274
|
428, 852
|
874, 1096
|
1112, 1186
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,130
| 138,588
|
3012+55433
|
Discharge summary
|
report+addendum
|
Admission Date: [**2112-5-27**] Discharge Date: [**2112-6-17**]
Date of Birth: [**2085-5-22**] Sex: F
Service: LIVER TRANSPLANT SERVICE
HISTORY OF PRESENT ILLNESS: This is a 27-year-old female who
was otherwise healthy who had a suicide attempt with Tylenol
overdose on [**2112-5-27**] that ultimately progressed to severe
hepatic necrosis.
HOSPITAL COURSE: The patient ultimately became
encephalopathic, was intubated for airway protection and an
ICP monitoring [**Last Name (un) **] catheter was placed into her right
hemicranium. After consultation with the family and with the
transplant service was obtained, the patient was listed as a
priority 1 status and ultimately underwent orthotopic liver
transplantation on [**2112-6-2**]. Her intraoperative course was
relatively unremarkable. There was only a 500 cc blood loss.
She had a duct to duct anastomosis with no T tube placed.
She had medial and lateral JP and left the operating room
intubated and with a Swan-Ganz catheter in the intensive care
unit. The patient stayed there for approximately five days
where she had received the typical protocol of induction
medications at the time of transplantation and was being
maintained on Neoral, CellCept and Solu-Medrol
postoperatively with a taper. Ultimately the patient had her
Swan-Ganz catheter discontinued. Her encephalopathy cleared.
Her ICP pressure stayed completely normal throughout her
intensive care unit stay. She never had any evidence of
infection. Once her [**Last Name (un) **] catheter was discontinued and her
Swan was removed, the patient had her arterial line removed
and she was actually transferred out to the floor.
Over the ensuing days the patient had her diet advanced.
After her diet was advanced the patient was noted to have a
significant amount of fluid draining from an anterior
abdominal drain. This was found to be likely ascites and she
was losing quite a bit of albumin. Therefore she was
resuscitated with albumin and ultimately the decision was
made to remove the drain and allow her body to reabsorb the
ascitic fluid. Her graft appeared to be functioning quite
well and her ALT and AST serially decreased from the several
thousand value preoperatively and postoperatively to a
somewhat normal range of 174 for the ALT and AST of
approximately 95. Her alkaline phosphatase was slightly
elevated at 267, however it had declined over several days.
Her albumin was 2.7 with a total bilirubin down to 1.6. Her
cyclosporine levels were being titrated serially and she was
requiring very minimal dosing. She did have some evidence of
cyclosporine toxicity which had induced a creatinine rise to
approximately 2.1 at peak and it was down to 1.9 prior to the
time of discharge. She was being maintained on 75 mg p.o.
b.i.d. of Neoral and CellCept 1 gram p.o. b.i.d. and
prednisone 15 mg p.o. q. day. She additionally was being
maintained on fluconazole 200 mg p.o. q. day, Bactrim
single-strength one tablet p.o. q. day, Valcyte 450 mg p.o.
q.o.d., Lasix 20 mg p.o. b.i.d. which was being held due to
the fact that the patient had undergone some orthostasis
secondary to her ascites loss, and metoprolol 25 mg p.o.
b.i.d. which was additionally being held, Protonix 40 mg p.o.
q.d., Colace 100 mg p.o. b.i.d., Percocet 5/325, 1-2 tablets
p.o. q. [**5-8**] p.r.n.
DISCHARGE MEDICATIONS: At discharge her medications will
include the above stated, although there may be a
modification stated during the discharge summary addendum.
DISCHARGE STATUS: Status post orthotopic liver transplant.
DISPOSITION: To home with a single [**Location (un) 1661**]-[**Location (un) 1662**] drain to JP
bulb suction. She will have a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] her.
She has received extensive education about her medications
and the need for their utility and she ultimately will be
followed up in the transplant clinic within a couple of days.
At the time of discharge the patient will receive her Neoral
level checks through her akinetic office and the results are
to be faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] clinic where the appropriate
dosage adjustments can be made.
There will be a discharge summary addendum to this report.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2112-6-15**] 12:10
T: [**2112-6-15**] 12:26
JOB#: [**Job Number 14368**]
Name: [**Known lastname 2245**], [**Known firstname **] Unit No: [**Numeric Identifier 2246**]
Admission Date: [**2112-5-27**] Discharge Date: [**2112-7-12**]
Date of Birth: [**2085-5-22**] Sex: F
Service: TRANSPLANT SURGERY
ADDENDUM: This is a Discharge Summary Addendum.
HOSPITAL COURSE: (continued)
1. On [**6-23**], the patient underwent venoplasty with
Interventional Radiology for stenosis of the right hepatic
vein. She was subsequently taken to the Operating Room on
[**2112-6-25**], for revision of the suprahepatic caval
anastomosis and liver biopsy. She was placed in the
Intensive Care Unit for close monitoring during this period.
Following the procedure, her T-bili rose to a peak of 2.6 and
eventually trended down to 1.5 on discharge.
On [**6-30**], which was postoperative day 27 from the original
procedure, she was transferred to the floor in stable
condition. Her diet was advanced. It was noted that her
outgoing phosphatase began to climb and on [**7-1**], she was
taken to endoscopic retrograde cholangiopancreatography where
anastomotic biliary stricture was found with successful stent
placement.
On [**7-5**], she was taken back to endoscopic retrograde
cholangiopancreatography because of continuing to rise
alkaline phosphatase and it was found that the stent
originally placed had migrated proximally. The stent was
exchanged successfully.
The patient had been placed on Lovenox and prior to discharge
the patient was initiated on Coumadin therapy for
anti-coagulation. On [**7-7**], the patient underwent CT scan
angiogram which showed normal hepatic artery and portal vein.
At this time, a urine culture which was sent was growing
Klebsiella and so she was given a course of Levofloxacin for
three days to cover her urinary tract infection.
By [**7-12**], the patient was ambulating well and voiding, was
tolerating p.o. and had an adequate analgesia with oral pain
medication. As previously stated, Coumadin therapy had been
initiated and Lovenox was to continue until her INR was in
the therapeutic range.
The patient was subsequently discharged in stable condition
with the follow-up arranged in [**Hospital 2247**] Clinic.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: Discharged to home with services.
DISCHARGE DIAGNOSES:
1. Fulminant liver failure secondary to Tylenol overdose.
2. Status post orthotopic liver transplant [**2112-6-2**].
3. Status post right hepatic vein thrombosis.
4. Status post right hepatic vein thrombectomy [**2112-6-23**].
5. Status post revision of suprahepatic caval anastomosis
[**2112-6-25**].
6. Status post right pleural effusion.
7. Status post right thoracentesis, complicated by
pneumothorax on [**2112-6-24**].
8. Status post endoscopic retrograde
cholangiopancreatography with stent placement on [**2112-7-1**].
9. Status post endoscopic retrograde
cholangiopancreatography with stent exchange [**2112-7-5**].
10. Postoperative pancreatitis.
11. Status post liver biopsy [**2112-7-8**].
12. Urinary tract infection.
13. Hyperglycemia.
DISCHARGE MEDICATIONS:
1. Bactrim Single strength one tablet p.o. q. day.
2. Valcyte 450 mg p.o. q. day.
3. Colace 100 mg p.o. twice a day.
4. Mycophenolate mofetil 500 mg p.o. four times a day.
5. Clonidine 0.1 mg p.o. three times a day.
6. Fluconazole 400 mg p.o. q. day.
7. Ursodiol 300 mg p.o. three times a day.
8. Prednisone 15 mg p.o. q. day.
9. Protonix 40 mg p.o. q. day.
10. Lovenox 40 mg subcutaneously q. day until INR is
therapeutic.
11. Coumadin 7 mg on the evening of discharge, dose to be
adjusted following laboratory values.
12. Dilaudid 4 mg p.o. q. four to six p.r.n. pain.
13. Neoral 100 mg p.o. twice a day.
14. Zofran 4 mg p.o. twice a day p.r.n. nausea.
DISCHARGE INSTRUCTIONS: The patient was instructed to
follow-up in [**Hospital 2247**] Clinic with Dr. [**Last Name (STitle) **] as scheduled.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**], M.D.,Ph.D. 02-366
Dictated By: [**First Name8 (NamePattern2) 2248**] [**Last Name (NamePattern1) 2249**], M.D.
MEDQUIST36
D: [**2112-7-24**] 17:42
T: [**2112-7-24**] 21:29
JOB#: [**Job Number 2250**]
|
[
"789.5",
"276.2",
"965.4",
"286.7",
"276.6",
"570",
"E950.0",
"572.2",
"996.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.59",
"39.49",
"99.10",
"51.10",
"99.15",
"96.6",
"97.05",
"96.72",
"39.50",
"54.91",
"50.11",
"01.18",
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
6877, 7637
|
7660, 8325
|
4886, 6768
|
8351, 8778
|
185, 363
|
6794, 6856
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,627
| 111,575
|
17154
|
Discharge summary
|
report
|
Admission Date: [**2156-4-20**] Discharge Date: [**2156-4-22**]
Date of Birth: [**2099-9-21**] Sex: F
Service: CARDIOLOGY INTENSIVE CARE UNIT
HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old
female with coronary artery disease status post RCA stent as
well as left circumflex stent, as well as hyperlipidemia, and
tobacco use who was admitted for carotid artery stenting.
The patient was noted initially in [**3-22**] to have a left
carotid bruit on examination. Subsequent duplex ultrasound
in [**3-22**] revealed left carotid 70 to 79 percent stenosis as
well as a 40 percent stenosis of the right carotid. The
patient was initially managed with Plavix and Lipitor. The
repeat ultrasound revealed further stenosis on the left up to
90 percent. The patient is referred for elective stenting of
the left carotid artery.
REVIEW OF SYSTEMS: Negative for any headaches, changes in
vision, changes in hearing, shortness of breath, chest pain,
dyspnea on exertion, PND, diarrhea, melena, BRBPR, or
myalgia.
PAST MEDICAL HISTORY: Coronary artery disease status post
left circumflex stent (Cypher in [**3-22**]), status post RCA
stent in [**5-22**] to the proximal RCA. A subsequent coronary
catheterization in [**8-22**] showed that the stents were patent,
though there was moderate branch disease. Her estimated
ejection fraction was 59 percent.
Hyperlipidemia.
Urinary tract infection.
Fibromyalgia.
Tendinitis.
Arthritis.
Right hearing loss.
Irritable bowel syndrome.
Lactose intolerance.
Carotid artery disease as detailed in the history of present
illness.
ALLERGIES: Include sulfa, erythromycin, and possibly also
penicillins. The patient also reports GI upset with aspirin.
She states that sulfa drugs cause nausea and facial swelling.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg.
2. Plavix 75 mg.
3. Protonix 40 mg.
4. Lipitor 10 mg.
5. Clonazepam p.r.n.
6. Tramadol p.r.n.
7. Cyclobenzaprine p.r.n.
SOCIAL HISTORY: She is married, lives with her husband. She
has an approximately 80-pack-year history of smoking, though
currently smokes 2 cigarettes per day. Denies any
significant alcohol use (drinks less than 1 glass of alcohol
a week), and denies any IVDA.
FAMILY HISTORY: Notable for ischemic stroke and stomach
cancer in her mother who had the stroke in her 60s and an MI
in her father, passed away at age 48. A sister has MS, and
several family members also have diabetes.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.5 degrees,
pulse of 40, blood pressure 114/46, respirations 16, oxygen
saturation 98 percent on room air. The patient was found to
be sitting in a chair, breathing comfortably, in no acute
distress. She was normocephalic/atraumatic. Pupils were
equally round and reactive to light. Extraocular muscles
were intact. Mucous membranes were moist. There were no
sores or lesions in the oropharynx. There was no JVD.
Regular rate and rhythm. Normal S1 and S2. No murmurs,
rubs, or gallops. Chest was clear to auscultation
bilaterally. Abdomen was soft, nontender, and nondistended.
Positive bowel sounds. There was no edema or calf
tenderness. Mental status examination is normal. The
patient had 5 plus upper and lower extremity strength.
Cranial nerves II-XII were intact. She had a normal sensory
examination, normal cerebellar examination, and normal gait.
LABORATORY DATA ON ADMISSION: White count is 12, hematocrit
is 25.8, platelets are 224,000, sodium is 145, potassium is
4.0, chloride 112, bicarbonate 24, BUN 8, creatinine 0.8,
glucose 102, calcium 8.3, magnesium 1.8, phosphorus 4.0, and
glycated hemoglobin is 5.4.
HOSPITAL COURSE: The patient was taken for elective coronary
artery stenting. Angiography was limited to the [**Doctor First Name 3098**], showed
no change in lesion in comparison to prior angiography. A
resting mean gradient of 30 mmHg was noted from the left CFA
to the aorta. Iliac angiography showed a very long diffuse
lesion in the left CIA. The [**Doctor First Name 3098**] was stented using
a PRECISE stent. Final angiography showed normal flow and no
evidence of distal embolism. The patient remained incident-
free throughout the procedure. She was, however, briefly
hypotensive with accompanying bradycardia during post
dilation that resolved with atropine and IV phenylephrine.
The patient was transferred to the cardiac intensive care
unit for post procedure monitoring. The patient was noted to
have ongoing bradycardia as well as hypotension and required
initially phenylephrine and subsequently was switched to
dopamine for maintenance of adequate postprocedure blood
pressure (target range 110:130 mmHg). The patient also
required several liters of normal saline boluses to maintain
target blood pressure. The patient's dopamine was weaned off
on [**4-21**], and the patient did not require dopamine for
adequate blood pressure maintenance for approximately 24
hours prior to discharge. Neurological examination did not
reveal any focal deficits (other than the aforementioned mild
right-sided hearing loss that was noted prior to this
procedure).
Hyperlipidemia. The patient's cholesterol panel was checked,
and the patient was found to have a total cholesterol of 230
with HDL of 33, a total to HDL ratio of 7.0, LDL calculated
of 167, and triglycerides of 150. Given the result of this
fasting lipid panel, the patient's Lipitor was increased from
10 mg q.d. to 40 mg q.d.
Fibromyalgia. The patient was maintained on her outpatient
regimen of Tramadol and cyclobenzaprine p.r.n. The patient
is discharged in stable condition.
DISCHARGE DIAGNOSES: Coronary artery stenosis status post
left coronary artery stent, coronary artery disease, and
fibromyalgia, as well as hyperlipidemia. The patient will
follow up with Dr. [**First Name (STitle) **] as well as with her cardiologist,
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], as well as with her primary care physician.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg q.d.
2. Plavix 75 mg q.d.
3. Cyclobenzaprine 10 mg h.s. p.r.n.
4. Clonazepam 0.5 mg h.s. p.r.n.
5. Tramadol 25 mg q.4-6h. p.o. p.r.n.
6. Lipitor 40 mg q.d.
[**First Name11 (Name Pattern1) 487**] [**Last Name (NamePattern4) **], [**MD Number(1) 32301**]
Dictated By:[**Last Name (NamePattern1) 8188**]
MEDQUIST36
D: [**2156-4-22**] 14:53:48
T: [**2156-4-23**] 09:40:33
Job#: [**Job Number 48137**]
|
[
"729.1",
"V45.82",
"272.4",
"997.1",
"427.89",
"458.29",
"305.1",
"V17.3",
"433.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"39.90",
"88.41",
"99.19"
] |
icd9pcs
|
[
[
[]
]
] |
2230, 2456
|
5615, 5965
|
5988, 6437
|
1807, 1947
|
3645, 5593
|
875, 1039
|
192, 855
|
3389, 3627
|
1062, 1781
|
1964, 2213
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,006
| 170,698
|
23196
|
Discharge summary
|
report
|
Admission Date: [**2121-12-20**] Discharge Date: [**2122-1-3**]
Date of Birth: [**2046-8-24**] Sex: F
Service: NEUROLOGY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
L frontal hemorrhage
Major Surgical or Invasive Procedure:
none
History of Present Illness:
75yo with hx of HTN, DM, breast CA, prior TIA was in USOH
last PM unitl approx 19:00 when, while watching TV with her
husband, she was noted to be "sleepy". Approx 30 minutes later,
she lost bladder then bowel continence and was brought to OSH by
approx 21:15. CT head done at 22:30 showed large left anterior
frontal hemorrhage with extension into the ventricle, plus
midline shift. Arrangements were made for tranport to [**Hospital1 18**]. Pt
went from GCS 14 to 8 by time of arrival to [**Hospital1 18**]. Pt intubated
on arrival for airway protection. Of note, Pt reportedly with R
hemiparesis per EMS and ED staff prior to intubation.
Past Medical History:
DMII
HTN
Breast CA, s/p mastectomy [**2-8**]
TIA [**2105**]
Carotid stenosis
Social History:
lives at home with husband, no kids or family nearby. two
sisters in [**Name2 (NI) **]
Family History:
noncontributory
Physical Exam:
Exam on admission
General: intubated, partially sedated
HEENT: Anicteric, MMM without lesions, OP clear
Neck: Supple, no LAD, no carotid bruits, no thyromegaly
CV: RRR s1s2 no m/r/g
Resp: CTAB no r/w/r
Abd: +BS Soft/NT/ND no HSM/masses
Ext: No c/c/e, distal pulses intact
Skin: No rashes, petechiae
MS: intubated, sedated, though with some purposeful movements-
reaching towards ETT
CN: I - not tested, II,III - PERRL; III,IV,VI - no
oculocephalic;
V- no corneal reflexes; VII - facial strength and symmetry
difficult to assess;IX,X - appearing to gag on ETT
Motor: nl bulk and tone, no tremor, rigidity or bradykinesia.
Appears to be moving all 4 est though L>R; withdraws to ungula
pressure in all 4 ext.
DTRs: [**Name2 (NI) **] (C56) BR (C6) Tri (C7) Pa (L34) Ac (S12) Plantar
L 2 2 2 2 2 down
R 2 2 2 2 2 up
Sensory: w/d to ungual pressure in all 4 ext.
Pertinent Results:
Admission: CT head: large L anterior frontal hemorrhage
extending into the
lateral ventricle; midline shift apparent.
Brief Hospital Course:
Pt was admitted to the neurosurgical service and then
transferred to the neurology service on HD 3 because of the lack
of any possible interventions for the patient.
Her hospital course by system:
Neuro: Pt was started on dilantin. She was weaned off all
sedating meds but continued to have significantly depressed
mental status, only posturing to deep stimulation. An EEG was
performed on [**9-24**] that showed diffuse slowing with no
epileptiform activity. LFT's and ammnonia were also checked and
were normal. Her exam remained essentially unchanged during her
course.
CV: Pt initially on labetolol drop which was weaned [**12-30**], after
which she was given PRN hydralazine and lopressor for any
Systolic BP's greater than 160. She remained stable on these
medications for the remainder of her course
RESP: Pt was dependent on mechanical ventilation throughout her
course. She did develop a ventilator associated pneumonia for
which she was treated with vancomycin and zosyn.
ID: Pt began to be febrile on [**12-20**], cultures from [**12-21**] and
[**12-23**] positive. Sputum positive for coag + staph and klebsiella,
urine positive for coag - staph and enterococcus. She was
started on vancomycin and zosyn. [**12-27**] follow up cultures showed
negative urine but sputum positive for staph aureus.
Antibiotics continued throughout her course. Her fever curve
improved over the course of her stay.
FEN/GI: Pt started on NG tube feeds of promote w/ fiber that she
tolerated well. She did have some hypernatremia that was
addressed by increased free water boluses and decreasing
infusions of IV NS. She was continued on protonix during her
stay.
ENDO: Pt was on an insulin sliding scale with stable d sticks
throughout course.
DISPO: Multiple discussions with pt's husband were held
regarding her neurologic status and poor prognosis. He seemed to
understand her situation but was very reluctant to make her CMO.
Family meeting held again on [**1-2**] and the decision was made to
make her CMO on [**1-2**] afternoon. She was extubated at that time.
Time of death: 4:13pm on [**2122-1-3**]. Husband was present.
Denied autopsy.
Medications on Admission:
Avandia 8 qd
Glipizide 10 qd
Lasix 20qd
Norvasc 5 qd
Plavix 75qd
Meclizine 12.5qd
Metformin 1000 qd
Protonix 40qd
Tamoxifen 10 qd
Vicodin 1 tab qd
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
stroke
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
|
[
"277.3",
"780.39",
"431",
"250.00",
"401.9",
"478.6",
"276.1",
"459.9",
"482.41",
"285.9",
"342.90",
"348.4",
"V66.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.42",
"96.6",
"99.04",
"96.04",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4620, 4629
|
2244, 2415
|
290, 296
|
4679, 4689
|
2101, 2112
|
4746, 4757
|
1189, 1206
|
4591, 4597
|
4650, 4658
|
4419, 4568
|
4713, 4723
|
2443, 4393
|
1221, 2082
|
230, 252
|
324, 968
|
2121, 2221
|
990, 1069
|
1085, 1173
|
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