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69,371
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Discharge summary
|
report
|
Admission Date: [**2193-1-9**] Discharge Date: [**2193-2-1**]
Date of Birth: [**2145-8-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2193-1-10**]
1. Mitral valve repair with a 28 mm [**Company 1543**] Profile 3D
annuloplasty ring (Ring data is the following: Model number
680R, serial number [**Serial Number 83091**]).
2. Tricuspid valve repair with a 34 mm [**Company 1543**] Contour 3D ring
(Ring data is the following: Model number 690R, serial number
[**Serial Number 83092**]).
3. Re-replacement of ascending aorta with a 24 mm Dacron tube
graft (Graft data is the following: Catalog number [**Serial Number 83093**], lot
number [**Numeric Identifier 83094**], serial number [**Serial Number 83095**]).
4. Aortic arch debranching procedure using a Vascutek graft from
the neo-ascending aorta to the left common carotid artery and
the innominate artery (Graft data is the following: Vascutek
Gelweave graft, catalog number [**Numeric Identifier 83096**], lot number
[**Telephone/Fax (3) 83097**], serial number [**Serial Number 83098**]).
5. Repair of pulmonary artery injury with a bovine pericardial
patch. 6. Removal of embolized stent graft to the right
pulmonary artery.
7. Redo sternotomy.
[**2193-1-11**]
1. Chest Closure
History of Present Illness:
47 year old Vietnamese speaking male with complex medical
history, including aortic surgery. He is being evaluated for
kidney transplant but due to issues with aorta and current
valvular abnormalities, severe MR [**First Name (Titles) **] [**Last Name (Titles) **], he is not a candidate.
He presents for cardiac cath for preoperative workup for his
upcoming extensive cardiovascular surgery scheduled on [**2193-1-10**].
Past Medical History:
1. Descending thoracic aortic aneurysm, status post stent
grafting with type 1 endoleak.
2. Mild to moderate aortic insufficiency.
3. Moderate to severe mitral regurgitation.
4. Moderate to severe tricuspid regurgitation.
5. Embolized stent to the right pulmonary artery.
6. Chronic renal failure (on hemodialysis).
7. History of retrograde type A aortic dissection after stent
grafting procedure requiring interposition Dacron tube graft
from the sinotubular junction to the distal ascending aorta.
8. Atrial fibrillation.
9. Right groin fistula
10.Subclavian stenosis s/p stenting (stent has migrated to right
main pulmonary artery)
11.Hypertension
Social History:
Lives with: Wife
Contact: Phone #
Occupation: Does not work
Cigarettes: Smoked no [X] yes [] last cigarette _____ Hx:
Other Tobacco use:
ETOH: < 1 drink/week [X] [**1-1**] drinks/week [] >8 drinks/week []
Illicit drug use -
Family History:
No premature coronary artery disease
Physical Exam:
Pulse: 74 Resp: 15 O2 sat: 100%
B/P 122/73
Height: 170cm Weight: 62kg
General: Well-developed asian male in NAD
Skin: Dry [X] intact [X] Well healed tracheostomy, left neck and
right groin incision
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs scattered rhonchi [X] well-healed sternotomy inc
Heart: RRR [] Irregular [X] Murmur [X] grade [**3-1**]
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema/Varicosities:
None
[X] A-V fistula right arm
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: - Left: -
Radial Right: - Left: -
Carotid Bruit:(B) thrill Right/Left: Trans murmur
Pertinent Results:
[**2193-1-21**] CT Chest: IMPRESSION: 1. Stenosis involving the distal
subclavian vein at its junction with the right internal jugular
vein. This may account for the patient's right arm swelling;
however the appearence is unchanged from the prior CT studies
[**2192-12-31**] and [**2192-10-26**]. An existing right internal
jugular vein catheter may be contributing to the reduced flow in
the right subclavian vein. 2. Distended right upper extremity
veins secondary to th AV fistual. Full evaluation of the AV
fistula graft with Doppler ultrasound would be of benefit.
3. Extensive reconstructive cardiac surgery as described with
patency of the major arterial branches.
4. Persistent endoleak identified at the level of the aortic
arch.
5. Mild splenomegaly.
6. Small subcutaneous fluid collection in the anterior neck as
described.
7. Large right sided pleural effusion.
.
[**2193-1-14**] RUQ Ultrasound: IMPRESSION: The gallbladder is not
significantly distended, and while there is gallbladder wall
thickening up to 8 mm and evidence of sludge/stones filling the
gallbladder, these findings are likely attributable to the
patient's congestive hepatopathy, ascites, and hypoalbuminic
state which all contribute to the gallbladder wall thickening.
However, acute cholecystitis, while unlikely due to the
relatively small [**Name (NI) **] size, cannot be completely excluded.
.
[**2193-1-10**] Intra-op TEE: PRE-BYPASS: The left atrium is dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. The right atrium is
dilated. No atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is severely dilated. Overall left ventricular
systolic function is moderately depressed (LVEF= 35 %). The
inferoseptal wall appears dyskinetic. The remaining segments
appear hypokinetic. The appearance of the ascending aorta is
consistent with a normal tube graft. There are few complex
(>4mm) atheroma in the descending thoracic aorta. An echogenic
structure and artifact is noted in the distal aortic arch. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. There is no aortic valve stenosis. Mild
to moderate ([**11-26**]+) aortic regurgitation is seen. The aortic
regurgitation jet is eccentric, directed toward the anterior
mitral leaflet. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Severe [4+]
tricuspid regurgitation is seen. There is a small pericardial
effusion. There is a echogenic structure in the Pulmonary
artery. Dr. [**Last Name (STitle) 914**] was notified in person of the results at the
time of the study.
.
[**2193-1-9**] 07:15PM BLOOD WBC-4.1 RBC-3.26* Hgb-11.0* Hct-32.1*
MCV-99* MCH-33.7* MCHC-34.2 RDW-15.4 Plt Ct-73*
[**2193-1-19**] 02:05AM BLOOD WBC-14.5* RBC-2.94* Hgb-9.4* Hct-26.9*
MCV-92 MCH-32.1* MCHC-35.1* RDW-20.9* Plt Ct-76*
[**2193-1-28**] 02:18AM BLOOD WBC-9.5 RBC-2.78* Hgb-8.8* Hct-25.4*
MCV-91 MCH-31.7 MCHC-34.7 RDW-20.4* Plt Ct-192
[**2193-1-29**] 04:19AM BLOOD WBC-12.9* RBC-2.84* Hgb-9.1* Hct-26.6*
MCV-94 MCH-32.1* MCHC-34.3 RDW-21.5* Plt Ct-197
[**2193-1-30**] 06:06AM BLOOD WBC-13.6* RBC-2.74* Hgb-8.8* Hct-26.4*
MCV-96 MCH-32.0 MCHC-33.2 RDW-22.1* Plt Ct-217
[**2193-1-31**] 06:24AM BLOOD WBC-13.1* RBC-2.69* Hgb-8.8* Hct-25.7*
MCV-96 MCH-32.9* MCHC-34.4 RDW-22.1* Plt Ct-275
[**2193-2-1**] 04:58AM BLOOD WBC-11.9* RBC-2.62* Hgb-8.4* Hct-25.4*
MCV-97 MCH-32.3* MCHC-33.3 RDW-22.6* Plt Ct-250
[**2193-1-9**] 07:15PM BLOOD PT-14.3* PTT-36.0 INR(PT)-1.3*
[**2193-1-16**] 02:00AM BLOOD PT-36.9* PTT-43.8* INR(PT)-3.6*
[**2193-1-29**] 09:06AM BLOOD PT-14.4* INR(PT)-1.3*
[**2193-1-30**] 06:06AM BLOOD PT-15.9* INR(PT)-1.5*
[**2193-1-31**] 06:24AM BLOOD PT-17.4* INR(PT)-1.6*
[**2193-2-1**] 04:58AM BLOOD PT-19.7* INR(PT)-1.9*
[**2193-1-9**] 07:15PM BLOOD Glucose-139* UreaN-45* Creat-6.9* Na-138
K-3.8 Cl-98 HCO3-28 AnGap-16
[**2193-1-15**] 02:02AM BLOOD Glucose-154* UreaN-18 Creat-2.5* Na-137
K-4.4 Cl-99 HCO3-25 AnGap-17
[**2193-1-22**] 02:07AM BLOOD Glucose-122* UreaN-18 Creat-1.6* Na-138
K-4.4 Cl-102 HCO3-26 AnGap-14
[**2193-1-31**] 06:24AM BLOOD Glucose-119* UreaN-46* Creat-5.3*# Na-134
K-4.2 Cl-92* HCO3-29 AnGap-17
[**2193-2-1**] 04:58AM BLOOD Glucose-75 UreaN-22* Creat-3.9*# Na-135
K-6.1* Cl-95* HCO3-29 AnGap-17
[**2193-1-30**] 06:06AM BLOOD ALT-41* AST-89* LD(LDH)-391* AlkPhos-117
Amylase-252* TotBili-14.7*
[**2193-2-1**] 04:58AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.2
Brief Hospital Course:
The patient was brought to the Operating Room on [**2193-1-10**] where
the patient underwent redo sternotomy, Mitral Valve repair,
Tricuspid Valve repair, removal of stent from PA with patch
closure, debranching of Innominate and Common Carotid Artery
with re-anastomosis with trifurcated arch graft and replacement
of Ascending Aorta. Post-operatively he was transferred to the
CVICU on Epinephrine, Levophed and Phenylephrine drips for
recovery and invasive monitoring. He was sedated and paralyzed
with an open chest. Chest was closed the following day. The
patient was started on CVVHD and was maintained on multiple
pressors for days. He received numerous blood products and
profound volume. He remained intubated for several days.
Anti-coagulation was resumed with Coumadin for chronic atrial
fibrillation. He developed thrombocytopenia, Coumadin was held
and HIT sent, which would return negative. Tube feeds were
initiated via Dob Hoff tube. Chest tubes were discontinued
without complication. As hemodynamics improved the patient was
weaned from inotropic and vasopressor support. He was extubated
on [**2193-1-17**], re-intubated [**2193-1-18**] for respiratory distress.
Bronchoscopy revealed thick secretions. Antibiotics were started
for sternal drainage. He was transitioned from CVVH to HD.
Antibiotic coverage was broadened for GNR and GPC in sputum as
well as Klebsiella in bronchial washings. The patient developed
swelling of the RUE. Vascular was consulted. Venogram revealed
known subclavian stenosis. Anti-coagulation was continued and
this will be managed conservatively. He developed a pleural
effusion and a pigtail catheter was placed on the right. Pacing
wires were discontinued when INR trended down to a safe range.
Diarrhea developed. Flexiseal was placed. Cdiff was negative
initially, but would eventually return positive. The patient was
treated accordingly.
Further volume was removed and the patient was extubated again.
Hepatology was consulted for hyperbilirubinemia and jaundice. He
did exhibit confusion following extubation- which is not unusual
given the length of his sedation and intubation. This improved
with Zyprexa and Haldol. He was oriented by the time of
discharge. He received a PICC on [**2193-1-24**].
He continued to make progress and was transferred to the
telemetry floor on [**2193-1-28**]. The patient was evaluated by the
physical therapy service for assistance with strength and
mobility. By the time of discharge on POD 22 the patient was
ambulating , the wound was healing and pain was controlled with
oral analgesics. The patient was discharged to [**Hospital3 **] in
[**Location (un) 1294**] in good condition with appropriate follow up
instructions.
Medications on Admission:
Lopressor 50(2)
Coumadin 2.5mg daily
Aspirin 81mg daily
Sevelamer 1600mg TID
Nephrocaps
Discharge Medications:
1. flu vaccine [**2191**] (36 mos+)(PF) 45 mcg (15 mcg x 3)/0.5 mL
Syringe Sig: One (1) ML Intramuscular NOW X1 (Now Times One
Dose).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever or pain.
6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
11. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
12. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia/agitation.
13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day:
adjust for goal INR of [**12-27**].5 for Atrial fibrillation.
15. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Descending thoracic aortic aneurysm
s/p stent grafting with type 1 endoleak.
Aortic insufficiency.
Mitral regurgitation.
Tricuspid regurgitation.
Embolized stent to the right pulmonary artery.
End stage renal failure (on hemodialysis).
Retrograde type A aortic dissection after stent grafting
procedure requiring interposition Dacron tube graft from the
sinotubular junction to the distal ascending aorta.
Atrial fibrillation.
Right groin arteriovenous fistula
Subclavian stenosis (s/p stenting)
Hypertension
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on [**2193-2-25**] at 1:15pm
Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD ([**Telephone/Fax (1) 62**] on [**2193-3-25**] at
1:40pm
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] P.([**Telephone/Fax (1) 83099**]) 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**
Labs: PT/INR for Coumadin ?????? indication: Atrial Fibrillation
Goal INR 2-2.5
First draw [**2-2**]
Completed by:[**2193-2-1**]
|
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icd9cm
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[
[
[]
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] |
[
"96.6",
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"96.04",
"39.22",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
12514, 12588
|
8239, 10955
|
326, 1436
|
13141, 13298
|
3680, 8216
|
14085, 14834
|
2840, 2878
|
11093, 12491
|
12609, 13120
|
10981, 11070
|
13322, 14062
|
2893, 3661
|
267, 288
|
1464, 1887
|
1909, 2561
|
2577, 2824
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,589
| 114,496
|
47110
|
Discharge summary
|
report
|
Admission Date: [**2154-5-4**] Discharge Date: [**2154-5-15**]
Service:
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old man, with
a history of dementia and atrial fibrillation, who presents
from home. He originally went to an outside hospital where a
chest x-ray revealed left pleural effusion and a large
cardiac silhouette. The patient was found to have increasing
shortness of breath and pleuritic chest pain radiating to his
back, and was transferred to the [**Hospital1 **]
Hospital for further evaluation and work-up. The patient
denies nausea, vomiting, diaphoresis, but does admit to
shortness of breath and chest pain, as above.
PAST MEDICAL HISTORY: 1) Atrial fibrillation, 2) Status post
spinal fusion, 3) History of prostate cancer, status post XRT
in [**2142**], 4) Mitral valve prolapse, 5) Status post knee
surgery, 6) Status post appendectomy, 7) History of pneumonia
eight months ago.
ALLERGIES: None.
MEDICATIONS: 1) coumadin 5 mg po qd, 2) lasix 20 mg po qd,
3) digoxin 0.25 mg po qd, 3) Aricept 5 mg po qd, 4) KCL 20 mg
po qd.
PHYSICAL EXAM ON ADMISSION: Generally, agitated, demented.
JVP was at 8 cmH2O. Distant heart sounds. Pulsus 15 mmH2O.
Bilateral rales at the bases. Decreased breath sounds, left
greater than right, at the bases. II/VI systolic murmur.
White count 8.5, crit 32.2, platelets 422. Sodium 138,
potassium 4.6, chloride 101, bicarb 25, BUN 31, creatinine
0.9, glucose 162. CT chest and abdomen revealed no aortic
dissection, but did reveal a 4x4 abdominal aortic aneurysm,
infrarenal, cardiomegaly, and a large pericardial effusion
with bilateral pleural effusions. EKG was atrial
fibrillation at a rate of 110, biphasic T waves in 4 through
6, but no alternans, no decreased voltage.
HOSPITAL COURSE - 1) PERICARDIAL EFFUSION: The patient was
monitored closely with daily measurements of his pulsus
paradoxus and close blood pressure monitoring, as it was
thought that he had possible impending tamponade. Serial
echocardiograms revealed some echocardiographic evidence for
tamponade, but the patient was able to maintain a normal to
high blood pressure.
Nevertheless, on hospital day #5, the patient was taken to
the Catheterization Lab and a pericardiocentesis was
performed where blood was removed from the pericardial space,
and there was found to be a loculated pericardial effusion
with significant amounts of blood clot. The patient's INR
was 6.5 at admission which may have explained the patient's
bloody pericardial effusion. There was cytology done on this
sample that was negative; however, malignancy was still a
concern in this patient with a history of prostate cancer.
The patient's pleuritic chest pain, shortness of breath
improved after pericardiocentesis. The patient was monitored
in the CCU for 48 hours, and the patient had symptomatic
improvement, was able to be weaned off the minimal amount of
oxygen, had decreased shortness of breath.
2) PLEURAL EFFUSION: The patient's pleural effusion was also
tapped and almost 2 liters of fluid were removed. This was
consistent with an exudative effusion; however, there was no
obvious cause for exudative effusion, no Gram stain findings.
The fluid culture was negative. The patient was afebrile
throughout his hospitalization and showed no sign of
infection. Again, malignancy was at the top of the list for
the possible etiology of the effusions. The pleural disease
service was consulted and considered pleuroscopy with biopsy.
However, the patient's pleural effusion did not
reaccumulate; therefore, pleuroscopy was not pursued.
However, at a future date pleuroscopy could be pursued for
both biopsy and pleurodesis if this patient has recurrent
problems with pleural effusions and shortness of breath.
3) ATRIAL FIBRILLATION: The patient's atrial fibrillation
was uncontrolled for several days with a high rate of 131-40.
Minimal rate control was pursued because of the patient's
possible tamponade physiology. When the patient's
pericardial effusion was further characterized and tapped,
more aggressive rate control was pursued with Lopressor which
was titrated up to 75 mg po tid. The patient was also
started on Norvasc for rate control and blood pressure
control. The patient's heart rate was better controlled at
the time of discharge, between 80 and 90.
The patient had a run of CHF when his rate was quite high in
the context of this pericardial effusion. The patient was
diuresed in the CCU, and the patient was no longer short of
breath, and was off oxygen at the time of discharge.
4) DEMENTIA: The patient had definite sundowning. He was
started on Zyprexa at 5:00 pm each day with prn Risperdal.
The patient responded well to this regimen and was minimally
disruptive. At time of discharge, the patient did require
1:1 sitter for much of his hospitalization, but this was
discontinued several days prior to discharge.
5) ACTIVITY LEVEL: The patient became physically
decompensated after being in bed for several days with his
shortness of breath and pericardial effusion. The patient
was seen by physical therapy and evaluated, and thought to be
a good candidate for acute rehab, as he had been pretty
independent and functional prior to discharge.
DISCHARGE CONDITION: Good. The patient was discharged to
acute rehab.
DISCHARGE MEDICATIONS: 1) Norvasc 7.5 mg po qd, 2)
Olanzapine 7.5 mg po q 5:00 pm every night, 3) Lopressor 75
mg po tid, 4) Risperdal 1 mg po bid prn, 5) digoxin 0.25 mg
po qd, 6) subcu heparin 5,000 U q 12 h, 7) lasix 20 mg po qd,
8) docusate 100 mg po bid, 9) Donepezil 5 mg po q hs.
DISCHARGE DIAGNOSES: 1) Congestive heart failure. 2)
Pericardial effusion. 3) Pleural effusion. 4) Atrial
fibrillation with rapid ventricular response. 5) Dementia.
6) Status post prostate cancer.
[**Doctor First Name 475**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 474**], M.D. [**MD Number(1) 9632**]
Dictated By:[**Last Name (NamePattern1) 7942**]
MEDQUIST36
D: [**2154-5-15**] 08:39
T: [**2154-5-15**] 07:57
JOB#: [**Job Number 99862**]
|
[
"423.9",
"424.0",
"427.31",
"V10.46",
"294.8",
"511.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"37.0",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
5274, 5325
|
5636, 6118
|
5349, 5614
|
112, 672
|
1116, 5252
|
695, 1101
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,501
| 178,823
|
32660
|
Discharge summary
|
report
|
Admission Date: [**2129-6-29**] Discharge Date: [**2129-7-5**]
Date of Birth: [**2049-3-23**] Sex: M
Service: MEDICINE
Allergies:
Ambien
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Chills
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 76105**] is an 80 yoM with PMH significant for COPD, PHTN,
PVD, HTN was sent from rehab for chills, nausea/vomiting and
paleness. Pt states that he was woken up from sleep because of
nausea the night before presentation. Also unable to tolerate
POs. Went to scheduled outpt appt with podiatric surgeons who
performed archilles tendon surgery. Felt chills upon return from
the appt, went to bed to warm up, and pt does not remember
anything from that point on until he woke up in the hospital.
.
Per records from NH, patient complained of nausea over the past
2 days. He had also had a non-productive cough over the past few
days as well. No report of fevers. At 1pm on the day of
admission he vomited up a moderate amount which was heme
positive. His oxygen saturation dropped to 80% on 3L and
increased to 89-90% on 5L. His vitals at this time were T 99.9
BP 80/40 AR 129 RR 26-28 O2 sat 87% on 5L. He appeared dusky and
was then transferred to [**Hospital1 18**] ED for further work-up.
.
Of note, the patient was discharged from [**Hospital1 18**] on [**6-21**]. He
underwent lengthening of his achilles tendon on [**6-14**].
Post-operatively his O2 saturation was 80% on RA. His O2 sats
remained low despite being on a non-rebreather and dropped to
the 70's while sleeping. He was transferred to the MICU for
closer monitoring. The pulmonary service was also consulted
during this time. The patient was treated with Cefpodoxime for
an aspiration pneumonia during this admission.
.
In the ED, initial vitals were T 100.5 BP 134/50 AR 119 RR 20 O2
sat 93% NRB. His O2 saturation dropped to 80% RA, then increased
to 87% on 5L NC. He was given 2L NS. He also received
Ceftriaxone 1gm, Vancomycin 1gm IV, Levaquin 750mg IV, and
Methylprednisone 125mg IV.
.
In the MICU, pt was continued on Vancomycin and Zosyn for
treatment for HAP, given pt's recent prior hospitalization and
rehab stay. Blood cultures were sent on [**2129-6-29**], which showed no
growth in 2 days (final result pending). IVFs were given to
maintain MAP>60. Pt was continued on ventimask with plan to
transition to NC. Pt continued to require ventimask during her
ICU stay. Pt's home antihypertensives were held while pt's blood
pressures normalized with IV fluids. Cr dropped to baseline with
hydration. Pt was transferred to floor in stable condition on
Hospital Day 3.
Past Medical History:
1. Chronic Lung disease with Pulm htn and low DLCO: Spirometry
FEV-1 85% of predicted
FVC 123%, FEV1 108%, ratio 87%, TLC 111%, DLCO 23%, pormovement
with broncodilator
2.Peripheral [**Date Range 1106**] disease: s/p bypass in legs, and on
coumadin
3.Pulmonary [**Date Range 1106**] disease
4.Chronic hypoxemia - on chronic O2
5.Renal insufficiency.
6.Ulcerative colitis
7.Hypertension
8.Seizure disorder
9.Peripheral edema associated with his PVD
11.Hypertension
12. Achiles contraction
13. Right lung spiculated mass, followed by outpatient
pulmonologist
Social History:
90 pack years smoking, quit 15 years ago, denies ETOH.
Family History:
DMII, CAD
Physical Exam:
vitals T 97.7 BP 88/46 AR 126 RR 23 O2 sat 93% on 50% VM
Gen: Awake and alert, responsive to commands
HEENT: Dry mucous membranes
Heart: RRR
Lungs: CTAB, poor airmovement at right lower base posteriorly,
+crackles at posterior bases.
Abdomen: Soft, NT/ND, +BS
Extremities: LLE in boot, no edema in RLE
Rectal: Guaiac negative
Pertinent Results:
[**2129-6-29**] 03:30PM BLOOD WBC-23.8*# RBC-4.09* Hgb-10.7* Hct-34.9*
MCV-85 MCH-26.1* MCHC-30.6* RDW-14.2 Plt Ct-584*#
[**2129-7-1**] 04:32AM BLOOD WBC-19.8* RBC-3.21* Hgb-8.3* Hct-27.4*
MCV-85 MCH-26.0* MCHC-30.4* RDW-14.0 Plt Ct-421
[**2129-6-29**] 03:30PM BLOOD Neuts-94.9* Bands-0 Lymphs-2.4* Monos-2.3
Eos-0.1 Baso-0.1
[**2129-6-29**] 03:30PM BLOOD Plt Smr-HIGH Plt Ct-584*#
[**2129-6-29**] 05:54PM BLOOD PT-24.9* PTT-29.4 INR(PT)-2.4*
[**2129-6-29**] 03:30PM BLOOD UreaN-40* Creat-1.6* Na-136 K-5.5* Cl-102
HCO3-22 AnGap-18
[**2129-7-1**] 04:32AM BLOOD Glucose-111* UreaN-29* Creat-1.3* Na-144
K-3.6 Cl-114* HCO3-21* AnGap-13
[**2129-6-29**] 03:30PM BLOOD ALT-14 AST-46* CK(CPK)-1277* AlkPhos-123*
TotBili-0.3
[**2129-6-29**] 03:30PM BLOOD Calcium-9.2 Mg-2.4
[**2129-6-29**] 06:36PM BLOOD Lactate-2.1* K-3.8
[**2129-7-4**] 04:35AM BLOOD WBC-8.6 RBC-2.92* Hgb-7.7* Hct-24.6*
MCV-84 MCH-26.4* MCHC-31.5 RDW-13.9 Plt Ct-441*
[**2129-7-4**] 04:35AM BLOOD Glucose-100 UreaN-15 Creat-1.2 Na-139
K-3.2* Cl-106 HCO3-24 AnGap-12
[**2129-7-4**] 04:35AM BLOOD calTIBC-255* VitB12-236* Folate-18.6
Hapto-433* Ferritn-55 TRF-196*
[**2129-7-4**] 04:35AM BLOOD Ret Aut-1.3
[**2129-7-4**] 04:35AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.9 Iron-10*
.
Relevant Imaging:
CXR [**2129-6-29**] There is focal area of pneumonic consolidation at
the right lung base. Left lung is clear. Surgical clips are seen
in the right axilla. Please followup the right lung base
pneumonic consolidation to clearance.
.
CXR [**2129-6-30**] The right lower lobe consolidation is grossly
unchanged but the left lower lobe linear opacities most likely
consistent with atelectasis have slightly improved. The upper
lungs demonstrate severe emphysema, but otherwise clear. Note
is made that the left costophrenic angle was not included in the
field of view. There is no appreciable pleural effusion or
pneumothorax.
.
CXR [**2129-7-1**] Little change with persistent right lower lobe
consolidation.
Brief Hospital Course:
Mr. [**Known lastname 76105**] is an 80 yo male with PMH as listed above who
presents with hypoxia, RLL infiltrate, and hypotension.
.
1)Hospital aquired pneumonia: Patient initially presented with
early sepsis physiology. He was tachycardic, hypotensive, and
had a significant leukocytosis. He had a RLL infiltrate on chest
Xray consistent with HAP (given his recent hospitalizations) and
was started on Vancomycin and Zosyn on [**6-29**] for 7 day
course. His hypotension resolved within 24 hours after he
received multiple fluid boluses. He was transferred to the floor
on [**7-1**] and did well with decreased oxygen requirement. Blood
cultures x 1 were NGTD at time of discharge. He was afebrile x
36 hours.
.
2)Hypoxia: At baseline, patient has COPD with cor pulmonale. Pt
states that he has emphysema, and is followed by a pulmonologist
in [**Location (un) 5131**]. Pt has been told that he requires 3L NC during
the day and a 40% ventimask at night but he is not always
compliant. Pt does use oxygen concentrator. Pt likely
decompensated in the setting of the pneumonia. He recieved 1
dose of steroids in the ED but this was stopped in the ICU since
his clinical presentation was not consistent with a COPD
exacerbation. During his stay in the MICU he was placed on nasal
cannula but required the 50% ventimask. He was continued on
antibiotics as above. On the floor, pt desatted to 70s on RA but
was satting in mid 90s on 5L NC at time of discharge. Goal will
be for patient to return to baseline of 3L nasal cannula with
40% facemask at night.
.
4)s/p Achilles tendon repair: Stable at this time. Should avoid
fluoroquinolones given increased risk for tendon rupture.
Podiatry (Dr. [**Last Name (STitle) 1140**] following. Per their recs: place in MP boot
while in-house and discharge in [**Hospital1 **]-valve cast. Sutures removed
on Monday [**2129-7-4**]. No dressing changes Please make sure patient
has b/l bivalve splints on.
.
5)Hypertension: Baseline blood pressures in low 100's. Decreased
to 80's at NH and upon transfer to the MICU. SBP 140s on tx to
floor with holding of home HTN regimen in MICU. Amlodipine and
HCTZ were restarted at home doses upon transfer to the floor. Pt
was not taking Lisinopril at home, although was listed in the
home med list. His SBP was 100s on Amlodipine and HCTZ. For
improved renoprotection, Amlodipine was D/C'd and was restarted.
SBP 100s-120s at time of discharge.
.
6)Acute on chronic renal insufficiency (GFR=42, Stage III):
Baseline creatinine is 1.2. Was elevated to 1.6 on admission,
however, Cr returned to baseline quickly with hydration. Was
likely pre-renal given history of nausea, vomiting, and
extremely dry mucous membranes on admission and rapid
improvement with fluids. Creatinine back to baseline 1.2 at time
of discharge.
.
7)Ulcerative colitis: Stable. Continued Asacol.
.
8)Peripheral [**Month/Day/Year **] disease: He is on Plavix and Coumadin 3 mg
PO daily as outpt. Coumadin was held for three days due to his
supratherapeutic INR (which is likely [**1-8**] his antibiotic
regimen), and was restarted at 2mg daily on [**2129-7-2**] and then 1
mg daily while we were following his INR and daily dosing
Coumadin. He will need to have his INR closely monitored as
outpatient with goal [**1-9**] while he is still on antibiotics. INR
2.1 [**7-4**] and 1.9 [**7-5**] on Coumadin 1mg PO daily so dose increased
to 2mg PO daily. Patient should have his INR checked on
Thursday, [**7-7**] and his dose adjusted for a target INR
between [**1-9**].
.
9) Anemia: Baseline HCT around 30. HCT dropped to 25 over
several day course of admission. He was transfused 1 unit PRBCs
on [**7-4**] for HCT 24.6. Studies revealed low iron, elevated
haptoglobin, low transferrin and borderline low TIBC and B12
with normal ferritin and folate. He likely has iron deficiency
anemia although would expect elevated TIBC and decreased
ferritin. He is currently on iron supplements. B12 levels also
low so started on B12 injections once daily x 7 doses and then
will need once weekly injections. He has a h/o UC and may have
occult bleeding but stool guaiacs were negative x2. He was
encouraged to follow up with his outpatient gastroenterologist
.
10) Code Status: Full Code, discussed at length with patient
Medications on Admission:
Docusate Sodium 100mg PO BID
Acetaminophen 325mg PO Q6H PRN
Clopidogrel 75mg PO daily
Omeprazole 20mg PO daily
Folic Acid 1mg PO daily
Tamsulosin 0.4mg PO QHS
Simvastatin 20mg PO daily
Mesalamine 1600mg PO TID
Lyrica 100mg PO TID
Ferrous Sulfate 325mg PO daily
Hydrochlorothiazide 12.5mg PO daily
Amlodipine 5mg PO daily
Warfarin 3mg PO daily
Lisinopril 10mg PO daily (on OMR, but pt states he stopped
taking this a long time ago)
Senna 8.6mg PO BID
Tramadol 50mg PO Q6H PRN
Albuterol Neb Q4H PRN
Oxycodone 5mg PO Q6H PRN
Tiotropium Bromide MDI
Advair MDI
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
9. Lyrica 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a
day).
10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
15. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
16. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
17. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection
once a day for 7 days: After should recieve one injection once a
week. .
18. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day:
Please check patient's INR on Thursday, [**7-7**]. Please
adjust coumadin for target INR between [**1-9**]. .
19. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
20. Zosyn 2.25 gram Recon Soln Sig: One (1) Intravenous every
six (6) hours for 1 days: Patient should complete antibiotic
course after nighttime dose on Wednesday, [**7-6**]. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Primary Diagnosis:
Recurrent aspiration pneumonia
COPD
.
Secondary:
1. Chronic Lung disease with Pulm htn and low DLCO: Spirometry
FEV-1 85% of predicted
FVC 123%, FEV1 108%, ratio 87%, TLC 111%, DLCO 23%, pormovement
with broncodilator
2.Peripheral [**Location (un) 1106**] disease: s/p bypass in legs, and on
coumadin
3.Pulmonary [**Location (un) 1106**] disease
4.Chronic hypoxemia - on chronic O2
5.Renal insufficiency, baseline Cr 1.2-1.3.
6.Ulcerative colitis
7.Hypertension
8.Seizure disorder
9.Peripheral edema associated with his PVD
10. Hypertension
11. Archilles tendon contraction s/p repair
12. Right lung spiculated mass, followed by outpatient
pulmonologist
Discharge Condition:
Fair. Currently satting mid 90s on 5L nasal cannula.
Comfortable. Afebrile.
Discharge Instructions:
You were admitted to the hospital because you had a fever, low
blood pressure, and low oxygen content in your blood, which were
likely due to a recurrent pneumonia. We treated you with
antibiotics, intravenous fluids, and oxygen. Please continue to
use oxygen at home, via nasal cannula on [**2-8**] L of oxygen during
the day, and via face mask on 40% during the night. Use of
oxygen is the only therapy definitively proven to extend life
expectancy of patients with COPD.
.
Please complete the 7 day course of antibiotics as instructed.
The last day of your antibiotics (Zosyn) is [**7-6**].
.
If you experience fevers, chills, nausea, vomiting, severe
coughing, shortness of breath, chest pain, or any other
worrisome symptoms, please call your primary care physician or
return to the emergency room.
Followup Instructions:
Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6481**], at
[**Telephone/Fax (1) 4775**] to make an appointment for follow-up within the
next 2 weeks.
Please have your INR checked to determine your Coumadin dosing
on Thursday, [**7-7**]. Please adjust for target INR [**1-9**].
Please attend the following appointments that have been made for
you:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 8645**]
Date/Time:[**2129-7-13**] 11:30
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 16550**] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 4775**]
Date/Time:[**2129-7-21**] 10:00
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2129-10-5**] 1:00
|
[
"799.02",
"280.9",
"492.8",
"585.3",
"V46.2",
"345.90",
"416.8",
"V58.61",
"417.9",
"556.9",
"786.6",
"440.4",
"403.90",
"440.20",
"584.9",
"V45.89",
"782.3",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12699, 12771
|
5698, 9962
|
272, 278
|
13489, 13569
|
3713, 4948
|
14421, 15322
|
3341, 3352
|
10568, 12676
|
12792, 12792
|
9988, 10545
|
13593, 14398
|
3367, 3694
|
226, 234
|
4966, 5675
|
306, 2672
|
12811, 13468
|
2694, 3252
|
3268, 3325
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
109
| 164,029
|
15322
|
Discharge summary
|
report
|
Admission Date: [**2140-1-19**] Discharge Date: [**2140-1-21**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
Ms. [**Known lastname **] is a 22 year old female with SLE, lupus nephritis,
ESRD on HD, malignant HTN, h/o TTP, and HOCM who presents with
HA and hypertensive urgency. Awoke this a.m. with 8/10 left
sided frontal HA - wasn't sure if it was d/t flare of uveitis
that had started on Monday or d/t HTN. Decided to skip HD and
come to ED for evaluation. No vision changes, numbness,
weakness, change in gait, chest pain, SOB. + Diarrhea x 1 day.
.
In ED patient was 217/140 but elevated to 254/152 --> received
labetolol IV 30 mg x 1 and MSO4 4mg and pressures dropped to
SBPs 208 and HA improved. Repeat labetolol with 50 mg x 1 and
repeated dose of morphine dropped pressures to 193/134 -->
labetolol gtt started, asa given, and HA resolved. Head CT
negative for intracranial bleed and CXR unremarkable.
.
ROS: cold for past week, no fevers, chills, CP, SOB, N/V, +
diarrhea.
.
Upon arrival to the floor, patient's BP was 191/126 - labetolol
gtt was not started. No sxs, no HA. She states that she is
compliant with all her meds and her mother cooks with no salt
and she has been adherent to diet.
Past Medical History:
1. Lupus - [**2134**]. Diagnosed after she began to have swolen
fingers, a rash and painful joints.
2. ESRD secodary to SLE - [**2135**]. Was initially on cytoxan, 1 dose
every 3 months for 2 years until began dialysis 3 times a week
in [**2137**] (T, Th, Sat). Awaiting living donor transplant from
mother.
3. HTN - [**2137**]. Normal BPs run 180's/120's. Has had 1
hypertensive crisis that precipitated seizures in the past.
4. Uveitis secondary to SLE - [**4-15**]
5. HOCM - per Echo in [**2137**]
6. Vaginal bleeding [**2139-9-20**]
7. Mulitple episodes of dialysis reactions
8. Anemia
9. Coag neg. Staph bacteremia and HD line infection - [**6-15**]
10. H/O UE clot, was on coumadin, but no longer
Social History:
Lives in [**Location 669**] with mother and 16 year old brother. Graduated
[**Name2 (NI) **] School and then got sick so currently is not working or
attending school. Denies any T/E/D.
Family History:
-No history of SLE.
-Grandfather has HTN.
-Distant history of DM.
-No history of clotting disorders
-No other history of other autoimmune diseases
Physical Exam:
Vitals: 98.0, 173/51, 86, 15, 100% RA
HEENT: L eye injected w/periorbital edema, R eye reactive w/
EOMI, anicteric sclera; MMM; OP clear
Neck: supple, no LAD, no thyromegaly
Cardiac: RRR, NL S1 and S2, + S4, III/VI systolic ejection
murmur @ LUSB radiating to apex and axilla, intensifies w/
Valsalva; no rub
Lungs: CTAB, no wheezes, rhonchi, crackles
Abd: soft, NTND, NABS, no HSM, no rebound or guarding
GU: no CVAT
Ext: warm, 2+ DP pulses, no C/C/E; L femoral dialysis catheter
Neuro: AOx3; CN II-XII intact; strength/sensation grossly intact
Pertinent Results:
UA: mod bld, 100 protein (present on prior UAs)
.
Radiology:
CXR: No acute CP abnormality
.
EKG: NSR, nml axis, nml intervals, borderline LAE, LVH, J point
elevation in V2,V3, TWI I, aVL, V5, V6. No change when compared
to prior on [**2139-11-26**].
.
CT HEAD: No intracranial hemorrhage.
Brief Hospital Course:
A/P: Patient is a 22 year old female with SLE, lupus nephritis,
ESRD on HD who presents with hypertensive urgency.
.
# Hypertensive urgency - Unclear precipitant. Possibly
secondary to pain from worsening uveitis. Compliant with meds.
Denies illicits and tox screen negative. Patient was started on
labetolol drip in ED with good BP response and was subsequently
transitioned to PO anti-hypertensives in ICU with maintenance of
stable SBPs in 150s-170s (baseline 170s-190s). Per
nephrologist's recommendations, home lisinopril was increased to
40 mg po bid from 40 mg po qd for better baseline BP control.
No clinical evidence of end organ damage (UA difficult ro
interpret in setting of CRF). CE's x 1 negative.
.
# Headache - No evidence by CT for intracranial bleed.
Headaches were well controlled with morphine sulfate and had
resolved by time of discharge.
.
# Uveitis - Followed by outpatient optho specialist. Optho not
consulted per patient's request.
.
# ESRD - Secondary to lupus nephritis. On transplant list.
Patient received hemodialysis in house with 500 ml ultrafiltrate
without complications. At dry weight of 45 kg per patient.
Began Sevalamer 800 TID with meals. Given difficulty in
interpreting renin and aldosterone levels in acutely ill
patients, these were not drawn and will need to be drawn at
outpatient follow up.
Medications on Admission:
Lisinopril 40 mg PO QD
Labetalol 600 PO TID
Valsartan 320 mg PO QD
Clonidine 0.3 mg transdermal QW
Prednisone 40 mg PO QD
Atropine 1 % [**Hospital1 **]
Prednisolone Acetate 1 % Q1H
Moxifloxacin eye drops qid
Lorazepam 1 mg PO Q4-6H PRN
Discharge Medications:
1. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day). Tablet(s)
2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
3. Atropine 1 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times
a day).
4. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
5. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic Q1H (every hour).
7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
8. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
9. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day.
10. Blood Pressure Kit Kit Sig: One (1) Kit Miscellaneous
once a day.
Disp:*1 Kit* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive urgency
Discharge Condition:
Good
Discharge Instructions:
Please take all of your blood pressure medications as
prescribed.
.
You should adhere to a low-salt diet, as increased levels of
sodium can drive your blood pressure up.
.
You are being discharged with a prescription for a home blood
pressure monitor which you can use to take daily measurements.
You should call your primary care physician for [**Name Initial (PRE) **] systolic blood
pressures greater than 180, or if you experience headaches,
nausea, vomiting, chest pain, shortness of breath, or any other
concerning symptoms.
Followup Instructions:
Please resume hemodialysis according to your regular schedule.
.
You are scheduled to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4883**] in the Division of
Nephrology on Wednesday, [**2-3**] at 9:30 AM. Please call
[**Telephone/Fax (1) 435**] if you need to reschedule.
.
You are scheduled to follow-up with your primary care physician,
[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2423**], on Tuesday, [**1-26**] at 3:30 PM. Please
call [**Telephone/Fax (1) 250**] if you need to reschedule.
.
You have been referred to see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2539**] in the Division
of Hematology for further evaluation of your anemia. This
appointment is scheduled for [**2-9**] at 3 p.m. His office
is located on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building on the [**Hospital1 18**]
[**Hospital Ward Name 516**]. Please call Dr.[**Name (NI) 44536**] administrative assistant,
[**Doctor First Name 8982**], at [**Telephone/Fax (1) 32192**] if you need to confirm or reschedule.
|
[
"403.01",
"585.6",
"V49.83",
"364.3",
"710.0",
"583.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
5955, 5961
|
3421, 4771
|
280, 295
|
6025, 6032
|
3107, 3360
|
6611, 7731
|
2377, 2526
|
5057, 5932
|
5982, 6004
|
4797, 5034
|
6056, 6588
|
2541, 3088
|
232, 242
|
323, 1431
|
3369, 3398
|
1453, 2158
|
2174, 2361
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,039
| 120,242
|
37163
|
Discharge summary
|
report
|
Admission Date: [**2126-11-8**] Discharge Date: [**2126-11-16**]
Date of Birth: [**2090-12-15**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Equilibrium problems
Major Surgical or Invasive Procedure:
None
History of Present Illness:
35M with 3 weeks of equilibrium problems
Past Medical History:
Hepatitis B
Social History:
Married
Family History:
Grandmother [**Name (NI) 11964**], no heart disease, pulm disease, cancer
Physical Exam:
On admission:
PHYSICAL EXAM:
O: T:97.3 BP:133 / 68 HR:75 R 18 O2Sats 100
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:[**3-31**] bilat EOMsfull
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 5to3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-2**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally, no clonus
Coordination: normal on finger-nose-finger
Upon discharge:
Oriented x 3. Full strength and sensation throughout.
No drift. Incision clean, dry, and intact.
Pertinent Results:
CTA [**2126-11-9**]:
IMPRESSION:
1. CT head demonstrates left cerebellar mass measuring
approximately 3 cm
with mass effect on the fourth ventricle and mild dilatation of
the temporal horns. MRI shows this mass to be containing
subacute hemorrhage.
2. CT angiography in correlation with cerebral angiography
demonstrates early venous filling adjacent to the left vertebral
artery in relation with the posterior arch of C1 indicating a
fistula. There is no distinct mass visualized in the partially
seen upper cervical spine to explain the
arteriovenous shunting.
3. No abnormal arteriovenous shunting identified in the region
of left
cerebellar mass.
4. The left cerebellar abnormality could be secondary to
hemorrhage from the arteriovenous fistula. However, cervical
spine MRI with gadolinium can help for further assessment.
5. Findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] at the time of
interpretation of this study on [**2126-11-10**] at 10 a.m.
Cerebral Angiogram [**2126-11-10**]:
Possible AVM from the left vertebral artery with possible
cavernoma.
C/T-spine MRI [**2126-11-11**]:
Unremarkable MRI scan. No fractures or stenosis noted.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 83717**] is a 35 yo male with a 3 week history of equilibrium
problems; an outside MRI showed a right cerebellar mass vs.
bleed. He was admitted to Neurosurgery at [**Hospital1 18**] on [**2126-11-8**]. On
[**11-10**] an cerebral angiogram was performed which showed a
possible AV fistula from the left vertebral artery. On [**11-11**] a
MRI of the C and T spine was performed which was unremarkable.
On [**2126-11-13**] the patient went to the OR for a posterior [**Last Name (un) **]
craniotomy for evacuation of the hemorrhage and resection of
possible cavernoma. The mass was sent to pathology but the
results are pending at the time of discharge.
The procedure went well and the patient was in the ICU overnight
for Q 1 hour neuro checks and for blood pressure control. He was
transferred to the floor on post-op day #1. The patient had some
difficulty with pain but it was significantly improved by
[**2126-11-16**]. He was in a soft collar for comfort. The patient was
ambulating and voiding on his own. He was taking in food and had
no nausea. He was discharged to home on [**2126-11-16**] with a plan to
follow-up with Dr. [**First Name (STitle) **] to review the pathology in 2 weeks.
Medications on Admission:
Aleve PRN
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
3. Methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO q4hr as
needed for Muscle spasm.
Disp:*80 Tablet(s)* Refills:*0*
4. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever, headache.
Discharge Disposition:
Home
Discharge Diagnosis:
Right Cerebellar Hemorrhage
Discharge Condition:
Mental Status:Clear and coherent
Activity Status:Ambulatory - Independent
Discharge Instructions:
General Instructions
??????Take your pain medicine as prescribed.
??????Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
??????If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, Please
refrain from taking unless cleared with Dr. [**First Name (STitle) **]
??????If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
Followup Instructions:
You will need to follow-up with Dr. [**First Name (STitle) **] in 2 weeks for staple
removal and to review your pathology. Please call Takeisha at
[**Telephone/Fax (1) 4296**] to make this appointment.
You also need to schedule an appointment with Dr. [**Last Name (STitle) 724**] in the
Brain [**Hospital 341**] Clinic in [**11-30**] weeks. You will not an MRI as this was
done while you were in the hospital. Please call [**Telephone/Fax (1) 1844**] to
schedule this appointment.
Completed by:[**2126-11-16**]
|
[
"228.09",
"723.1",
"338.18",
"431",
"V12.09",
"780.4",
"447.0",
"781.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
4918, 4924
|
3124, 4362
|
340, 347
|
4996, 4996
|
1911, 3101
|
6209, 6724
|
495, 571
|
4422, 4895
|
4945, 4975
|
4388, 4399
|
5096, 6186
|
616, 808
|
280, 302
|
1793, 1892
|
375, 417
|
1060, 1777
|
601, 601
|
5010, 5072
|
439, 453
|
469, 479
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,182
| 157,708
|
53473
|
Discharge summary
|
report
|
Admission Date: [**2106-9-7**] Discharge Date: [**2106-9-12**]
Date of Birth: [**2030-6-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Hydrochlorothiazide / Demerol
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Shortness of breath, decreased exercise tolerance
Major Surgical or Invasive Procedure:
[**2106-9-7**] Mitral Valve Replacement(27mm [**Company 1543**] Mosaic Porcine)
and Two Vessel Coronary Artery Bypass Grafting(Left internal
mammary artery to left anterior descending, vein graft to PDA).
History of Present Illness:
Mrs. [**Known lastname 109949**] is a 76 year old female with worsening shortness of
breath and decreased exercise tolerance. Echocardiogram in
[**2106-8-11**] showed moderate to severe mitral regurgitation with
an LVEF of 40%. There was evidence of pulmonary hypertension
with a PASP aroung 40mmHg. Subsequent cardiac catheterization
revealed severe three vessel coronary artery disease and
confirmed severe mitral regurgitation. There was mild systolic
ventricular dysfunction, with an LVEF around 42%. PASP was
estimated at 60mmHg. Based upon the above, she was referred for
cardiac surgical intervention.
Past Medical History:
Congestive Heart Failure
Peripheral Vascular Disease
Bilateral Renal Artery Stenosis - s/p Bilateral Stenting
Hypertension
Hypercholesterolemia
History of Seizure
Anemia
History of Atrial Fibrillation
History of Lymphoma, s/p chemotherapy - no recurrence
Migraine Headaches
Hysterectomy
Tonsillectomy
History of Sciatica
Social History:
Married. Lives with husband and has 5 children. 1 glass of wine
per night. She does not smoke.
Family History:
Denies any significant history
Physical Exam:
VS: 64 14 151/60 5'8" 149lbs
Gen: NAD
Skin: Unremarkable
HEENT: EOMI, PERRL, NC/AT OP benign
Neck: Supple, FROM -JVD
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused -edema, lateral BLE varicosities
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**2106-9-7**] - ECHO: PRE-BYPASS: 1. The left atrium is dilated. No
spontaneous echo contrast is seen in the body of the left
atrium. No mass/thrombus is seen in the left atrium or left
atrial appendage. No spontaneous echo contrast is seen in the
left atrial appendage. 2. No atrial septal defect is seen by 2D
or color Doppler. 3. There is mild to moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild global left ventricular hypokinesis with
somewhat worse hypokinesis of the apical segment. Overall left
ventricular systolic function is mildly depressed (LVEF= 40 %).
Given the degree of mitral regurgitation, intrinsic left
ventricular function is likely more depressed. 4. The right
ventricular cavity is mildly dilated. There is mild global right
ventricular free wall hypokinesis with more severe apical
hypokinesis. 5. There are simple atheroma in the aortic root.
There are simple atheroma in the ascending aorta. There are
simple atheroma in the descending thoracic aorta. 6. There are
three aortic valve leaflets. The aortic valve leaflets are
mildly thickened. Trace aortic regurgitation is seen. 7. The
mitral valve leaflets are mildly thickened. There is mild
prolapse of the anterior mitral valve leaflet tip and slight
retraction of the posterior leaflet. There is moderate to severe
(3+), mostly central, mitral regurgitation. 8. The tricuspid
valve leaflets are mildly thickened. 8.There is a trivial
pericardial effusion. POST-BYPASS: The patient is receiving
epinephrine by infusion. 1. Right ventricular systolic function
is improved. The apical segment may still be mildly hypokinetic.
2. Left ventricular systolic function is also improved. Ef now
about 50%. No obvious focal defects. 3. There is a bioprosthetic
valve in the mitral position. It is well seated with normal
leaflet function. There is trace perivalvular mitral
regurgitation. The maximum gradient across the valve is 13 mm Hg
with a mean of 6 mm Hg. 4. Aortic contours post-decannulation
are intact.
[**9-10**] CXR: Small improvement in right apical pneumothorax.
Persistent left lower lobe atelectasis.
[**2106-9-7**] 02:51PM BLOOD WBC-9.2# RBC-2.83* Hgb-9.2* Hct-26.9*
MCV-95 MCH-32.7* MCHC-34.3 RDW-14.2 Plt Ct-142*
[**2106-9-12**] 05:20AM BLOOD WBC-7.4 RBC-2.73* Hgb-8.5* Hct-24.5*
MCV-90 MCH-31.4 MCHC-34.9 RDW-15.9* Plt Ct-157
[**2106-9-7**] 02:51PM BLOOD PT-13.9* PTT-42.6* INR(PT)-1.2*
[**2106-9-12**] 05:20AM BLOOD PT-12.3 PTT-24.8 INR(PT)-1.1
[**2106-9-7**] 02:51PM BLOOD UreaN-14 Creat-0.6 Cl-109* HCO3-24
[**2106-9-10**] 06:35AM BLOOD Glucose-126* UreaN-27* Creat-0.8 Na-132*
K-4.6 Cl-99 HCO3-28 AnGap-10
[**2106-9-12**] 05:20AM BLOOD UreaN-14 Creat-0.6 K-4.1
[**2106-9-9**] 02:33AM BLOOD Calcium-8.1* Phos-4.0 Mg-2.5
Brief Hospital Course:
Ms. [**Known lastname 109949**] was a same day admit after undergoing all
pre-operative work-up prior to admission. On day of admission
she was brought directly to the operating room where she
underwent a coronary artery bypass graft and mitral valve
replacement. Please see operative report for surgical details.
Following surgery she was transferred to the CSRU for invasive
monitoring in stable condition. Within 24 hours she was weaned
from sedation, awoke neurologically intact and extubated. Beta
blocker and diuretics were initiated following patient being
weaned from Inotropes. She was gently diuresed towards her
pre-op weight. CXR on post-op day one revealed a right
pneumothorax. Her HCT trended down and on post-op day two was
found to be 20.7. She was transfused two units of blood with an
adequate rise to almost 29. She appeared stable and was
transferred to the SDU for further management on post-op day
two. Chest tubes and epicardial pacing wires were removed per
protocol. She did have a mild to moderate right-sided
pneumothorax after chest tube removal. This appeared to diminish
by time of discharge. Over the next several days she remained
stable and slowly improved without complications. She worked
with physical therapy for strength and mobility. On post-op day
five she appeared to be doing well and was discharged home with
vna services and the appropriate follow-up appointments.
Medications on Admission:
Aspirin 325mg qd, Zocor 20mg qd, Labetolol 400mg [**Hospital1 **], Prazosin
1mg qd, Lisinopril 40mg qd, Trileptal 300mg qAM and 600mg qPM,
MVT, Calcium plus D
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
3. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours).
Disp:*60 Packet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*50 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*40 Tablet(s)* Refills:*2*
9. Oxcarbazepine 600 mg Tablet Sig: 0.5 Tablet PO QAM (once a
day (in the morning)).
Disp:*50 Tablet(s)* Refills:*2*
10. Oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO QPM (once
a day (in the evening)).
Disp:*50 Tablet(s)* Refills:*2*
11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft
Mitral Regurgitation s/p Mitral Valve Replacement
PMH: Congestive Heart Failure, Peripheral Vascular Disease,
Bilateral Renal Artery Stenosis - s/p Bilateral Stenting,
Hypertension, Hypercholesterolemia, History of Seizure, Anemia,
History of Atrial Fibrillation, History of Lymphoma, s/p
chemotherapy - no recurrence
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 [**4-15**] weeks, call for appt
Dr. [**Last Name (STitle) 911**] in [**2-13**] weeks, call for appt
Dr. [**Last Name (STitle) **] in [**2-13**] weeks, call for appt
[**Hospital Ward Name 121**] 2 in 1 week for wound check and to have urinalysis
performed to check for resolution of positive UA previously
Completed by:[**2106-10-26**]
|
[
"V12.72",
"272.0",
"401.9",
"512.1",
"427.31",
"414.01",
"780.39",
"424.0",
"443.9",
"285.9",
"V10.79",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.60",
"36.11",
"35.23",
"39.61",
"99.04",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7747, 7796
|
4793, 6204
|
345, 551
|
8214, 8220
|
1995, 4770
|
8555, 8928
|
1661, 1693
|
6413, 7724
|
7817, 8193
|
6230, 6390
|
8244, 8532
|
1708, 1976
|
256, 307
|
579, 1189
|
1211, 1533
|
1549, 1645
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,928
| 138,722
|
45540
|
Discharge summary
|
report
|
Admission Date: [**2205-10-8**] Discharge Date: [**2205-10-11**]
Date of Birth: [**2128-9-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Angina
Major Surgical or Invasive Procedure:
[**2205-10-8**] CABGx4 (Lima->LAD, SVG->OM, SVG->Diag, SVG->PDA)
History of Present Illness:
Mr. [**Known lastname **] is a 76 yo male with known coronary disease. He had
recent worsening of angina, experiencing chest discomfort
associated with diaphoresis and lightheadedness after
vacuuming. Had EKG changes in ER and was taken for urgent cath
which showed severe 3VD with LAD in-stent restenosis. He was
therefore referred for elective surgical revascularization.
Past Medical History:
CAD s/p LAD cypher [**3-10**]
hypertension,
hypotriglyceridemia,
back surgery [**09**] years ago,
arthroscopic surgery on the right knee in [**2197**],
sigmoid polyps and
UGIB [**2-8**] nsaids in [**2198**]
b/l hip replacement
Social History:
The patient is married, lives with his wife and works in sales
and marketing. He quit smoking 30 years ago and smoked one half
pack per day times 25 years. Occasional Etoh, no illicits. Walks
without need of cane or walker.
Family History:
Mother died at 83 of CHF and diabetes
Father died at 67 of MI
Brother died of MI in 50s
Physical Exam:
NAD HR 60 BP 153/76
Lungs CTAB
CV RRR no M/R/G
Abdomen soft/NT/ND
Trace LE edema
2+ pp
Pertinent Results:
[**2205-10-8**] TEE PRE-BYPASS: 1. No atrial septal defect is seen by 2D
or color Doppler. 2. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. There is
mild to moderate regional left ventricular systolic dysfunction
of the anterior, anterolateral and apical segments. Overall left
ventricular systolic function is mildly depressed (LVEF= 40-45
%). 3. Right ventricular chamber size and free wall motion are
normal. 4. The descending thoracic aorta is mildly dilated.
There are complex (>4mm) atheroma in the descending thoracic
aorta. 5. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Mild to moderate ([**1-8**]+)
aortic regurgitation is seen. 6. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent coronary artery bypass
grafting surgery with Dr. [**Last Name (STitle) **]. For surgical details, please
see seperate dictated operative note. Intraoperative
echocardiogram was notable for systolic congestive heart failure
with an LVEF of 40%. Following the operation, he was brought to
the CVICU for invasive monitoring. Within 24 hours, he awoke
neurologically intact and was extubated without incident. He
maintained stable hemodynamics and transferred to the SDU on
postoperative day one. Chest tubes and pacing wires were removed
without complication. He remained in a normal sinus rhythm as
beta blockade was advanced as tolerated. Due to steady clinical
improvement with diuresis, he was medically cleared for
discharge to home on postoperative day three. At discharge, his
bp was 108/60 with a hr of 86. His room air saturations were
94%.
Medications on Admission:
Diovan/HCTZ 160/25 qd, lipitor 10 [**Last Name (LF) **], [**First Name3 (LF) **] 325 qd, plavix
(stopped [**9-30**]), coumadin (stopped [**9-30**]), metoprolol, prilosec
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
6. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO BID (2 times a day) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Prilosec 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 With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease s/p NSTEMI - s/p CABG
Mild Systolic Congestive Heart Failure(EF 40%)
History of LAD stent Cypher [**2202**]
Hypertension
History of UGI bleed ([**2203**]),
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) **] in [**4-11**] weeks, call for appt
Dr. [**Last Name (STitle) 1699**] 2-3 weeks, call for appt
Dr. [**Last Name (STitle) **] 2-3 weeks, call for appt
Already Scheduled appointments:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Date/Time:[**2207-3-13**] 9:45
Completed by:[**2205-10-11**]
|
[
"V15.82",
"428.20",
"428.0",
"285.9",
"413.9",
"414.01",
"996.72",
"V45.82",
"401.9",
"E878.4",
"788.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
4578, 4636
|
2367, 3268
|
329, 396
|
4860, 4868
|
1521, 2344
|
5204, 5639
|
1309, 1399
|
3488, 4555
|
4657, 4839
|
3294, 3465
|
4892, 5181
|
1414, 1502
|
283, 291
|
424, 800
|
822, 1051
|
1067, 1293
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,441
| 136,751
|
16567
|
Discharge summary
|
report
|
Admission Date: [**2160-9-11**] Discharge Date: [**2160-9-18**]
Date of Birth: [**2092-10-8**] Sex: F
Service: VSURG
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
acute ischemic Right foot.
Major Surgical or Invasive Procedure:
Thrombectomy of iliofemoral and femoral-popliteal
graft.
Right iliofemoral graft thrombectomy.
Dacron patch angioplasty of femoral anastomosis stenosis.
Atherectomy of popliteal artery dissection.
Angioplasty of the popliteal artery.
Angioplasty and stenting of the proximal iliofemoral
anastomosis with a 10 x 40 Smart self-expanding stent
History of Present Illness:
67y/o female with history of thrombectomy of right femoral to
above knee popliteal bypass graft [**5-2**] presents to Emergency
Room for onset of right lower extremity cramping at 1300 [**9-11**].
Symptoms progressed to coldness and numbness and by time patient
arrive to the Emergency Room the patient had diminished strength
of foot on exam. Now admitted for further care.
Past Medical History:
COPD
Peripheral vascular disease
history of Deep vein thrombosis
s/p Right arterial bypass
Social History:
Occasional alcohol, quit tobacco
Family History:
non contributory
Physical Exam:
Vital signs: 116/67 70-24 95% oxygen saturation on three liter
of oxygen via nasal cannula.
GEneral: alert in no acute distress, arrives with potable oxygen
tank.
Lungs: clear to auscultation
Heart: regular rate rythmn
Abdomen: begnin
Extremity: right foot cool to palpation. Motor intact. Strenght
[**2-1**] and sensation diminshed.
Pulses: Right leg : femoral biphasic signal only with absent
pulses distally to frmoral artery. Left leg: femoral artery
palpable, left popliteal monophasic dopperable signal, left
pedal pulses monophasic dopperable signal only.
Pertinent Results:
[**2160-9-11**] 11:54PM PH-7.17*
[**2160-9-11**] 11:54PM freeCa-1.24
[**2160-9-11**] 11:38PM GLUCOSE-127* UREA N-20 CREAT-0.5 SODIUM-140
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-29 ANION GAP-9
[**2160-9-11**] 11:38PM CK(CPK)-62
[**2160-9-11**] 11:38PM CALCIUM-8.5 PHOSPHATE-2.9 MAGNESIUM-1.4*
[**2160-9-11**] 11:38PM WBC-14.2* RBC-4.16* HGB-11.2* HCT-35.2*
MCV-85 MCH-26.9* MCHC-31.8 RDW-15.2
[**2160-9-11**] 11:38PM PLT COUNT-395
[**2160-9-11**] 10:38PM TYPE-ART PO2-65* PCO2-58* PH-7.34* TOTAL
CO2-33* BASE XS-3 INTUBATED-INTUBATED VENT-CONTROLLED
[**2160-9-11**] 10:38PM GLUCOSE-185* LACTATE-1.3 NA+-136 K+-4.1
CL--101
[**2160-9-11**] 10:38PM HGB-12.1 calcHCT-36
[**2160-9-11**] 10:38PM freeCa-1.25
[**2160-9-11**] 08:11PM CALCIUM-10.6* PHOSPHATE-4.4# MAGNESIUM-2.0
[**2160-9-11**] 08:11PM WBC-16.3*# RBC-4.97 HGB-13.6 HCT-41.4 MCV-83
MCH-27.4 MCHC-32.8 RDW-15.3
[**2160-9-11**] 08:11PM NEUTS-90.4* BANDS-0 LYMPHS-5.9* MONOS-2.5
EOS-1.2 BASOS-0.1
[**2160-9-11**] 08:11PM PLT SMR-HIGH PLT COUNT-537*
[**2160-9-11**] 08:11PM PT-16.8* PTT-26.0 INR(PT)-1.8
Brief Hospital Course:
[**2160-9-11**] admitted. underwent urgent surgery.IV heparization
began in the emergency roo. Right femoral artery exploration.
Thrombectomy of femoral-popliteal bypass graft and ileo femoral
bypass graft.Pateint was extubated in stable condition and
transfered to PACU for continued care with palpable femoral
pulse [**Last Name (un) **] right and biphasic dopperable signals of popliteal,
and pedal pulses.
[**2160-9-12**] POD#1 on set atrial fibrillation started on diltizem
for rate control. Followed by cardology.Patient returned to
surgery secondary to a cold pulsless foot.s/p right
ileio-femoral thrombectomy. Dacron patch angioplasty.
arteriography with mechanical athrectomy of right popliteal
artery and angioplasty and stenting of proximal ileofemoral
graft anastmosis . Transfered to SICU for continued care
intubated.Iv heparin continued. neosynephrin Iv for low blood
pressure.
[**2160-9-13**] POD #[**12-30**] Requird increased PEEP to improve oxygenation.
Wean to extubate. remains NPO electrolytes repleated.Neo to wean
maintain systolic blood pressure to >60.
Transfused 2 units PRBC's for HCT. of 28.2. postransfusion HCt.
30.1.
[**2160-9-14**] POD#[**1-29**] Extubated. neo weaned off.HCT. remained stable
30.1. Pulse exam remained stable. Diet advanced as tolerated.
Coumadization began. Temperature max. 101.2-98.4
[**2160-9-15**] POD#[**3-1**] Plavix started. Iv heparin continued.INR 5.5 IV
heparin discontinued. Transfused one unit PRBC's Hct. 35 post
transfusion.Bowel movement.Coumadin held for elevated
INR.Patient transfered to VICU. Pulse exam stable.Evaluated by
physical thearphy will require rehabilitation at discharge.
Trunkle rash noted and Ancef discontinued.leavquin discontinued.
Diuresis continued patient still postive fluid balance.Central
line discontiued .
[**Date range (1) 23212**] #5-6/4-5 Remains in Vicu.IV morphine discontiued
and percocets for analgesic control started.
[**2160-9-18**] POD#6-7/5-6 Discharged to rehab.Stable with dopperable
right foot pulses.
Medications on Admission:
see discharge medications
Discharge Medications:
1. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) INH
Inhalation Q6H (every 6 hours): 1 puff q6hours prn.
5. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
9. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO once a
day: Please continue to have INR levels checked by your PCP.
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QD (once a day) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
COPD requiring home 02
history of deep vein thrombosis
history of MI
peripheral vascular disease
hypertension
mitral valvle fibroelastoma
Discharge Condition:
Good
Discharge Instructions:
If you experience any leg pain, coldness, or weakness, or if you
have any chest pain, difficulty breathing, nausea/vomiting, or
fevers/chills, please seek medical attention.
Followup Instructions:
Provider: [**Name10 (NameIs) 1111**],[**Name11 (NameIs) 1112**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3121**] Appointment should
be in [**1-1**] weeks.
Please follow up with Dr. [**Last Name (STitle) **] to follow your INR and
Coumadin levels: [**Telephone/Fax (1) 8477**]
Completed by:[**2160-9-19**]
|
[
"996.74",
"427.31",
"E878.2",
"440.20",
"444.22",
"425.3",
"496",
"444.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.57",
"39.50",
"39.90",
"88.48",
"99.04",
"39.49"
] |
icd9pcs
|
[
[
[]
]
] |
6140, 6203
|
2978, 4997
|
319, 667
|
6385, 6391
|
1870, 2955
|
6613, 6933
|
1252, 1270
|
5073, 6117
|
6224, 6364
|
5023, 5050
|
6415, 6590
|
1285, 1851
|
253, 281
|
695, 1072
|
1094, 1186
|
1202, 1236
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,318
| 166,265
|
44213
|
Discharge summary
|
report
|
Admission Date: [**2154-12-19**] Discharge Date: [**2154-12-23**]
Date of Birth: [**2080-11-30**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2840**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
The patient is a 74 year-old female with a history significant
for stage IV sarcoidosis with combined restrictive/obstructive
disease, asthma, dCHF, and pulmonary HTN who was initially
admitted to the MICU with two days of worsening shortness of
breath and wheezing. Productive cough w/ clear sputum and
SOB/wheezing that progressively worsened while visiting her
family in [**Doctor First Name 5256**] for [**Holiday 1451**]. However, she was
able to wait until she got off the flight back to [**Location (un) 86**] to come
to the hospital.
.
No intubations for asthma exacerbations in the past. She was
last hospitalized about a year ago. At [**Holiday 1451**] in North
[**Doctor First Name **], she notes recent contact with 2 young children with
URI symptoms. She has received her influenza and pneumovax
vaccines. Upon arriving to the ED, her vitals were significant
for RR 36 and 99% on continuous nebs. She was given
methylpredisolone 125mg IV and Levaquin/Ceftriaxone for a
concerning apical infiltrate on CXR.
.
In the MICU, antibiotics were broadened to
Vanc/Cefepime/Levaquin, in setting of advanced lung disease
secondary to sarcoidosis, pulmonary hypertension, and severe
COPD, asthma, and a history of MRSA. She was weaned from
continuous albuterol and iptratropium nebs to q4h and started
back on her home montelukast, albuterol MDI, and Advair. Her
steroid regimen was changed to methylpredisolone 60mg IV q8h.
Upon transfer, her O2 requirement is at 1L O2 NC.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, constipation. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
Past Medical History:
1. Stage IV sarcoidosis - Chronic and fibrotic. The patient has
significant pulmonary manifestations, but no history of
ophthalmologic, hepatic, dermatologic, or renal manifestations.
She is followed by Dr. [**Last Name (STitle) **] in Pulmonary Clinic.
2. COPD with combined obstructive/restrictive lung disease
3. Asthma
4. Hypertrophic cardiomyopathy w/ Diastolic congestive heart
failure - followed by Dr. [**Last Name (STitle) 73**]
5. Pulmonary hypertension w/ PASP of 45
6. Osteoporosis
7. Anemia
8. Hypertension
9. Osteonecrosis of the bilateral femoral heads (incidental
finding on imaging. The patient followed up with Dr. [**Last Name (STitle) **]
regarding this on [**2154-8-7**])- no tx until symptomatic
10. Hyperglycemia. When on steroids she uses regular insulin
scale at that time.
.
PAST SURGICAL HISTORY:
1. Status post hysterectomy for fibroids
2. Status post bilateral breast implants - [**2114**]'s
3. Status post right rotator cuff repair
4. s/p cataract surgery last year
5. Being evaluated for face lift in plastics
Social History:
Denies tobacco, denies EtOH, denies illicit drug use, lives with
daughter
Family History:
mother with breast cancer
sister with uterine cancer
son with hip cancer in 20's, now in 40's.
Physical Exam:
Vitals: T 96.8, BP 120/48, HR 102, RR 18 and 95 on 1L O2 NC
Gen: Mild respiratory distress, sitting comfortably in chair
HEENT: PERRL, EOMI, anicteric sclera, oropharynx clear without
lesions or erythema
Neck: no LAD, no JVD
CV: RRR, nl S1/S2, III/VI blowing systolic murmur heard best of
LUSB, radiating to the axilla
Resp: prolonged expiratory phase with wheezing, rhonchi in upper
lobes bilaterally; profound accessory muscle use with
inspiration
Abd: +BS, soft, mildly tender, ND, no HSM appreciated
Extrem: WWP, 2+ DP pulses, no edema, no cyanosis/clubbing;
mildly calcified/arthritic DIP joints in fingers
Neuro: CN II-XII intact, full strength and sensation to light
touch in all extremities; gait and cerebellar fxn not assessed.
Skin: no rashes/lesions, no jaundice
Pertinent Results:
Labs on admission (to MICU):
.
139 / 97 / 14
---------------79 AG = 10
4.4 / 32 / 0.8
.
12.0 \ 41.8 / 262
N 87.8, L 6.8, M 4.3, E 0.7, B 0.5
.
ABG in ED: 7.34/60/44/34
.
Labs on transfer to floor:
.
140 / 100 / 29
------------------151 AG = 8
4.7 / 32 / 0.8
.
Ca: 9.4 Mg: 2.5 P: 3.5 ∆
.
13.2 \ 37.8 / 258
.
PT: 11.2 PTT: 30.2 INR: 0.9
.
ABG: 7.31/57/76/30
.
Labs on discharge:
143 / 98 / 24
----------------105
4.6 / 41 / 0.8
.
WBC 7.9, Hb 12.0, Hct 37.0, Plt 258
.
MICROBIOLOGY:
[**2154-12-19**] Rapid Respiratory Viral Screen & Culture
(Nasopharyngeal swab)
Respiratory Viral Culture: NGTD
Respiratory Viral Antigen Screen: Negative for Resp Viral
Antigen.
.
IMAGING / STUDIES:
CXR ([**2154-12-19**]):
IMPRESSION:
1. Pulmonary fibrosis from end-stage pulmonary sarcoidosis.
Innumerable
calcified mediastinal and hilar lymph nodes.
2. Emphysema.
3. Increased opacification within the lung apices, which could
represent a
superimposed infectious or inflammatory process.
.
Brief Hospital Course:
This is a 72 year old female with a hx of end-stage sarcoidosis,
COPD/asthma, dCHF, and pulmonary HTN who was initially admitted
to the MICU with hypercarbic and hypoxemic respiratory failure,
likely [**2-19**] to viral etiology vs. presumed apical pneumonia and
COPD exacerbation in setting of profound lung disease.
.
#. Respiratory: She has significant pulmonary fibrosis [**2-19**]
sarcoidosis as well as severe COPD and asthma, with yearly
admissions for respiratory difficulties. With new apical
infiltrates on CXR + wheezing with improvement on nebulizers,
COPD exacerbation on a background of profoundly diseased lungs
was considered to be the most likely cause. She was initially
admitted to the MICU due to hypoxic/hypercarbic respiratory
failure (pH 7.23, pCO2 74) and started on continuous nebulizer
treatments, IV steroids, and broad antibiotic coverage. Once
her neb treatments were spaced to every 4 hours, she was
transferred to the floor, where her antibiotics were eventually
narrowed to Levaquin alone for coverage of community acquired
pneumonia for a total 7-day course. Pulmonary was consulted and
recommended a 12-day steroid taper upon discharge, as well as
her current home regimen of nebulized and inhaled
bronchodilators and sildenafil/verapimil treatments for
pulmonary hypertension. She will follow-up with Dr. [**Last Name (STitle) **] and
Dr. [**Last Name (STitle) **] two weeks after discharge and will be sent home with
VNA for continued monitoring of her respiratory status.
.
#. Metabolic alkalosis: Likely compensation of CO2
retention/respiratory acidosis. Her alkalosis continued to
worsen up until discharge, but her clinical condition improved,
satting well on 1L O2. She is normally on 0.5L O2 at home.
.
# Chronic diastolic CHF: She remained euvolemic on exam, no
pulmonary edema on CXR, no JVD, and no LE edema. She did
require a small dose of Lasix over one evening for worsening
shortness of breath. Otherwise, she was stable on her
every-3-days regimen on furosemide.
Medications on Admission:
ALBUTEROL SULFATE - 2.5 mg/3 mL Solution for Nebulization Q4
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler Q4
ALENDRONATE [FOSAMAX] - 70 mg qweekly
CLOTRIMAZOLE - 10 mg Troche 4 times daily
FLUTICASONE [FLOVENT HFA] - 220 mcg Aerosol - 1 puff(s) inhaled
[**Hospital1 **]
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg [**Hospital1 **]
FUROSEMIDE [LASIX] - 20 mg Tablet Q3 days
IPRATROPIUM BROMIDE - 0.2 mg/mL (0.02 %) neb Q6 hours
MONTELUKAST [SINGULAIR] - 10 mg QPM
PANTOPRAZOLE - 40 mg daily
SILDENAFIL [REVATIO] - 20 mg TID
VERAPAMIL SR- 180 mg daily
ACETAMINOPHEN - 1000mg TID PRN
CALCIUM CARBONATE - 500 mg (1,250 mg) TID
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - 1,000 unit daily
COENZYME Q10 - 100 mg daily
FERROUS SULFATE - 325 mg daily
INSULIN REGULAR HUMAN [HUMULIN R] - sliding scale
OMEGA-3 FATTY ACIDS - 1,000 mg daily
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
3. Acetaminophen Extra Strength 500 mg Tablet Sig: Two (2)
Tablet PO three times a day as needed for pain.
4. calcium carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO three times a day.
5. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
6. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. sildenafil 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation every six (6) hours as needed for wheeze.
9. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. montelukast 10 mg Tablet Sig: One (1) Tablet PO QPM.
11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
shortness of breath or wheezing.
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for sob/wheeze.
13. Flovent HFA 220 mcg/Actuation Aerosol Sig: One (1)
Inhalation twice a day.
14. clotrimazole 10 mg Troche Sig: One (1) Troche Mucous
membrane QID (4 times a day).
15. furosemide 20 mg Tablet Sig: One (1) Tablet PO every 3 days.
16. coenzyme Q10 100 mg Capsule Sig: One (1) Capsule PO once a
day.
17. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
18. Humulin R 100 unit/mL Solution Sig: per sliding scale units
Injection once a day: Please only use this insulin while you are
taking prednisone. Use your sliding scale to determine the
amount, as you have done before.
19. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 1 days: Please take until [**12-24**].
Disp:*1 Tablet(s)* Refills:*0*
20. prednisone 20 mg Tablet Sig: see taper schedule Tablet PO
once a day: Please start with 60 mg x 2 days, 40 mg x 5 days, 20
mg x 5 days
.
Disp:*21 Tablet(s)* Refills:*0*
21. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis:
COPD exacerbation
.
Secondary diagnoses:
Sarcoidosis
Pulmonary hypertension
Diastolic heart failure
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 5903**],
It was a pleasure treating you at [**Hospital1 1170**]. You were admitted because of your shortness of breath,
cough, and your history of lung disease. You were initially
admitted the intensive care unit so we could closely monitor
your breathing and oxygen levels in your blood. We gave you
nebulizer treatments, extra oxygen, antibiotics, and steroid
treatments to help you breathe better. When you no longer
required very frequent nebulizer treatments and high levels of
oxygen, you were transferred to the regular medicine floor and
we monitored you.
.
When you were breathing well at your baseline level of home
oxygen, we felt comfortable sending you home. Upon your
discharge, you will continue on antibiotics, oral steroids, and
your home nebulizer and inhaler treatments.
Please remember to weigh yourself every morning, [**Name8 (MD) 138**] MD if
weight goes up more than 3 lbs.
We have made the following changes to your medications:
START Levaquin 750mg by mouth every other day until [**12-27**]
START Prednisone taper, as written on your prescription
.
You should continue to take your other medications as prescribed
by your doctors, including your nebulizer and inhaler
treatments.
Followup Instructions:
The following appointments are scheduled for you to follow-up
with your primary care physician and your pulmonologist.
Department: GERONTOLOGY
When: MONDAY [**2154-12-30**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Last Name (NamePattern1) 280**] [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2155-1-8**] at 2:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2155-1-8**] at 2:30 PM
With: DR [**Last Name (STitle) **] & DR [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2155-1-16**] at 3:40 PM
With: [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: MONDAY [**2155-2-10**] at 1:20 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: GERONTOLOGY
When: WEDNESDAY [**2155-4-9**] at 10:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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80,560
| 199,298
|
27854
|
Discharge summary
|
report
|
Admission Date: [**2185-4-29**] Discharge Date: [**2185-5-2**]
Date of Birth: [**2138-7-24**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
hypotensive
Major Surgical or Invasive Procedure:
none
History of Present Illness:
46 y/o woman with a history of ESLD secondary to EtOH abuse. The
patient is being followed by Dr. [**Last Name (STitle) **] at [**Hospital3 **]. The
patient was diagnosed with liver disease approx 3 years ago. She
was able to obstain from drinking for 1 year, but then slowly
began to drink again. She states that she drinks during
stressful events in her life 1-2 bottles of wine. She was
recently hospitalized at [**Hospital3 **] [**2185-3-4**] for
increasingshortness of breath and was found to have bilateral
pleural effusions. She was re-admitted on [**2185-4-13**] for
hypotension/dizziness and frequent falls. She had a BP of 70/49
in the ED and was admitted to the MICU. She also was found to
have pleural effusions and had 2 thorocentesis performed
removing 4L total. Her respiratory status improved. Per her HCP
she also had episodes of confusion. On [**2185-4-22**] her bilirubin was
24.4 and on [**2185-4-25**] it was 34.4. She has been on Prednisolone 40
mg for some time now. Platelets 41k and INR 2.4 She states her
lab values improved and she improved clinically and was
discharged last Friday. Reportly her bilirubin was trending up
at the time of discharge. She reports that since she was
discharged she has been sleepy/fatigued. She has also noticed
some mild abdominal distention as well. She also has had more
frequent episodes of dizziness. She reports that her jaundice
has also worsened.
.
The patient was seen in clinic today for evaluation for
transplant. She states her last drink was [**3-3**]. She was
seen in clinic and advised to come in for admission for further
management.
.
Currently, the patient feels fatigued/sleepy. She denied any
F/C/N/V/D. She also denied abdominal pain. Pt reports poor po
intake and weight loss.
.
ROS: The patient denies any fevers, chills, nausea, vomiting,
abdominal pain, diarrhea, constipation, melena, hematochezia,
chest pain, shortness of breath, orthopnea, PND, lower extremity
edema, cough, focal weakness, vision changes, headache, rash or
skin changes.
.
Past Medical History:
EtOH Cirrhosis: diagnosed ~3yrs ago. Pt followed by Dr. [**Last Name (STitle) **] at
[**Hospital3 **] ([**Telephone/Fax (1) 66580**]). No biopsy
.
Abnormal pap smears, Colposcopy negative, Cervical polyp
Social History:
Living Situation: Pt lives by herself. She has a boyfriend and
her HCP is her friend [**Name (NI) 67878**] [**Name (NI) 34816**] ([**Telephone/Fax (1) 67879**], [**Telephone/Fax (1) 67880**]).
She currently works doing research in artificial inteligence.
Tobacco: denied
EtOH: drinks heavy during traumatic life (divorce, death of her
father). She started to drink in excess in [**2174-12-16**] after her
divorce. She was sober for 1 year after her initial dignosis of
cirrhosis 3 years ago. She has replapsed and continues to drink.
She can drink up to 1-2 bottles of wine per day. She has never
been to detox or rehab. She has attended AAA meetings.
IVDU: denied
Family History:
Father died of pancreatic Ca
No family history of liver disease
Physical Exam:
On transfer to the MICU
Vitals 95.4 P51 BP 95/46 RR 12 O2 99% on NRB
General Marked jaundice, unresponsive
HEENT sclera icteric, pupils 5mm->4mm R, 6->5mm L, fundi without
papilledema
Neck REJ in place
Pulm Lungs clear bilaterally on anterior exam, no rales or
wheezing appreciated
CV Bradycardic regular S1 S2 no m/r/g
Abd Soft distended +bowel sounds no masses appreciated +fluid
wave no hepatomegaly appreciated
Extrem Cool, muscles atrophic, 1+ bilateral edema, palpable
pulses
Neuro Unarousable to voice or sternal rub, does not withdraw to
noxious stimuli, patellar DTRs brisk bilaterally, toes mute on
plantar stimulation
Derm healing small abrasions on dorsa of feet
Foley in place with amber urine
Pertinent Results:
[**2185-4-29**] 03:30PM WBC-9.7 RBC-2.75* HGB-11.0* HCT-32.4*
MCV-118* MCH-39.9* MCHC-33.9 RDW-21.4*
[**2185-4-29**] 03:30PM PLT SMR-LOW PLT COUNT-99*
[**2185-4-29**] 03:30PM NEUTS-90.2* LYMPHS-4.3* MONOS-5.3 EOS-0.1
BASOS-0.1
[**2185-4-29**] 03:30PM PT-37.1* PTT-65.7* INR(PT)-4.1*
[**2185-4-29**] 03:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2185-4-29**] 03:30PM AFP-2.2
[**2185-4-29**] 03:30PM ALBUMIN-3.2* CALCIUM-9.3 PHOSPHATE-3.0
MAGNESIUM-2.0
[**2185-4-29**] 03:30PM LIPASE-111*
[**2185-4-29**] 03:30PM ALT(SGPT)-96* AST(SGOT)-151* LD(LDH)-622* ALK
PHOS-280* AMYLASE-126* TOT BILI-48.0*
[**2185-4-29**] 03:30PM GLUCOSE-193* UREA N-38* CREAT-1.0 SODIUM-131*
POTASSIUM-4.3 CHLORIDE-92* TOTAL CO2-29 ANION GAP-14
[**2185-4-29**] 01:45PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2185-4-29**] 01:45PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-8* PH-7.0 LEUK-TR
[**2185-4-29**] 01:45PM URINE RBC-0-2 WBC-[**2-17**] BACTERIA-FEW YEAST-NONE
EPI-[**5-25**] TRANS EPI-[**2-17**]
[**2185-4-29**] 01:45PM URINE GRANULAR-0-2 HYALINE-0-2
[**2185-5-1**] 07:35AM BLOOD WBC-11.0 RBC-2.73* Hgb-11.1* Hct-32.2*
MCV-118* MCH-40.8* MCHC-34.6 RDW-21.6* Plt Ct-99*
[**2185-5-1**] 07:35AM BLOOD PT-40.8* PTT-84.2* INR(PT)-4.5*
[**2185-5-1**] 07:35AM BLOOD Glucose-113* UreaN-49* Creat-1.5* Na-137
K-3.8 Cl-95* HCO3-29 AnGap-17
[**2185-5-1**] 07:35AM BLOOD ALT-107* AST-176* LD(LDH)-605*
AlkPhos-283* TotBili-51.8*
[**2185-5-1**] 07:35AM BLOOD Albumin-3.2* Calcium-9.2 Phos-4.5 Mg-2.0
[**2185-4-29**] 03:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2185-5-1**] 02:10PM BLOOD Type-ART Temp-35.6 pO2-78* pCO2-36
pH-7.52* calTCO2-30 Base XS-5 Intubat-NOT INTUBA
[**2185-5-1**] 02:10PM BLOOD Glucose-145* Lactate-2.8* Na-131* K-3.7
Cl-93*
[**2185-5-1**] 02:10PM BLOOD freeCa-1.11*
[**2185-4-29**] 01:45PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.007
[**2185-4-29**] 01:45PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-8* pH-7.0 Leuks-TR
[**2185-4-29**] 01:45PM URINE RBC-0-2 WBC-[**2-17**] Bacteri-FEW Yeast-NONE
Epi-[**5-25**] TransE-[**2-17**]
[**2185-4-29**] 01:45PM URINE CastGr-0-2 CastHy-0-2
URINE CULTURE (Final [**2185-4-30**]): NO GROWTH.
[**5-1**] CT head
1. New large right subdural hematoma. New small left subdural
hematoma. New sulcal subarachnoid hemorrhage, left greater than
right.
2. Severe right subfalcine and uncal herniation. The midbrain is
compressed against the left tentorium.
3. Compression of the right lateral and third ventricles, with
entrapment
and severe dilatation of the left lateral ventricle.
4. Unchanged left anterior parafalcine density, which may
represent a
meningioma.
RUQ:
IMPRESSION:
1. Nodular cirrhotic liver, consistent with underlying
cirrhosis. Apparent
cyst in the left lobe, with no other focal liver lesions
identified. However,
the detection of liver lesions with ultrasound in a cirrhotic
liver is
limited. MRI may be performed to further assess (along with
evaluation of the
above mentioned pancreatic lesion).
2. Reversal of flow in the main portal vein and right portal
vein.
3. Ascites and splenic varices consistent with portal
hypertension.
4. Gallstones within the gallbladder neck, though no definite
findings to
suggest acute cholecystitis.
5. Hepatic veins and hepatic arteries appear patent.
6. Two complex cystic lesions near or within the uncinate
process of the
pancreas. Further evaluation with MRI is recommended.
7. Bilateral pleural effusions.
CXR:
Bilateral effusions are demonstrated, left more than right, with
bibasilar
areas of atelectasis. The effusions are also seen within the
right major
fissure. There is no evidence of pneumothorax. The upper lungs
are
unremarkable. The heart size cannot be evaluated given its
obscuration by
pleural fluid.
Brief Hospital Course:
Pt is a 46yo F with EtOH cirrhosis presents from clinic with
decompensated liver failure.
.
#: Subdural Hematoma:
Pt had an unwitnessed fall in hospital on [**4-30**]. A CT head
performed that day showed no definitive bleeding, though note
was made of a 10x9mm hyperdensity associated with the falx. The
radiologic differential included subdural hematoma versus
meningioma. This finding was discussed with the neurosurgery
team who felt no immediate surgical intervention was needed and
followup CT scan was recommended. The patient's primary team on
the liver service reviewed the patients records and this was
felt to be an old finding. The following day Ms. [**Known lastname 67881**]
appeared slightly more lethargic, but was oriented x3 and
interacting appropriately. She was found later in the day
unresponsive. She was intubated in the MICU. An emergent CT head
was obtained following transfer to the MICU which showed large
right sided subdural hematoma with subfalcine and uncal
herniation. An emergent neurosurgical evaluation was sought once
these findings were made. The neurosurgery team felt that given
the patient's end stage liver disease, any surgical procedure
would likely be lethal to her. The patient was given mannitol
according to neurosurgery recommendations. Following discussion
wtih the health care proxy, the decision was made to proceed
with comfort measures only. As the patient had expressed a
desire to pursue organ donation, we contact[**Name (NI) **] the [**Location (un) 511**]
Organ Bank to explore this possibility. Kidney donation was
considered but ultimately declined due to the patient's elevated
creatinine by the following morning, despite hemodynamic support
overnight with vasopressors. The family declined an autopsy.
#. EtOH Cirrhosis: The patient was recently discharged from
[**Hospital6 **]. She had been having worsening jaundice
and increasing bilurubin with a MELD of 34 at the time of
discharge from [**Hospital3 **]. She reported feeling lethargic,
light-headed and noticed increasing abdominal distention. She
was seen in [**Hospital 1326**] Clinic for possible transplant
evaluation, but was not a current candidate given recent
drinking ([**3-3**] last drink). On admission she was
lethargic/fatigued but AAOx3. She did not have asterixis or
other signs of encephalapathy. She also did not have
fever/chills or abd pain. She was continued on lactulose titrate
to [**2-16**] BM per day and rifaximin. Her diuretics were held
secondary to hypotension and she was continued on naldolol with
holding parameters. She underwent RUQ U/S with dopplers that
showed cirrhotic liver. Her INR was 4.1 on admission contiuned
to trend up, additionally, her bilirubin also continued to trend
up 51.8 prior to MICU transfer.
.
#. Hypotension: The patient had SBP ranging between 80-100's.
The patient stated she felt weak, but has been a chronic issue.
This was likely secondary to over diuresis with lasix and
spironalactone as well as poor po intake. Her diuretics were
held and the patient was given IVF to maintain SBP above 80.
#. Pleural Effusions: Pt recently admitted to [**Hospital3 2568**] with
pleural effusions. Reportly 2L of fluid was removed on two
occasions. Lung exam shows mild dullness to percussion at bases
and CXR shows effusions. The patient's resp status was stable
and she was satting well on room air.
.
#. EtOH Abuse: The patient reports that her last drink was [**3-3**].
Social work consult was placed.
.
#. Pyuria: Pt with positive UA on admission, but likely
contamination given multiple epis. Urine cx was no growth and pt
was asymptomatic. No treatment was started.
Medications on Admission:
At admission:
Lasix 60mg TID
Lactulose daily
Prevacid 30mg [**Hospital1 **]
Multivitamin daily
Klor-Con (Potassium) 40meq daily
Rifaximin 400mg TID
Spironolactone 25mg [**Hospital1 **]
Nadolol 20mg daily Prednisolone 40mg daily
On transfer to MICU:
lactulose 30mg TID
rifaximin 400mg TID
prednisone 20 daily
protonix 40mg po bid
mvt
Discharge Medications:
not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
subdural hematoma
end stage liver disease secondary to alcohol abuse
Discharge Condition:
deceased
Discharge Instructions:
not applicable
Followup Instructions:
not applicable
|
[
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"348.4",
"584.9",
"225.2",
"511.9",
"571.2",
"789.59",
"571.1",
"E888.9",
"458.9",
"E849.7",
"570",
"852.21",
"286.7",
"303.90",
"791.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
12144, 12153
|
8069, 11721
|
312, 318
|
12265, 12275
|
4107, 8046
|
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|
3300, 3365
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12105, 12121
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11747, 12082
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12299, 12315
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3380, 4088
|
261, 274
|
346, 2375
|
2397, 2602
|
2618, 3284
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,525
| 111,063
|
52673
|
Discharge summary
|
report
|
Admission Date: [**2116-6-1**] Discharge Date: [**2116-6-13**]
Date of Birth: [**2050-4-3**] Sex: M
Service: MEDICINE
Allergies:
Neupogen / Neurontin / Dilaudid
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
HD catheter change over wire
Midline placement
History of Present Illness:
Mr. [**Known lastname **] is a 66 yo M with Obesity hypoventilation syndrome,
?COPD, afib s/p cardioverson, ESRD on HD, PVD with recent
admission for TMA ulcer s/p debridement who presents with
altered mental status, shortness of breath, and hypotension. The
patient was found to be confused at [**Hospital3 2558**] with T96,
HR102, BP70/52, RR21, 80%RA -> 90%3L. Underwent routine [**Hospital3 2286**]
on saturday, but stopped 15 min short because his [**Hospital3 2286**]
catheter clotted. His wife states that he has been declining
over the last few weeks. He has also complained of burning in
his urine over the last few days. At baseline he is oriented,
though occationally confused.
.
In the ED, T 103.4, BP 60-70s systolic. R femoral line placed.
Given vanco, zosyn, 125mg solumedrol for wheezing on exam. CXR,
CT torso performed. His BP remained <90 systolic after 2L IVF ->
levohed started. ABGs 7.14/81/220 on NRB. Lactate normal.
Patient was put on CPAP with ABG 7.13/71/75. He was then takn
off CPAP because he seemed more somnolent. However, respiratory
then placed him on BiPAP with improvement in his symptoms. Per
the family, the patient is DNI. Responds to voice but is sleepy.
.
On arrival to the floor, he is somnolent but arousable, though
quickly falls back asleep.
Past Medical History:
PMH:
1) Atrial Fibrillation - s/p cardioversion in [**10-13**]. Was
maintained on coumadin for 6 months. Currently not
anticoagulated due to fall risk.
2) Pericardial effusion - s/p drainage, unclear etiology
3) ESRD from ATN in setting of acute gastroenteritis, s/p failed
cadaveric kidney transplant in [**2109**]. Dialyzed at [**Location (un) **] Tues,
Thurs, Sat.
4) Abdominal wall hernia - s/p repair after transplant
5) Multiple knee surgeries 20 years ago
6) Poor access, Right Tunnelled line
7) Baseline SBP's in 90s
9) Hypercapnia due to obesity hypoventilation syndrome
10) non-melanoma skin cancer
11) septic knee
Social History:
Denies any history of Tobacco use, no EtOh use for [**Last Name (un) **] than 20
years, no drug use. Lives with his wife, now on disability. Used
to work as a spray painter. Has 3 children and multiple
grandchildren.
Family History:
History of CAD (mother died at age 70), cancer
Physical Exam:
Gen: somnolent/sleeping, snoring, arousable to painful stimuli
HEENT: anicteric sclera, MM dry, PERRL
Neck: large, supple, no LAD
Heart: Irregularly irregular, no m/r/g
Lung: Coarse BS anteriorly, ppor inspiratory effort,
uncooperative
Abd: obese, soft NT/nD +BS no rebound or guarding
Ext: s/p R foot amp with VAC in place, no pitting edema
Skin: diffuse ecchymosis in upper ext
Neuro: somnolent, arousable, moving arms
Pertinent Results:
Lab Data:
141 \ 102 \ 22 \ 69
5.7 \ 23 \ 5.1
.
ALT: 15 AP: 111 Tbili: 0.3 Alb:
AST: 54
Lip: 9
.
11.6 \ 10.7 / 181
/ 35.5 \
.
N:86.7 L:8.1 M:3.1 E:1.3 Bas:0.7
.
PT: 15.6 PTT: 33.6 INR: 1.4
.
U/A: large blood, few bacteria
.
ABG: 7.13/71/75
.
Imaging:
CXR:
UPRIGHT RADIOGRAPH OF THE CHEST: The heart size is mildly
enlarged. Mild perihilar congestion is noted bilaterally.
Mediastinal contours are prominent. Increased interstitial
markings are noted in the right
perihilar region. The distal tip of [**Last Name (un) 2286**] catheter projects
into the right atrium.
IMPRESSION: Increased interstitial markings of the right hilum.
DIfferentials include asymmetric pulmonary edema or aspiration.
.
CT Head:
No acute processes
.
CT Torso:
No PE
Small R pleural effusion.
No acute intraabdominal findings.
.
EKG: Afib with RVR at 115bpm, no chage otherwise from prior.
.
TTE [**6-2**]:
The left atrium is elongated. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
The aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a fat pad.
.
IMPRESSION: Suboptimal technical quality. Global left
ventricular function is probably normal, but a focal wall motion
abnormality cannot be fully excluded. The right ventricle is not
well seen. No pathologic valvular abnormality seen. Pulmonary
artery systolic pressure is mildly elevated.
.
Compared with the prior study (images reviewed) of [**2116-5-13**],
there is less tricuspid regurgitation. Left ventricular function
appears slightly more vigorous. The heart rate is now slower.
Brief Hospital Course:
66 yo M with obesity hypoventilation, atrial fibrillation not on
coumadin, ESRD on HD, and PVD with recent TMA ulcer s/p
debridement, who presents with altered mental status and
hypotension in the setting of HD catheter related VRE line
sepsis.
# VRE Sepsis: Due to contaminated HD line. Patient presented
with altered mental status and hypotension requiring pressors
(levophed) and high dose steroids in ICU. Initially was treated
with Vancomycin/Zosyn until line cultures from HD line grew VRE,
then switched to Daptomycin. No evidence of endocarditis on TTE,
although was of poor quality. Negative surveillance cultures and
no new murmurs on exam or stigmata of endocarditis. Patient
eventually became more hemodynamically stable, defervesced, and
pressors were weaned off. Treated with daptomycin (dosed on HD
days) for [**Last Name (un) **] related sepsis (start date from day of HD line
removal on [**5-7**]). Was placed on a steroid taper
(prednisone) to be eventually weaned down to his home dose of 5
mg PO daily. Patient underwent a TTE and subsequently a TEE to
evaluate for possible endocarditis which was negative. HD line
was removed and new line was placed. Patient to complete 14 day
course of IV antibiotics to be completed on [**2116-6-19**].
.
#Hypercarbic Respiratory Failure:
ABG on presentation consistent with acute on chronic respiratory
acidosis which improved on BiPAP and was continued on the floor.
Continued albuterol nebs. Eventually weaned off oxygen and
satting > 90% on room air on discharge.
.
#Altered Mental Status: Likely due to sepsis + hypercarbia.
Required haldol and zyprexa in the ICU. Eventually recovered and
was AOx3 and back to baseline status after sepsis and
hypercarbia were both treated (see above) and when called out to
the floor.
.
#Atrial fibrillation: Rate controlled. Not anticoagulated due to
fall risk. Held meds in setting of sepsis, but were restarted
once hemodynamically stable (digoxin and metoprolol).
# ESRD on HD: Patient is s/p failed cadaveric renal transplant,
and receives HD on TThSat. Was noted to be confused and
hypotensive at HD. Renal followed while in house. HD tunneled
line was pulled and a femoral line was placed for HD
temporarily. Once surveillance cultures were negative, tunnelled
HD line was replaced in R subclavian position and HD was
continued.
# PVD s/p TMA debridement: He is s/p surgery on [**5-11**] with wound
vac placement. Has known peripheral [**Month/Day (4) 1106**] disease. Tissue
culture without growth on culture. Was seen on [**5-22**] by Dr.
[**Last Name (STitle) 3407**] with good granulation tissue. Patient was continued on
plavix and aspirin. Wound care saw the patient and was concerned
about right foot where vac tissue had been. [**Last Name (STitle) **] surgery was
reconsulted regarding possible bone exposure and question of
osteomyelitis. [**Last Name (STitle) **] surgery replaced a wound vac which needs
to be changed every three days. He will will need follow up with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within the next week as he will likely need a
skin graft on his right metatarsal.
# L knee pain: Subacute onset, appears to be in patellar space.
[**Month (only) 116**] be due to chronic osteoarthritis from obesity. LENIs
negative for DVT. No popliteal cyst palpated. Does have history
of septic arthritis of the knees in the past, but no effusions
noted on exam. Continued percocet prn for pain and monitored.
# Hyperglycemia: No history of DM. [**Month (only) 116**] be elevated in setting of
recent infection.
Treated with humolog insulin sliding scale and will be
discharged back to rehab on sliding scale.
#Code: DNR/DNI
Medications on Admission:
Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours)
Clopidogrel 75 mg PO DAILY
Omeprazole 20 mg PO DAILY (Daily).
Prednisone 5 mg PO at bedtime.
Simvastatin 10 mg PO DAILY
Vitamin A 10,000 unit (1) Tablet PO once a day.
Heparin (5000 Units) Injection TID
Digoxin 125 mcg PO EVERY OTHER DAY
Aspirin 325 mg PO DAILY (Daily).
Cyanocobalamin 1000 mcg PO DAILY
Docusate Sodium 100 mg PO BID
Senna 8.6 mg PO BID
Bisacodyl 10 mg PO DAILY (Daily)
Heparin (Porcine) 5,000 unit/mL Solution Sig: 4000-[**Numeric Identifier 2249**]
unit dwell Injection PRN (as needed) as needed for line flush:
Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
Morphine 15 mg PO Q8H (every 8 hours) as needed for pain.
Nephro-Vite 0.8 mg PO once a day.
Metoprolol Tartrate 1.25 mg PO twice a day
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**1-10**] Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
2. Clopidogrel 75 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. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)): please start [**2116-6-18**].
5. Prednisone 20 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) for 3 days: please start [**2116-6-12**].
6. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) for 3 days: please start [**2116-6-15**].
7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Vitamin A 10,000 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO T,TH,SAT ().
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): please hold for BM > 2 per day.
15. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day:
please hold for BM > 2 per day.
16. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
17. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): please hold for BP < 100.
19. Morphine 15 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain: please hold for sedation or RR < 12.
20. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
21. Insulin Lispro 100 unit/mL Solution Sig: please see insulin
sliding scale Subcutaneous ASDIR (AS DIRECTED).
22. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q48H (every 48 hours) for 9 days: end date
[**2116-6-19**]. Please give dose after Hemodialysis.
23. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
1' Diagnosis
Vancomycin Resistant Enterococci Sepsis
Delirium
2' Diagnosis
End Stage Renal Disease on Hemodialysis
Obesity Hypoventilation
Atrial Fibrillation
Discharge Condition:
afebrile, hemodynamically stable, tolerating POs
On a wet to dry dressing, will need Wound vac when returning to
[**Hospital3 2558**].
Discharge Instructions:
You were admitted with confusion and low blood pressures. You
were diagnosed with a bacterial infection in the blood stream
likely from your hemodialysis line. You required admission to
the ICU and were treated with IV fluids, medications to support
your blood pressure, and IV antibiotics. Your HD line was
removed, and you were treated with Daptomycin. Your HD line was
replaced and you underwent a TEE to rule out endocarditis which
was negative. You were evaluated by infectious disease team as
well as by [**Hospital3 1106**] surgery.
You will need to have your wound vac replaced when you are at
rehab.
Please take your medications as directed.
1. Take daptomycin Intravenous until [**2116-6-19**].
2. Continue to taper your steroids as directed.
Return to the hospital or call your PCP if you experience any of
the following symptoms: fever > 101 F, worsening confusion,
chest pain, abdominal pain, diarrhea, or any other symptoms not
listed here concerning enough to warrant physician [**Name Initial (PRE) 2742**].
Followup Instructions:
YOU WILL NEED YOUR WOUND VAC RE-PLACED WHEN YOU GET BACK TO
[**Hospital3 **].
Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office at [**Telephone/Fax (1) 1241**] for
appointment within the next 7 days.
You should follow up with your primary care doctor within [**1-10**]
weeks of discharge from rehab. Your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],[**First Name3 (LF) 2946**] S.
can be reached at [**Telephone/Fax (1) 2205**].
You should also continue to follow up with your nephrologist
within 1 month of discharge.
Listed below are the appointments that you already have
scheduled:
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2116-6-15**] 11:00
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2116-6-14**]
|
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|
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|
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3,935
| 107,901
|
48415
|
Discharge summary
|
report
|
Admission Date: [**2151-3-6**] Discharge Date: [**2151-3-17**]
Service: MEDICINE
Allergies:
Sulfonamides / Dicloxacillin
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Transfer from assited living with worsening SOB
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
This is a 86 y/o F with h/o atrial fibrillation off warfarin,
Diastolic CHF EF 70%, CAD, HTN, [**First Name3 (LF) **] sinus syndrom s/p PPm,
severe AS who presents with about 1 day of SOB.
.
Patient reports that she felt more SOB about 1 day ago. Denied
fevers, chills, chest pain. She reports being compliant with her
medications. No weight changes
.
In the Ed, VS 102 T Rectally, HR 104, BP 119/68, RR 37 Sats 97%
on NRB. chest x ray pulmonary edema. PRoBNP [**Numeric Identifier **]. She received
125 Iv solumedrol, 40 lasix, cefepime, Levofloxacine. She was
place CPAP initially tolerated it, then BP droped into the 60's
SBP, dopamine was started and a central line was placed.
.
ROS: Denied fever, chills, SOB, cough, chest pain, abdominal
pain, blood in stools, weight gain or weight loss
Past Medical History:
- Atrial fibrillation: off coumadin secondary to epistaxis
- [**Numeric Identifier **] sinus syndrome: temporary pacer placed during [**11-20**]
admission, was to return for permanent [**Month/Year (2) 4448**] placement,
which was again deferred during [**1-21**] admission secondary to
medical illness
- hx of VT with torsades morphology in [**3-22**], was on amiodarone,
recently stopped for hypothyroidism
- Aortic stenosis-> echo [**8-22**] showing peak gradient 76 mm Hg.
- CAD s/p NSTEMI in [**1-21**] and [**2-19**] s/p ballooning of LAD
- diasolic CHF (EF 70%)
- HTN
- Hyperlipidemia
- Chronic venous stasis
- Squamous cell carcinoma: right medial calf, s/p excision
[**11-20**], positive margins on 1st and 2nd excision attempts, needs
XRT to area 6 weeks after the wound heals.
- UTI
- rectal ulcers: possibly from constipation and straining
- History of C diff colitis
- Anemia: from blood loss after GI bleed
- Urge incontinence
- Depression
- Colon adenoma in [**2141**]: last colonoscopy in [**2143**], no polyps
- s/p hysterectomy
- Hypothyroidism
Social History:
Currently living in Chestnut park [**Doctor Last Name **]. No tobacco use. no
history of alcohol abuse. Her husband is deceased. She has a
social worker [**Name (NI) **] [**Name (NI) 33578**] at [**Telephone/Fax (1) 101940**] who follows her
closely.
Family History:
non contributory
Physical Exam:
Vitals: T: 96.6 P:95 R:25 BP: 131/66 SaO2: 95% NRB
General:
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: JVD 15
Pulmonary: Lungs crackles bilaterally
Cardiac: RRR, nl s1-s2. RUSB eyection murmur
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: 1+ edema. + R tibial ulcer.
Neurologic: alert, oriented, x3, non focal.
Pertinent Results:
Admit Labs:
-----------
[**2151-3-6**] 03:10PM WBC-6.1 RBC-4.10* HGB-12.6 HCT-38.7 MCV-94
MCH-30.7 MCHC-32.6 RDW-15.2
[**2151-3-6**] 03:10PM NEUTS-78.7* LYMPHS-12.5* MONOS-8.0 EOS-0.6
BASOS-0.3
[**2151-3-6**] 03:10PM GLUCOSE-145* UREA N-23* CREAT-1.2* SODIUM-136
POTASSIUM-5.4* CHLORIDE-103 TOTAL CO2-22 ANION GAP-16
[**2151-3-6**] 03:10PM CK(CPK)-86
[**2151-3-6**] 03:10PM cTropnT-<0.01
[**2151-3-6**] 03:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2151-3-6**] 03:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2151-3-6**] 09:22PM TYPE-ART TEMP-37.0 RATES-/18 O2-100 O2
FLOW-10 PO2-73* PCO2-40 PH-7.41 TOTAL CO2-26 BASE XS-0 AADO2-613
REQ O2-98 INTUBATED-NOT INTUBA
[**2151-3-6**] 11:18PM TSH-4.5*
[**2151-3-6**] 11:18PM CK-MB-5 cTropnT-0.08*
[**2151-3-6**] 11:18PM CK(CPK)-62
.
Other Labs/Studies:
-------------------
[**2151-3-9**] 03:59AM BLOOD WBC-3.3* RBC-3.52* Hgb-11.2* Hct-33.7*
MCV-96 MCH-31.9 MCHC-33.3 RDW-14.5 Plt Ct-105*
[**2151-3-12**] 07:00AM BLOOD WBC-3.5* RBC-3.53* Hgb-11.2* Hct-33.2*
MCV-94 MCH-31.7 MCHC-33.6 RDW-14.2 Plt Ct-110*
[**2151-3-6**] 03:10PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier **]*
[**2151-3-11**] 08:00AM BLOOD T4-6.6 calcTBG-1.00 TUptake-1.00
T4Index-6.6 Free T4-1.0
[**2151-3-11**] 08:00AM BLOOD TSH-14*
[**2151-3-7**] 5:59 am URINE Source: Catheter.
**FINAL REPORT [**2151-3-8**]**
Legionella Urinary Antigen (Final [**2151-3-8**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
[**2151-3-7**] 5:30 am Influenza A/B by DFA
Source: Nasopharyngeal aspirate.
**FINAL REPORT [**2151-3-7**]**
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2151-3-7**]):
Negative for Influenza A viral antigen.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2151-3-7**]):
POSITIVE FOR INFLUENZA B VIRAL ANTIGEN.
.
TTE ([**3-12**]):
The left atrium is markedly dilated. There is moderate symmetric
left ventricular hypertrophy. There is severe regional left
ventricular systolic dysfunction with global hypokinesis,
akinesis of the mid and distal anterior wall and apex. Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size is
normal. with mild global free wall hypokinesis. The ascending
aorta is moderately dilated. The aortic valve leaflets are
severely thickened/deformed. Significant aortic stenosis is
present (not quantified). No aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. There is
moderate thickening of the mitral valve chordae. Mild to
moderate ([**12-16**]+) mitral regurgitation is seen. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2151-3-8**]
.
CHEST (PA & LAT) [**2151-3-12**] 9:30 AM
There has been marked improvement in pulmonary edema, still
there is mild interstitial pulmonary edema. Left lower lobe
retrocardiac atelectasis has decreased. There is a small left
pleural effusion. There is no pneumothorax. Moderate
cardiomegaly is stable as are enlarged central pulmonary
arteries very suggestive of pulmonary hypertension. Left
transvenous [**Month/Day/Year 4448**] leads terminate in standard position in
the right atrium and right ventricle. There is also a small
right pleural effusion, lesser in amount than in the left side.
IMPRESSION: Improved pulmonary edema.
.
TTE ([**3-8**]):
The left atrium is markedly dilated. The right atrium is
markedly dilated. The estimated right atrial pressure is
10-15mmHg. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is severe global left ventricular hypokinesis (LVEF = 20-25 %)
(basal lateral wall has preserved systolic function). No masses
or thrombi are seen in the left ventricle. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. with
depressed free wall contractility. The ascending aorta is
moderately dilated. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2). Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. The
tricuspid valve leaflets are mildly thickened. There is moderate
to severe pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2150-8-28**],
the LVEF is now severely depressed
.
BILAT LOWER EXT VEINS [**2151-3-8**] 11:18 AM
BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler
son[**Name (NI) 1417**] of bilateral common femoral, superficial femoral, and
popliteal veins were performed which demonstrate normal
compressibility, flow, and augmentation.
IMPRESSION: No evidence of DVT.
.
US ABD LIMIT, SINGLE ORGAN PORT [**2151-3-7**] 1:14 PM
A limited portable ultrasound examination was performed by the
radiology resident. Survey demonstrates dirty shadowing from
numerous loops of small bowel within the lower abdomen and
pelvis. No mass lesions were identified. The bladder cannot be
evaluated given intraluminal Foley catheter.
IMPRESSION: Limited ultrasound demonstrates no superficial mass
lesions identified within the abdomen or pelvis. Findings may be
confirmed with non- emergent CT of the abdomen and pelvis if
clinically warranted.
Brief Hospital Course:
87 yo woman with multiple medical problems including [**Name2 (NI) **] sinus
s/p PPM, afib (off anticoagulation [**1-16**] epistaxis), pumonary HTN,
diastolic CHF, CAD, severe AS, COPD who presents with shortness
of [**Month/Day (2) 1440**], DFA positive for Flu B.
.
The patient was initially admitted to the [**Hospital Unit Name 153**] due to
hypotension and need for vasopressors.
.
# Respiratory Distress/Hypoxemia
Likely multifactorial, including Influenza and acute heart
failure (systolic). Initially was on antibiotics for possible
pneumonia, however there was no evidence of a bacterial
pneumonia, so these were stopped.
.
# Influenza
DFA for Influenza B was positive. Patient was given a 5-day
course of Tamiflu. Her oxygen saturation and overall
respiratory status improved. She was maintained in respiratory
isolation.
.
# Acute Systolic CHF with h/o Chronic Diastolic CHF
This was likely in setting of acute viral illness (?-viral
myocarditis). EF dropped from normal to 20-25%. The patient
had significant pulmonary edema. She was diuresed with IV lasix
with improvement in respiratory status. Her B-blocker was
subsequently restarted. ACE inhibitor was held due to
borderline blood pressure. A TTE was repeated 4 days later and
did not show any signifcant change. This should be re-assessed
in about 3 months to determine need for ICD. Cardiac enzymes
were mildly elevated (likely in setting of demand), however did
not meet criteria for an NSTEMI.
.
# Severe Aortic Stenosis
Confirmed on both echocardiograms. Given this condition,
patient was not diuresed more aggressively. Patient will follow
up with outpatient cardiologist to discuss treatment options;
and lasix daily dose was halved to 20 mg daily.
.
# Hypotension: normal WBC, no left shift in differential. Normal
lactate. In the setting of fevers concerning for sepsis. U/A
negative. Was initially on dopamine, however this was titrated
off. Blood pressure medications were slowly introduced.
.
# Rhythm - Atrial Fibrillation/SSS s/p PPM
Rate was well controlled. She had an episode in which she had an
80-beat run of what appeared to be a wide complex tachycardia.
There was some thought that was V-tach and she was started on an
amiodarone drip and then coverted to oral amiodarone. After
discussion with her primary cardiologist, this appeared to be
most consistent with an SVT. After transfer to the medicine
floor, the amiodarone was stopped as she has no tolerated this
in the past and since a B-blocker had been restarted.
.
# CKD: basline 1-1.1. This was stable.
.
# hypothyroidism
Was continued on her home meds. Rechecking TSH showed a level
of 14. Free T4 and Free T4 index were normal. Since dose was
only adjusted two weeks prior, dose was left as is. TSH should
be rechecked 6 weeks after dose adjustment to ensure adequate
level.
.
# depression: continued on outpatient regimen
Medications on Admission:
tylenol
Advair1 1 puff [**Hospital1 **]
Albuterol sulfate 90 mcg 2 puff q4-6h as needed
Aspirin 81
Atorvastatin 80 mg once a day
Atrovent HFA
Calcium 500
Celexa 60 mg qd
Colace [**Hospital1 **] 100 mg\
Iron 325
Lasix 40 qd
Levoxyl 100 qd
Metoprolol xl 37 qd
Lisinopril 10 mg qd
prilosec 20 qd
senna
Vitamin C
Vitamin D
Discharge Medications:
1. Becaplermin 0.01 % Gel Sig: One (1) Appl Topical DAILY
(Daily): To R calf ulceration. .
2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO
three times a day.
8. Ergocalciferol (Vitamin D2) 400 unit Tablet Sig: 2.5 Tablets
PO once a day.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
10. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: 1.5
Tablet Sustained Release 24 hrs PO once a day: 37.5mg daily.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO twice a day.
14. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a
day.
15. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every six (6) hours as needed for shortness of [**Hospital1 1440**]
or wheezing.
16. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation three times a day.
17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary: 428.33 HEART FAILURE, (B2) ACUTE ON CHRONIC DIASTOLIC
Secondary: 401.1 HYPERTENSION, BENIGN
Secondary: 414.01 CAD, NATIVE VESSEL
Secondary: 311 DEPRESSION, NOS
Secondary: 496 CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Secondary: 427.31 ATRIAL FIBRILLATION
Secondary: 424.1 AORTIC STENOSIS-INSUFFICIENCY
Secondary: 428.21 HEART FAILURE, (A1) ACUTE SYSTOLIC
Secondary: 244.9 HYPOTHYROIDISM
Secondary: 284.1 PANCYTOPENIA
Secondary: 427.0 TACHYCARDIA, SUPRAVENTRICULAR
Secondary: 487.1 INFLUENZA WITH OTHER RESPIRATORY MANIFESTATIONS
Unsigned
Discharge Condition:
Stable
Discharge Instructions:
Return to the [**Hospital1 18**] Emergency Department for: Shortness of
[**Hospital1 1440**], fevers.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2151-3-24**]
9:30
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2151-3-24**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1879**], M.D. Date/Time:[**2151-3-30**] 2:30
|
[
"244.9",
"311",
"403.90",
"424.1",
"496",
"V10.83",
"585.9",
"427.31",
"414.01",
"428.33",
"284.1",
"428.0",
"428.21",
"487.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13545, 13617
|
8730, 11624
|
284, 308
|
14205, 14214
|
2988, 8707
|
14364, 14723
|
2510, 2528
|
11994, 13522
|
13638, 14184
|
11650, 11971
|
14238, 14341
|
2543, 2969
|
196, 246
|
336, 1136
|
1158, 2223
|
2239, 2494
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,814
| 135,578
|
36534+58094
|
Discharge summary
|
report+addendum
|
Admission Date: [**2140-6-18**] Discharge Date: [**2140-7-28**]
Date of Birth: [**2101-9-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Intubation and Mechanical Ventilation
Paracentesis
Thoracentesis
History of Present Illness:
Mr. [**Known lastname **] is a 38 year old man with presumed EtOH cirrhosis who
presents from an OSH after being found down at home. Per OSH ED
records, EMS was called by a landscaper who found the pt on the
floor in his own feces and urine, confused. Pt recalls falling,
denies head trauma or LOC. Unclear how long he was down. House
in "state of disgust" per EMT. He was brought to the [**Hospital 1562**]
hospital ED. At the OSH, BP was stable, HR in the 110-120s. Hct
was 15. Head CT negative. She was given 1 unit RBC, unasyn,
banana bag, and transferred to [**Hospital1 18**] for further management.
.
Per outpatient notes, liver disease was first recognized by his
PCP [**Last Name (NamePattern4) **] [**2135**]. He is a heavy alcohol drinker, drinking [**4-20**] gallon
bottles of wine daily for many years. He made one attempt at
rehab in [**2134**] and was reportedly sober for 1 year, but has since
relapsed. Over the past 6 months or so, he has been having
worsening abdominal distention, leg swelling. He has been having
progressive difficulty walking secondary to weakness. He was
seen by Dr. [**First Name (STitle) **] at [**Hospital1 112**] in the past 2-3 months and work-up of
his liver disease has been started. Per Dr.[**Name (NI) 79913**] notes, he has
poor PO intake, weight loss of 60-80 lbs over the past 6 months,
daily vomiting (?hematemesis). [**Name (NI) 1094**] father also notes history of
blood in stool and urine over the past few weeks. Lab work-up
and diagnostic para were done however we do not have results
currently. Also, pt was referred to hepatology and also [**Hospital **]
rehab but has not followed through. Has never been hospitalized.
.
In the ED, initial vitals were T 99.4, BP 125/69, HR 126, RR 22,
93% on 4L. Labs here were notable for Hct 17.5, CK 935. Guaiac
positive. Diagnostic paracentesis was performed with results
consistent with SBP. He was given a dose of vancomycin and 1
unit RBC. Admitted to the MICU for further evaluation and
monitoring.
.
On the floor, he has no complaints. BP has dropped as low as 70s
systolic but is responsive to fluids.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
EtOH cirrhosis
"Kidney problems" (unknown baseline)
HTN (never treated)
Hypercholesterolemia
x/p L knee arthroscopic surgery '[**20**]
s.p L axilla cyst resection '[**32**]
s/p MVA '[**34**]
Social History:
Lives alone. Self-employed, import/export business. Drinks 4
bottles of wine per day, has been drinking for many years.
Smokes up to 3 cigars a day. No history of illicit drug use
Family History:
n/c
Physical Exam:
Exam on Arrival to MICU:
Vitals: T: 98.6, BP: 150/28, P: 123, R: 20, O2: 90% on
General: chronically ill appearing, tremulous, jaundiced, slow
to respond to questions,
HEENT: icteric sclera, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic murmur
throughout the precordium
Abdomen: distended, diffusely tender to palpation, +fluid wave,
no hepatosplenomegaly
Rectal: light brown guaiac positive stool per ED
Ext: 3+ LE edema with signs of chronic venous stasis
bilaterally, bilateral dopplerable DP pulses
Neuro: A+O x 2 (name, hospital in [**Location (un) 86**]), +asterixis
Exam on Arrival to Floor:
Vitals: T: 97.5, BP: 124/70, P: 85, R: 25, O2: 97%RA
General: NAD, chronically ill appearing, cachetic, jaundiced,
slow to respond to questions,
HEENT: icteric sclera, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic murmur
throughout the precordium
Abdomen: distended, mild tenderness to palpation, +fluid wave
Ext: 2+ LE edema with signs of chronic venous stasis bilaterally
Pertinent Results:
Admission:
[**2140-6-18**] 01:50AM BLOOD WBC-14.1* RBC-1.67* Hgb-5.9* Hct-17.5*
MCV-105* MCH-35.4* MCHC-33.8 RDW-17.3* Plt Ct-168
[**2140-6-18**] 01:50AM BLOOD PT-30.5* PTT-57.3* INR(PT)-3.1*
[**2140-6-18**] 01:50AM BLOOD Glucose-94 UreaN-24* Creat-1.2 Na-139
K-3.5 Cl-106 HCO3-23 AnGap-14
[**2140-6-18**] 01:50AM BLOOD ALT-39 AST-165* CK(CPK)-935* AlkPhos-53
TotBili-12.4*
[**2140-6-18**] 01:50AM BLOOD Lipase-96*
[**2140-6-18**] 01:50AM BLOOD CK-MB-6 cTropnT-0.01
[**2140-6-18**] 01:50AM BLOOD Albumin-1.7* Calcium-7.2* Phos-5.4*
Mg-2.1 Iron-50
[**2140-6-18**] 01:50AM BLOOD calTIBC-55* VitB12-1813* Folate-6.0
Ferritn-1102* TRF-42*
[**2140-6-22**] 03:32AM BLOOD Hapto-<20*
[**2140-6-18**] 01:50AM BLOOD Ammonia-48*
[**2140-6-18**] 01:50AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE
HBcAb-NEGATIVE
[**2140-6-18**] 01:50AM BLOOD HCV Ab-NEGATIVE
[**2140-6-18**] 01:50AM BLOOD AFP-2.8
[**2140-6-18**] 01:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
C. diff negative: ([**6-19**], [**4-24**], [**6-25**], [**6-29**], [**7-4**])
Blood Cx: NO GROWTH ([**6-18**], [**6-18**], [**6-19**], [**6-25**], [**6-26**], [**6-26**], [**6-27**], [**6-27**],
[**6-28**], [**6-28**])
Urine Culutre: NO GROWTH [**6-22**], [**6-26**], [**6-28**]
GRAM STAIN (Final [**2140-6-19**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2140-6-21**]): NO GROWTH.
[**2140-6-18**] 4:00 am PERITONEAL FLUID
**FINAL REPORT [**2140-6-24**]**
GRAM STAIN (Final [**2140-6-18**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2140-6-21**]):
REPORTED BY PHONE TO DR [**Last Name (STitle) **] [**2140-6-19**], 1:35PM.
SERRATIA MARCESCENS. RARE GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SERRATIA MARCESCENS
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final [**2140-6-24**]): NO ANAEROBES ISOLATED.
ECG:
Sinus tachycardia. Low QRS voltage in the limb leads. There are
non-specific
T waves flattening. No previous tracing available for
comparison.
[**6-18**] Abd U/S
IMPRESSION:
1. Patent hepatic vessels without evidence of thrombus.
2. Cirrhotic liver.
3. The gallbladder is filled with sludge and tiny stones. There
is no
evidence of cholecystitis.
4. Moderate ascites throughout the abdomen.
5. Hyperdynamic hepatic venous waveforms may represent fluid
overload or
tricuspid insufficiency.
[**6-18**] CT_Chest
IMPRESSION:
1. As noted on chest radiograph, there is a large left pleural
effusion,
atelectasis of the left lower lobe, and multifocal parenchymal
consolidations,
greatest in the right upper lobe consistent with multifocal
pneumonia.
2. Anasarca, with at least moderate abdominal ascites,
subcutaneous edema,
and gallbladder wall edema.
3. Splenomegaly
4. CT evidence of anemia.
[**6-20**] ECHO
The left atrium is mildly 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
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 estimated pulmonary artery systolic pressure is normal.
There is a small pericardial effusion. There are no
echocardiographic signs of tamponade.
[**6-22**] CT-Torso
IMPRESSION:
1. Cirrhotic liver, with splenomegaly, recanalized paraumbilical
vein, and a
large amount of ascites, increased from [**2140-6-18**].
2. No definite evidence of intra-abdominal abscess.
3. Large left pleural effusion, with associated
consolidation/atelectasis of
the adjacent lung, unchanged.
4. Diffuse areas of ground-glass and airspace opacities in the
lungs, likely
infectious/inflammatory, with a component of fluid overload.
[**7-1**] LENI
IMPRESSION:
1. No evidence for DVT in the bilateral lower extremities.
Please note that
the calf veins were not evaluated.
2. Significant soft tissue edema bilaterally.
[**7-12**] CT-chest
MPRESSION:
1. Very large left pleural effusion causes near complete left
lung collapse.
2. Large volume ascites.
3. Scattered right lung ground-glass opacities consistent with
improved/resolving pneumonia.
[**7-13**] CT-chest
IMPRESSION:
1. Decrease in size of now small to moderate layering
nonhemorrhagic left
pleural effusion with persistent complete opacification of the
left lung, most
likely due to persistent but improved collapse, may be
responsible for the
shortness of breath of the patient because of new disequilibrium
in V/Q
matching. No signs of hemorrhage on the left and no
pneumothorax.
2. Increased ground-glass opacity in the right middle lobe and
right lower
lobe, could be worsening infection, hemorrhage or aspiration.
New tiny right
pleural effusion and basal atelectasis.
3. Anemia.
4. Cirrhosis, large amount of ascites and splenomegaly.
[**2140-7-18**] CXR:
Moderate left pleural effusion has increased more than left
basilar collapse, as evidenced by new slight rightward
mediastinal shift. Cardiomediastinal contours are otherwise
unchanged. Lung volumes remain low, but the right lung is
grossly clear. Post-pyloric feeding tube appears to have been
withdrawn slightly, but the tip remains in the vicinity of the
fourth portion of the duodenum.
Brief Hospital Course:
ICU course:
The patient was admitted to the hospital with altered mental
status. He was admitted to the ICU with a suspected pneumonia
and spontaneous bacterial peritonitis. He was volume
recussitated with crytalloid and colloid. He required intubation
and mechanical ventilation for respiratory failure (presumed due
to pneumonia) aggresive volume recussitation, and altered mental
status. He underwent paracentesis which grew pan-sensative
serratia species. He was initially on broad spectrum antibiotics
which were narrowed to ceftriaxone only. He completed a 14 day
course for SBP on [**2140-7-1**]. Inital blood cultures were negative,
but a set on [**2140-6-25**] grew coag-negative staph in one bottle,
thought to be a contaminant. His PICC line was subsequently
removed and IV Vancomycin was discontinued. Following initial
hemodynamic stabilization with volume and treatment with
antibiotics, he required diuresis. His diuresis was limited by
worsening renal function, which improved with slowed diuresis.
He also suffered a dropping hematocrit requiring multiple units
of blood. Portal gastropathy was identified on EGD, but no
active bleeding was visualized. Due to continued transfusion
requirements he had a repeat EGD which again demonstrated portal
hypertensive gastropathy without active bleeding. He was managed
conservatively given his respiratory problems. [**Name (NI) **] remained
hemodynamically stable and afebrile, was successfully extubated
and transferred to the medical floor for further management.
Hepatology service:
On the medical floor, he was continued on oral diuresis,
ciprofloxacin for SBP prophylaxis, and transfusions as needed.
Nutrition was consulted and tube feedings were adjusted to meet
his metabolic demands. His mental status cleared with aggresive
lactulose. His pleural effusion persisted however the patient
was not oxygen dependent. With ambulation during physical
therapy, the patient became transiently short of breath. CXR was
consistent with a worsened left-sided pleural effusion. The
patient was given 10U FFP and a thoracentesis was performed on
[**7-13**] and 3.2 liters was removed. He quickly became dyspneic and
CXR showed re-expansion pulmonary edema which required
intubation and transfer to the MICU. Positive pressure
ventilation and diuresis re-airated his left lung. He
self-extubated on [**7-15**] in the evening and did well the following
day. Given he remained hemodynamically stable and aerating well,
he was transferred back to the medical floor.
He did not require oxygen supplementation after transfer. A
follow-up chest xray was ordered and showed a persistant
left-sided hydrothorax, lower left lung collapse and slight
mediastinal shift. Repeat chest x-rays were done to follow
despite clinical improvement which showed no change. Diuresis
was increased and paracentesis performed (see below) to allow
for more agressive fluid removal. Despite findings on imaging,
the patient remained asymptomatic while at rest not requiring
oxygen. After several days of more aggressive diuresis, physical
therapy was initiated and the patient did well without further
symptoms. He will need repeat CXR as an outpatient to monitor
for resolution of his pleural effusion.
His anemia persisted, requiring transfusions 1-2U every several
days. There was no evidence of GI bleeding (no hematemesis and
persistently guaiac negative). Hematology was consulted to
comment on the transfusion-dependent anemia, and noted it was
likely multifactorial in nature. He was continued on
multivitamins, folic acid, thiamine. Iron supplementation was
not initiated given his multiple transfusion requirements. Given
he was guaiac negative and his underlying pulmonary issues, it
was felt a colonoscopy was not necessary at this time. He will
likely require follow-up endoscopy in the future, which will be
scheduled on an outpatient basis. He will also continue to
require transfusions on an outpatient basis and weekly CBC
checks.
His renal function remained stable on twice daily lasix and
spironolactone. With aggressive diuresis the patient's weight
stabilized and began to decrease. Of note, nadolol was started
in the ICU but discontinued on the medical floor to allow for
aggressive diuresis. It was not restarted prior to discharge and
may need to be reconsidered on an outpatient basis. A
therapeutic paracentesis was performed and removal of 2.5L of
clear, yellow-colored fluid was removed successfully, and cell
counts were not suggestive of infection. His lower extremity
edema improved significantly as well.
He was seen by social work for alcohol cessation counseling. He
was discharged to rehabilitation with follow-up planned at the
liver center.
Medications on Admission:
None
Discharge Medications:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-19**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
6. Multivitamin 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 Q12H (every 12 hours).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO QID (4
times a day).
11. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO TID (3 times a day): continue this
medication until you follow up with Dr. [**Name (NI) **].
12. Cipro 250 mg Tablet Sig: One (1) Tablet PO once a day: This
is to prevent infections of your abdominal fluid.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Alcohol Abuse
Cirrhosis
Alcholic Hepatitis
Spontaneous Bacterial Peritonitis
Hepatic Encephalopathy
Malnutrition
Discharge Condition:
Requiring rehab with assistance in activites of daily living and
physical therapy
Discharge Instructions:
You were admitted to the hospital with an infection of the fluid
in your abdomen. You required treatmet in the ICU, including
intubation and mechanical ventilation on a breathing machine.
You came to the regular medical floor and took medications to
get fluid off of you and to clear your mind. You also worked
with physical therapy.
You were quite weakened by your illness and required the
services of a rehabilitation hospital to get your strength back.
You were discharged to this rehabilitation hospital. It is very
important that you keep up your diet. It is hoped that you can
consume [**2131**] calories/day. If you can not, then the best thing
would be to insert a feeding tube in your nose and get tube
feedings through it.
It is very important that you take all medications as
prescribed. Your medications will keep the fluid off of your
legs and abdomen and will help to keep your mind clear. It is
essential that you abstain from further alcohol use as this will
continue to damage your allready very damaged liver. Please
attend all scheduled outpatient appointments.
If you develop more confusion, fevers, abdominal pain, black
stools, or blood from your bowel movements, please contact your
health care providers right away.
Followup Instructions:
Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2140-8-1**] 9:10
Name: [**Known lastname 2892**],[**Known firstname **] [**Last Name (NamePattern1) **] Unit No: [**Numeric Identifier 13229**]
Admission Date: [**2140-6-18**] Discharge Date: [**2140-7-28**]
Date of Birth: [**2101-9-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4097**]
Addendum:
Please note:
-Wound care recommendations were included in discharge paperwork
to rehabilitation center.
-pentoxifylline not on discharge medication list
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 49**] - [**Location (un) 50**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4098**] MD [**MD Number(2) 4099**]
Completed by:[**2140-7-28**]
|
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icd9cm
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[
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icd9pcs
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,560
| 174,125
|
51203
|
Discharge summary
|
report
|
Admission Date: [**2184-8-12**] Discharge Date: [**2184-8-18**]
Service: MEDICINE
Allergies:
Antihistamines
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
fatigue, weakness, and red/dark stools x2-3wk
Major Surgical or Invasive Procedure:
EGD [**2184-8-13**]
History of Present Illness:
Mr. [**Known lastname **] [**Age over 90 **]yo man with a history of extensive peripheral
vascular disease, CAD, metastatic prostate CA, who presents w/
fatigue, weakness, and red/dark stools x2-3wk. He reports loose
red/dark stools on at least a daily basis. No abd pain, N/V.
No prior [**Last Name (un) **] known. No lightheadeness, CP, or SOB. Pt??????s son
encouraged pt to seek care, so he was brought to ED for further
eval.
In ED, afebrile, HR 60s, SBP 100s (baseline 110-130s). Hct 21,
then 14 on repeat, though no interim blood loss (? Hct 14
spurious value). Guaiac +. Pt being admitted to MICU for
further eval & tx of GIB. Of note, pt also started on cefazolin
for possible LLE cellulitis.
Past Medical History:
1. CAD: IMI and complete heart block prior to CABG in
[**2169-12-30**].
2. Complete heart block in [**2169**], s/p PPM
3. Atrial fibrillation
4. Mitral valve abnormality with thrombus; on Coumadin since
[**2168**].
5. TIA's in [**2167**].
6. Right CVA in [**2176-8-30**].
7. Hypertension.
8. Hypercholesterolemia.
9. Prostate cancer diagnosed in [**2169-2-27**]; treated with
Lupron/Premarin.
10. Peptic ulcer disease greater than 50 years ago.
11. Spinal stenosis with disk disease.
12 Herpes zoster.
13. Venostasis disease.
14. Peripheral vascular disease; followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1476**]
since [**2175**].
PAST SURGICAL HISTORY:
1. CABG times four with left leg vein on [**2170-1-1**] byDr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], at [**Location (un) 511**] [**Hospital **] Hospital.
2. Left CEA in [**2176-5-30**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1476**].
3. Right CEA with Dacron patch angioplasty in [**Month (only) **] of2000
by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1476**].
4. Status post right BKA to RLE
5. L SFA occlusion, tx??????d w/ angioplasty & stent on [**2183-11-5**].
Social History:
patient lives with his wife. [**Name (NI) **] gets around in wheelchair. He
does not smoke cigarettes. He occasionally drinks alcohol.
Family History:
nc
Physical Exam:
ENT: pale sclerae.
ABDOMEN: Soft.
LYMPH NODES: Exam is negative in the supraclavicular and
axillary region.
NECK: Supple without masses.
EXTREMITIES: R BKA; LLE w/ skin brkdown over shin & medial
malleoulus-->stage II ulcer, erythema surrounding lesion.
Pertinent Results:
[**2184-8-12**] 07:55PM BLOOD WBC-15.0*# RBC-2.35*# Hgb-6.4*#
Hct-21.0*# MCV-89 MCH-27.2# MCHC-30.4*# RDW-14.0 Plt Ct-398
[**2184-8-13**] 06:28AM BLOOD WBC-14.4* RBC-3.51*# Hgb-10.3*#
Hct-30.6*# MCV-87 MCH-29.2 MCHC-33.6# RDW-14.2 Plt Ct-282
[**2184-8-13**] 02:00PM BLOOD Hct-26.7*
[**2184-8-14**] 03:43AM BLOOD WBC-13.2* RBC-3.57* Hgb-10.0* Hct-32.5*
MCV-91 MCH-27.9 MCHC-30.7* RDW-14.5 Plt Ct-227
[**2184-8-15**] 05:58AM BLOOD WBC-11.2* RBC-3.52* Hgb-10.2* Hct-30.8*
MCV-88 MCH-28.9 MCHC-33.0 RDW-14.6 Plt Ct-227
[**2184-8-16**] 05:35AM BLOOD WBC-9.3 RBC-3.57* Hgb-10.0* Hct-31.0*
MCV-87 MCH-28.0 MCHC-32.3 RDW-14.7 Plt Ct-261
[**2184-8-17**] 05:15AM BLOOD WBC-9.7 RBC-3.63* Hgb-10.3* Hct-32.2*
MCV-89 MCH-28.3 MCHC-31.9 RDW-14.8 Plt Ct-245
[**2184-8-18**] 09:50AM BLOOD WBC-9.3 RBC-3.59* Hgb-10.1* Hct-32.0*
MCV-89 MCH-28.2 MCHC-31.7 RDW-14.8 Plt Ct-278
[**2184-8-12**] 07:55PM BLOOD PT-31.9* PTT-31.4 INR(PT)-3.3*
[**2184-8-13**] 06:28AM BLOOD PT-24.4* INR(PT)-2.4*
[**2184-8-13**] 02:00PM BLOOD PT-19.1* PTT-30.5 INR(PT)-1.8*
[**2184-8-14**] 03:43AM BLOOD PT-17.8* PTT-36.2* INR(PT)-1.6*
[**2184-8-15**] 05:58AM BLOOD PT-17.6* PTT-30.7 INR(PT)-1.6*
[**2184-8-18**] 09:50AM BLOOD PT-15.3* PTT-36.4* INR(PT)-1.4*
[**2184-8-12**] 07:55PM BLOOD Glucose-109* UreaN-40* Creat-1.5* Na-136
K-4.7 Cl-104 HCO3-22 AnGap-15
[**2184-8-13**] 06:28AM BLOOD Glucose-107* UreaN-33* Creat-1.3* Na-138
K-4.4 Cl-107 HCO3-20* AnGap-15
[**2184-8-15**] 05:58AM BLOOD Glucose-100 UreaN-36* Creat-2.1* Na-137
K-3.6 Cl-106 HCO3-20* AnGap-15
[**2184-8-16**] 05:35AM BLOOD Glucose-99 UreaN-32* Creat-1.8* Na-137
K-3.3 Cl-106 HCO3-21* AnGap-13
[**2184-8-18**] 09:50AM BLOOD Glucose-145* UreaN-18 Creat-1.3* Na-140
K-3.6 Cl-108 HCO3-23 AnGap-13
[**2184-8-12**] 07:55PM BLOOD CK(CPK)-51
[**2184-8-12**] 07:55PM BLOOD cTropnT-0.03*
[**2184-8-13**] 06:28AM BLOOD Albumin-3.1*
[**2184-8-14**] 03:43AM BLOOD PSA-107.6*
[**2184-8-12**] 09:12PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Culture:
[**8-12**] Ucx negative. Bcx negative x2
[**8-14**] Wound Culture MRSA
[**8-16**] H.pylori negative
Imaging:
[**8-13**] EGD:
Findings: Esophagus: Normal esophagus.
Stomach:
Mucosa: Erythema, erosion and ulceration of the mucosa were
noted in the antrum.
Duodenum:
Mucosa: Erosion, erythema, and ulceration of the mucosa with
contact bleeding were noted in the anterior bulb.
Impression: Erythema, erosion and ulceration in the antrum
Erosion, erythema, and ulceration in the anterior bulb
Otherwise normal EGD to second part of the duodenum
Recommendations: Routine post procedure orders
Please start [**Hospital1 **] PPI.
Continue to trend HCT.
Brief Hospital Course:
[**Age over 90 **]yo man w/ multiple medical problems including metastatic
prostate cancer (to bone), afib on coumadin, CAD, who p/w
fatigue & weakness in setting of red/dark stools x2-3wk. Found
to have hct 21, down from low to mid-30s. Stool guaiac
positive.
# GIB: The pt was transfused a total of 5 units pRBCs and his
HCT stabalized. PPI therapy was initiated. Serial HCTs were
followeded initial q6 hours and then less frequently. The GI
service was consulted and an EGD was performed; no clear source
for bleeding was identified. The pt's anticoagulation was
revered with Vit K and FFP pre-procedure. An EGD was performed
on [**8-13**] which was significant for Erythema, erosion and
ulceration in the antrum. Erosion, erythema, and ulceration in
the anterior bulb. Otherwise normal EGD to second part of the
duodenum. Biopsies were not taken due to contact bleeding.
[**Name2 (NI) **]-procedure, the patient's HCT remained stable throughout the
remainder of his hospital course. H.pylori serologies were
drawn and were negative.
.
# CAD: The pt has a remote hx of IMI. He did not demonstrate any
sxs of ischemia during this admission. The pt's home atenolol
was intially held in the setting of unstable plasma volume. The
pt's home Plavix and Coumadin (pt not on ASA at home) were held
as well given the drop in HCT with presumed GI bleed. Post-EGD,
the HCT remained stable and he was restarted on his plavix and
coumadin upon discharge without events. He will be bridged at
discharge with lovenox.
#Afib/CHB: The pt is s/p PPM. His Coumadin was held and his
anticoagulation reversed for the acute bleed. The pt's BB and
diltiazem were also held. Once stabilized, he was restarted on
all his home medications without difficulty.
# PVD: The pt is s/p RLE BKA and bilateral CEA. At admission,
his skin was warm, well perfused, though some stage 2 ulcers on
LLE (L medial malleolus & L shin); Cipro and nafcillin were
started for a question ulcer infection, possible with
Pseudomonas. The vascular surgery and wound services were
consulted and followed the pt's progress. No e/o osteo, local
cellulitis. A wound culture was positive for MRSA and given the
sensitivities, the cipro and nafcillin were d/c and the patient
was started on Bactrim DS for a full 14 day course. Patient
scheduled for 2wk follow-up with Dr. [**Last Name (STitle) **].
# Prostate CA: mets to bones. Continued on premarin, flomax
Code: FULL (confirmed by MICU team)
Medications on Admission:
ATENOLOL - 25 mg qpm
ATORVASTATIN 10 mg tabs Tablet(s take one pill a day;two pills
on Mon/Wed/Friday
CONJUGATED ESTROGENS [PREMARIN] ?????? 3.75 mgevery morning
DILTIAZEM HCL [DILTIA XT] - 120 mg once a day
SPIRONOLACTONE - 12.5 mg every evening
TAMSULOSIN - 0.4 mg once daily
WARFARIN - (- 2 mg Tablet - qd, last dose [**2183-11-2**] pre angiogram
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Conjugated Estrogens 0.625 mg Tablet Sig: Six (6) Tablet PO
QAM (once a day (in the morning)).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day for 6 weeks.
Disp:*84 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Two (2)
Tablet PO BID (2 times a day) for 14 days.
Disp:*56 Tablet(s)* Refills:*0*
8. Lovenox 120 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous once a day for 10 days.
Disp:*10 syringes* Refills:*0*
9. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day: Hold
if SBP<100 or HR<60.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] senior life
Discharge Diagnosis:
Upper gastrointestinal bleed
Discharge Condition:
Stable in good condition
Discharge Instructions:
You were admitted to the hospital because of upper
gastrointestinal bleeding that had manifested as red/dark
stools. In the Emergency Department you were noted to have a
very low red blood cell count, likely because of this bleeding.
Because of this concern for gastrointestinal bleeding you were
admitted to the Medical ICU for observation. While in the ICU,
you were seen by the Gastroenterologists who did an upper
endoscopy which showed some erosions in the mucosa of your
stomach but no active bleeding or deep ulcers. Because your red
blood cell count was low, you were given 5 units of red blood
cell tranfusion. You did not have any further bleeding or
decreases in your red blood cell count and were deemed stable
for discharge on [**8-18**].
You were seen by the Vascular surgeons while you were in the
hospital for your left lower leg ulcers. A culture was done of
the ulcer because of surrounding redness. The culture grew out
a bacterial MRSA. You will be treated with bactrim for this
bacteria for a full 14 day course.
You were taken off of your home Diltiazem and Spironolacton
because of blood pressure. You should have your blood pressure
checked by the visiting nurse service and followed up with your
primary doctor to address adding this medication back. You will
be taking a new medication, Lovenox which is a daily injection
as well a Bactrim, which is an antibiotic for your leg ulcers.
The Bactrim will be a 14 day course.
Call your primary doctor or go to the Emergency Room if you have
any persistent fevers, any sudden weakness, any blood in your
stool or very dark/black stools.
Followup Instructions:
Follow-up with your new primary care provider, [**Name10 (NameIs) 39063**] [**Name8 (MD) 106250**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2184-9-1**] 3:00
Follow-up with your Vascular [**Last Name (LF) 5059**], [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2184-9-9**] 2:30
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icd9cm
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20,577
| 172,803
|
47935
|
Discharge summary
|
report
|
Admission Date: [**2190-2-9**] Discharge Date: [**2190-2-11**]
Date of Birth: [**2125-5-16**] Sex: M
Service: MEDICINE
Allergies:
Cephalosporins / Metoclopramide / Infed
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Blood stools
Major Surgical or Invasive Procedure:
EGD [**2190-2-10**]
History of Present Illness:
Mr. [**Known lastname 101054**] is a 64 male with DMII, ESRD on HD, Hep C and Hep
B, who presented from dialysis after having blood streaked stool
and Hct drop of 27 to 20. The patient also has a PMH significant
for chronic anemia, internal hemorrhoids, gastritis, ischemic
colitis, and AVMs in his small bowel and colon. Of note, Mr
[**Known lastname 101054**] received a colonoscopy 2 weeks ago for acute on chronic
anemia (his Hct had drifted down to 17.9), and his colonoscopy
was normal. Prior to the current episode of bloody stool, Mr
[**Known lastname 101054**] denied history of melena. His last EGD one year ago in
[**2188-12-25**] was unremarkable. While having the bloody stool
yesterday the pt denied nausea, vomiting, abdoinal pain or
discomfort. He came to the Ed at [**Hospital1 18**] [**2190-2-9**] where initial VS
98.1, 75, 157/88, 18 and 100/RA. He had one maroon stool in ED.
Rectal exam notable for guaiac + brown to marroon stool but
otherwise abdomen benign. Refused NG lavage. Access obtained
with 2 x 16g peripherals. His Hct in the ED was found to be 20.
He was transferred to the MICU where he received 3 units of
blood with hematocrit increasing from 20 to 27.
GI was consulted in the ED and plans were made to do EGD. Pt
underwent EGD today which showed gastritis but no active
bleeding.
Of note, he did not get full dialysis yesterday and states that
his last dialysis was Saturday.
ROS:
(+)As per HPI. Also + for chronic diarrhea over the past 6
months (pt thinks this has correlated with decreasing his
methadone dose).
Past Medical History:
-- CKD V from diabetic nephropathy on HD since [**5-/2183**]
-- DM2 for over 20 years on insulin
-- Hepatitis C genotype 4; liver biopsy [**2186-8-10**] revealed grade
1 inflammation and stage III fibrosis; never treated with IFN
-- S/p bilat BKA ([**2179**], [**2183**]) for polymicrobial chronic
osteomyelitis; wears prostheses and uses walker
-- H/o ischemic colitis with GIB (approx [**2180**]), occ BRBPR; known
small bowel AVMs
-- HTN
-- H/o TB (age 15, Rx with PAS/INH x 2 yrs)
-- Hep B core Ab positive (negative viral load in [**2185**])
-- H/o IV drug use (heroin), on methadone since [**2159**] (100 mg
daily; does not recall name/number of methadone program)
-- Prior right AV fistula infection
-- H/o VRE and MRSA
-- Chronic anemia
-- Prior MSSA HD line infection
-- Prior ESBL Klebsiella wound infections
-- s/p penectomy for necrosis [**1-26**] arterial insufficiency
Social History:
Retired computer worker. Smokes 5 cigarettes per day x 10+
years; denies alcohol use; former IVDU. Came to [**Hospital1 18**] from [**Hospital1 1501**]
the Embassy House in [**Hospital1 1474**]
Family History:
Several siblings with diabetes
Physical Exam:
ADMISSION EXAMVitals:
T:98.4 P: 80 BP:124/62 R: 18 SaO2:85% on RA --> 94% 2L (does not
use O2 at home)
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, Mildly dry MM, no lesions noted in OP
Neck: supple, no JVD
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: bilateral BKAs, no edema
Lymphatics: No cervical, supraclavicular lymphadenopathy noted.
Skin: fleshy, crusty papular lesions along right forearm and
left knuckles.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
slowly
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. movign all
extremities
Pertinent Results:
ADMISSION LABS
[**2190-2-9**] 08:41AM BLOOD WBC-4.6 RBC-2.23* Hgb-6.5* Hct-20.7*
MCV-93 MCH-29.3 MCHC-31.5 RDW-17.5* Plt Ct-209
[**2190-2-9**] 08:41AM BLOOD PT-15.6* PTT-35.8* INR(PT)-1.4*
[**2190-2-9**] 08:41AM BLOOD Glucose-132* UreaN-74* Creat-8.0*# Na-145
K-6.9* Cl-109* HCO3-23 AnGap-20
[**2190-2-9**] 08:47AM BLOOD Glucose-129* Lactate-1.3 Na-145 K-6.9*
Cl-108 calHCO3-24
Brief Hospital Course:
64 yo M with PMH of ESRD, DM2, Hepatitis C as well as gastritis,
colonic AVM and internal hemorrhoids, who presented [**2190-2-9**] from
HD after having brown to marroon stools.
# GI bleed: Given hematocrit drop to 20.7 from most recent of
27.4, patient was admitted to ICU. During first day of
admission, patient was treated with IV Pantoprazole and 3U PRBC.
Hct improved appropriately. The following day, he underwent
EGD and was found to have esophageal varices, erosive gastritis
in the setting of portal hypertensive gastritis, duodenitis but
otherwise normal EGD to second part of the duodenum. Given
concern that esophageal varices may represent worsening liver
disease, liver ultrasound was obtained. This showed slightly
nodular surface and enlargement of the left lobe, suggesting
cirrhosis, without evidence of a focal lesions. The portal vein
demonstrated normal hepatopetal flow and was patent. An
incidental finding was a hypoechoic region that measured 3.0 x
2.8 x 1.9 cm (see below). GI recommended that the patient get a
capsule endoscopy as an outpatient given concern for AV
malformations or other small bowel pathology causing the melena.
The patient was restarted on a clear diet then advanced to
regular cardiac/diabetic diet. He tolerated this well. He did
finally have one small melenotic stool the afternoon of [**2190-2-11**],
but his hematocrit was stable at 28 on discharge. The patient
was given the number to call and schedule his capsule endoscopy
in the next 1 to 2 weeks and was scheduled GI follow up on [**3-17**] [**2189**]. The patient was told to not restart his aspirin
given the bleeding until he talks with his primary care doctor.
He was discharged on twice daily 40 mg omeprazole. He should
continue to get daily hematocrit checks until his melena stops
and his hematocrit is stable.
.
# Pancreatic mass: An incidental finding on the patient's liver
ultrasound was a hypoechoic region that measured 3.0 x 2.8 x 1.9
cm. It was difficult to assess whether this region represented
part of the duodenum or arises from the pancreatic head or
ampulla. Further imaging was recommended, however the patient
did not want to stay in the hospital for this test. He was
given the number to call and schedule this as an outpatient. He
should get a CT abdomen with contrast with pancreatic
sequencing. It would be preferable that he schedule this test
on a day before he has hemodialysis.
.
# Hepatitis: The patient has suggestion of cirrhosis on liver
ultrasound. He does not follow with a hepatologist and has
never had therapy for his hepatitis. He was scheduled an
outpatient appointment with Dr. [**Last Name (STitle) 7033**] in hepatology on [**3-10**].
.
# End stage renal disease: The patient normally receives
dialysis on T/Th/Saturday. He was dialyzed the morning of
[**2190-2-11**]. His outpatient medications, Sevelamer and Cinacalcet,
were continued.
.
# Diabetes type II: The patient's last HbA1c was 5.5 on [**11-2**].
He was continued on his home dose insulin.
.
# History of IV drug use. The patient was continued on his home
dose of methadone 10 mg twice a day.
.
# Upper extremity edema/facial edema. The patient was noted to
have significant left arm and facial edema. Per OMR records he
presented with this back in Novermber [**2188**] and underwent full
work up with ultrasound, CT and MR venography which all did not
show evidence of clot. The patient was not on coumadin. He did
not receive DVT prophylactic anticoagulation during this
hospitalization given the concern for GI bleeding.
.
# Code: full code
Medications on Admission:
1. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
8. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. Methadone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for diarrhea.
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two
(2)Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous HD PROTOCOL (HD Protochol) -- Through [**2190-1-31**]
13. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-26**] Sprays Nasal
QID (4 times a day) as needed for congestion.
14. Aranesp (Polysorbate) 100 mcg/mL Solution Sig: One (1) ml
Injection once a week.
15. Insulin
Insulin Glargine (Lantus) 15mg subcutaneous, qhs
16. Insulin
Insulin Lispro (Humalog) Administer according to the following
sliding scale: 2 units for BS 151-200, 4 units for BS 201-250, 6
units for BS 251-300, 8 units for BS 301-350, 10 units for BS
351-400. Please check fingerstick blood sugars qid
17. Bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day
as needed for constipation.
18. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for pain.
19. Doxepin 10 mg Capsule Sig: One (1) Capsule PO at bedtime
20. Vitamin B12 1000mg daily.
21. Ferrous sulfate 325 mg po daily.
Discharge Medications:
1. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
5. Methadone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Lo-Peramide 2 mg Tablet Sig: Two (2) Tablet PO four times a
day as needed for diarrhea.
7. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
8. Aranesp (Polysorbate) 100 mcg/mL Solution Sig: One (1)
injection Injection once a week: on Tuesdays.
9. Doxepin 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
10. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
13. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15)
units Subcutaneous at bedtime.
14. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehab
Discharge Diagnosis:
Primary diagnosis:
Gastritis
Esophageal varices
Duodinitis
Pancreatic lesion
Secondary diagnosis:
End stage renal disease
Diabetes
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 came to the hospital because you were having bright red
blood in your stool at hemodialysis. You had an upper endoscopy
which showed that you have Esophageal varices, Erosive gastritis
in the setting of portal hypertensive gastritis, and Duodenitis.
It is possible that these are the sources of your bleeding.
However, the GI doctors would [**Name5 (PTitle) **] [**Name5 (PTitle) **] to have another study
called a capsule endoscopy to varify this. You are on a
medication called pantoprazole to help protect your stomach from
bleeding.
While you were here you also had a liver ultrasound. This
showed that your liver may have some cirrhosis. It also showed
an incidental finding of a lesion that is near your pancreas.
Further studies need to be obtained to find out if this is a
mass or tumor. We would like you to have a CT scan to better
assess what this lesion is. You can have this done as an
outpatient.
The following changes have been made to your medications:
Please increase omeprazole to 40 mg twice a day
Please stop aspirin and talk to your primary care doctor about
when to restart this medication
Please follow up with your primary care doctor. You should also
follow up with the gastroenterologists as well as a
hepatologist.
Followup Instructions:
Please follow up with your primary care doctor in the next 1 to
2 weeks. Someone will call you from his office to schedule this
appointment. If you do not get a phonecall please call his
office at [**Telephone/Fax (1) 6019**].
Please also schedule your capsule endoscopy study for sometime
in the next 1 to 2 weeks. To do this you need to call ([**Telephone/Fax (1) 26817**] and hit the number #[**Serial Number **]. This will take you to the
receptionist (named [**Name (NI) 13544**]) who will make the appointment for
you. At least 2 weeks after you have this study you will need
to follow up with the gastroenterologists. We have made a
follow up appointment for you on [**3-17**], at 2pm with Dr.
[**Last Name (STitle) 101145**] [**Name (STitle) **]. Please come to the RA [**Hospital Unit Name **]
([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **] for this appointment.
You also should follow up with a liver doctor for your hepatitis
and liver cirrhosis. We have made an appointment for you on
[**3-10**] at 8:30 am at the Liver Center in the [**Hospital Unit Name **],
located at [**Last Name (NamePattern1) **] on the [**Location (un) **], Suite 8E. You will
be seeing Dr. [**Last Name (STitle) 7033**].
In addition, you stated that you did not want to stay in the
hospital to have a CT scan of your abdomen. You will still need
to get this CT scan to better evaluate the mass seen on your
liver ultrasound. Please call to schedule a time to get this
scan. The number to call is [**Telephone/Fax (1) 327**]. Please hit #1 when
prompted to get to the scheduler.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
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28,296
| 178,835
|
3569
|
Discharge summary
|
report
|
Admission Date: [**2202-8-10**] Discharge Date: [**2202-8-23**]
Date of Birth: [**2123-1-29**] Sex: M
Service: MEDICINE
Allergies:
Serax
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Presented to emergency room with 1 day history of nausea and
vomiting and possible aspiration pneumonia
Past Medical History:
-Parkinson disease s/p deep brain stimulator placement
-HTN
-Diabetes mellitus
-hyperlipidemia
-Shy-[**Last Name (un) **] syndrome
-diaphragmatic hernia
-ventral hernia
-GERD
-CKD
- h/o subtotal colectomy with Hartmann's pouch
- h/o end ileostomy and G-tube for sigmoid volvulus ([**2198**] -
[**Doctor Last Name **])
- ORIF R humerus fracture ([**2193**])
.
Social History:
Patient lives in [**Location **] with his wife, who has been disabled
for many decades now; and has aides to care for her and him 24
hours a day. His family owns a real estate company in [**Location (un) **].
He is retired from developing a construction company, and has 5
children. A daughter in an internist in [**Name (NI) 531**].
Family History:
Father: died of skin cancer
Brother #1: prostate cancer
Brother #2: CVA
Physical Exam:
On admission:
Temp:98.0 HR:85 BP:103/59 Resp:24 O(2)Sat:88% low
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Extraocular muscles
intact
Oropharynx within normal limits
Chest: coarse breath sounds
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nondistended, diffusely tender
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: + increased muscle tone
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Pertinent Results:
On admission:
[**2202-8-10**] 03:40PM BLOOD WBC-7.2 RBC-4.14* Hgb-13.3* Hct-40.1
MCV-97 MCH-32.2* MCHC-33.1 RDW-13.7 Plt Ct-311
[**2202-8-10**] 03:40PM BLOOD Neuts-89.0* Lymphs-5.9* Monos-3.3 Eos-0.1
Baso-1.7
[**2202-8-10**] 03:40PM BLOOD PT-13.8* PTT-24.7 INR(PT)-1.2*
[**2202-8-10**] 03:40PM BLOOD Glucose-211* UreaN-28* Creat-2.1* Na-138
K-4.7 Cl-99 HCO3-24 AnGap-20
[**2202-8-10**] 03:40PM BLOOD ALT-14 AST-23 AlkPhos-128 TotBili-0.6
[**2202-8-10**] 03:40PM BLOOD Lipase-57
[**2202-8-10**] 03:40PM BLOOD Calcium-9.4 Phos-4.5 Mg-1.8
[**2202-8-10**] 03:42PM BLOOD Lactate-4.2*
.
On discharge:
.
[**2202-8-22**] 06:45AM BLOOD WBC-8.9 RBC-3.18* Hgb-9.6* Hct-30.6*
MCV-96 MCH-30.3 MCHC-31.6 RDW-13.7 Plt Ct-635*
[**2202-8-22**] 06:45AM BLOOD Glucose-97 UreaN-12 Creat-1.0 Na-139
K-4.0 Cl-105 HCO3-30 AnGap-8
[**2202-8-22**] 06:45AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.8
.
Studies:
.
[**8-16**] CXR: FINDINGS: In comparison with the study of [**8-14**], there
are continued low lung
volumes. Extensive left basilar consolidation is again seen with
continued
less prominent opacifications in much of the right lung. The
findings are
consistent with widespread pneumonia, possibly complicated by
increased
pulmonary venous pressure in a patient with prominence of the
cardiomediastinal silhouette.
Deep brain stimulators are again seen.
.
[**8-22**] CXR:
There are low lung volumes. Cardiac size is top normal. Large
left lung
consolidation consistent with pneumonia is minimally improved
from prior
study. Hazy opacities in the right lung are unchanged, also
consistent with
pneumonia. There are no new lung abnormalities. There is no
pneumothorax.
If any there is a small left pleural effusion. Brain stimulators
are again
seen.
.
[**8-10**] CT abd/pelvis: 1. High-grade small-bowel obstruction at the
level of small bowel containing supraumbilical ventral abdominal
wall hernia with distal decompression. No perforation or other
complication.
2. Cholelithiasis without cholecystitis.
3. Consolidation at the left lung base posteriorly may represent
aspiration.
4. Markedly distended stomach containing fluid and gastric
contents as a
result of the small bowel obstruction.
.
[**8-16**] Video swallow study:
FINDINGS: Barium passes freely through the oropharynx without
evidence of
obstruction. There was no gross aspiration or penetration. For
details,
please refer to the speech and swallow division note in OMR.
IMPRESSION:
No penetration or aspiration.
Brief Hospital Course:
Mr. [**Known lastname 16284**] is a 79 year old gentleman with PMH s/f advanced
Parkinson's disease/Shy-[**Last Name (un) 16294**] Syndrome, DM, HTN, ventral
hernia and distant sigmoid volvulus (s/p colectomy w/ostomy in
place), who was admitted with SBO which resolved w/ conservative
management, now with aspiration PNA, likely present at
admission.
.
#SBO: The patient was admitted to the surgical service. He has a
history of subtotal coletomy with Hartmann's pouch and end
ileostomy for sigmoid volvulus. An NG tube was placed and the
patient was managed conservatively with fluids and electrolyte
repletion. His SBO eventually resolved and he maintained good
ostomy output without nausea or vomiting during his admission to
the medical service.
.
#Aspiration pneumonia: The patient was admitted with a CXR
concerning for aspiration. He was started on broad-spectrum
antibiotics, which were tapered to Levaquin. The patient was
then transferred to the medicine service where he developed
increasing hypoxia. Antibiotics were then re-broadened and the
patient was closely followed with serial chest X rays; O2
support was intitially via Venturi mask, but the patient was
weaned to nasal cannula. He completed an 8-day course of
broad-spectrum antibiotics and was discharged with home oxygen.
O2 saturations on the day of discharge were 95-96% on 1L nasal
cannula. The patient passed a video swallow study and was kept
on soft foods and thin liquids during this admission.
.
#PARKINSONS/SHY-[**Last Name (un) **]: The patient was continued on his home
medications Sinemet and [**Last Name (un) 16285**]. He is s/p placement of deep
brain stimulators. Sertraline was continued for depression.
Physical therapy was consulted and helped work with the patient
and helped him advance his activity.
.
#ACUTE ON CHRONIC RENAL FAILURE. The patient's creatinine was
closely monitored. On admission, creatinine was 1.5. With close
monitoring of the patient's output and IV fluid hydration, the
patient's creatinine stabilized at 1.0.
.
#AGITATION: The patient was maintained on his home medications
quetiapine and trazodone at night. He occasionally required
extra doses of these medications and would intermittently become
very agitated at night - this frequently led to hypoxia and
increased O2 requirement.
.
#DM: The patient's home glipizide therapy was held. Fasting AM
glucose levels were checked and ranged from 100-160s. The
patient was received SSI and a diabetic diet.
.
#GERD: The patient was continued on his home omeprazole.
.
# GROIN RASH: The patient received antifungal cream and powder
for a candidal rash.
.
# HYPERLIPIDEMIA: The patient was continued on his home
medication simvastatin.
.
# SOFT STOOL: Resolved. C. diff toxin negative x3.
.
#The patient received subQ heparin for DVT prophylaxis. He
remained full code during this admission. He was discharged with
close follow-up by his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 141**].
Medications on Admission:
1. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
2. Quetiapine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed for sleep.
5. Sinemet-25/250 25-250 mg Tablet Sig: One (1) Tablet PO BID at
6:30 AM and 9AM.
6. Sinemet-25/250 25-250 mg Tablet Sig: 1.5 Tablets PO BID at
11:30AM and 4:30PM.
7. Sinemet-25/250 25-250 mg Tablet Sig: 1.75 Tablets PO qd at
2:00 PM.
8. Sinemet-25/250 25-250 mg Tablet Sig: Two (2) Tablet PO qd at
7:00PM.
9. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Vesicare 5 mg Tablet Sig: One (1) Tablet PO once a day.
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Ropinirole 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day): 2 mg TID at 6:30AM, 9:00AM, and 2:00PM.
14. Ropinirole 2 mg Tablet Sig: 1.5 Tablets PO qd at 11:30AM.
15. Restasis 0.05 % Dropperette Sig: One (1) drop in both eyes
Ophthalmic twice a day.
16. Patanol 0.1 % Drops Sig: Two (2) drops per eye Ophthalmic
twice a day as needed for itching.
17. Miralax 17 gram/dose Powder Sig: One (1) 17 gram dose PO
once a day as needed for constipation.
Discharge Medications:
1. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
2. Quetiapine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed for sleep.
5. Sinemet-25/250 25-250 mg Tablet Sig: One (1) Tablet PO BID at
6:30 AM and 9AM.
6. Sinemet-25/250 25-250 mg Tablet Sig: 1.5 Tablets PO BID at
11:30AM and 4:30PM.
7. Sinemet-25/250 25-250 mg Tablet Sig: 1.75 Tablets PO qd at
2:00 PM.
8. Sinemet-25/250 25-250 mg Tablet Sig: Two (2) Tablet PO qd at
7:00PM.
9. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Vesicare 5 mg Tablet Sig: One (1) Tablet PO once a day.
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Ropinirole 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day): 2 mg TID at 6:30AM, 9:00AM, and 2:00PM.
14. Ropinirole 2 mg Tablet Sig: 1.5 Tablets PO qd at 11:30AM.
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for groin rash.
16. Restasis 0.05 % Dropperette Sig: One (1) drop in both eyes
Ophthalmic twice a day.
17. Patanol 0.1 % Drops Sig: Two (2) drops per eye Ophthalmic
twice a day as needed for itching.
18. Miralax 17 gram/dose Powder Sig: One (1) 17 gram dose PO
once a day as needed for constipation.
19. Home Oxygen
Home oxygen at 1-4 LPM continuous, pulse-dose for portability
Diagnosis: Aspiration pneumonia
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Small bowel obstruction
Aspiration pneumonia
Secondary:
Parkinson disease s/p deep brain stimulator placement
HTN
Diabetes mellitus
Hyperlipidemia
GERD
h/o subtotal colectomy with Hartmann's pouch
h/o end ileostomy and G-tube for sigmoid volvulus ([**2198**] -
[**Doctor Last Name **])
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 16284**],
It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted for a small bowel
obstruction that resolved with conservative management. Your
hospital course was complicated by pneumonia - likely,
aspiration pneumonia, for which you were treated with
broad-spectrum antibiotics and oxygen support.
We made no major changes to your medication regimen and you
should continue to take your medications as directed by Dr.
[**Last Name (STitle) 141**]. We did add miconazole powder for the rash in your
groin to be used as needed.
An appointment with Dr. [**Last Name (STitle) 141**] is scheduled for next Thursday,
[**9-2**] at 4 pm. You can call his office if this needs to be
re-scheduled.
You were discharged with oxygen to be used at home and the
visiting nurses will help to wean you from oxygen as your
strength improves and as your body continues to absorb the fluid
and infection from your lungs.
Followup Instructions:
The information for your follow-up appointment with Dr. [**Last Name (STitle) 141**]
is listed below:
Department: INTERNAL MEDICINE
When: THURSDAY [**2202-9-2**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], MD [**Telephone/Fax (1) 142**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
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|
10717, 10717
|
1849, 1849
|
11955, 12365
|
1191, 1264
|
8708, 10299
|
10400, 10696
|
7324, 8685
|
10968, 11932
|
1279, 1279
|
2444, 4304
|
228, 262
|
335, 440
|
1863, 2430
|
10732, 10944
|
462, 823
|
839, 1175
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,088
| 193,394
|
25885
|
Discharge summary
|
report
|
Admission Date: [**2116-6-13**] Discharge Date: [**2116-6-29**]
Date of Birth: [**2054-12-7**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Assault with posterior head laceration Trauma Transfer
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt was drinking and was assaulted, Pt fell backward hitting
head, Unclear LOC
Past Medical History:
DM, HTN, CABG
Social History:
Lives with sons and exchange student
+ETOH
Physical Exam:
On admission:
96.3 74 20 201/97 95% RA
Gen: Alert, Oriented x 1, MAE
HEENT: 4cm laceration L occiput, stapled from OSH, PERRL, EOMI
Neck: C collar on
Lungs: CTAB
Cardiac: RRR
Abd: soft NT/ND
Rectal: guiac neg, good tone
Pertinent Results:
[**2115-6-14**]
Cspine CT: negative
Initial head CT:
Left parietal and left frontal acute subdural hematomas. Acute
left temporal intraparenchymal hematoma. Acute subarachnoid
hemorrhage in the
left sylvian fissure and anterior to the right frontal and right
temporal
lobes.
[**2116-6-26**] 04:45AM BLOOD WBC-6.9 RBC-3.41* Hgb-11.5* Hct-33.7*
MCV-99* MCH-33.8* MCHC-34.3 RDW-12.7 Plt Ct-306
[**2116-6-25**] 04:45AM BLOOD WBC-6.1 RBC-3.81* Hgb-13.1* Hct-38.3*
MCV-101* MCH-34.4* MCHC-34.2 RDW-13.0 Plt Ct-292
[**2116-6-14**] 02:20AM BLOOD Glucose-134* UreaN-6 Creat-0.7 Na-134
K-3.6 Cl-98 HCO3-26 AnGap-14
[**2116-6-13**] 03:03PM BLOOD Glucose-127* UreaN-6 Creat-0.6 Na-135
K-3.8 Cl-98 HCO3-25 AnGap-16
[**2116-6-21**] 05:05AM BLOOD ALT-35 AST-25 AlkPhos-93 TotBili-0.5
[**2116-6-26**] 04:45AM BLOOD Calcium-8.9 Phos-4.0 Mg-1.8
[**2116-6-14**] 02:20AM BLOOD Calcium-9.0 Phos-2.5* Mg-1.5*
[**2116-6-13**] 12:05AM BLOOD ASA-NEG Ethanol-138* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
Pt was assaulted fell backward striking head. Was worked up at
OSH and found to have SDH, ICH, and SAH, was the Transferred to
[**Hospital1 18**]. Pt was hemodynamically stable Alert and Oriented, was
admitted to the TSICU for obs and seizure prophylaxis. Shortly
after being admitted the patient developed DTs, requiring
intubation, subsequently pt developed some Congestive Heart
Failure, but once this resolved the patient was successfully
extubated and moved to the floor. On the floor the patient did
well, being cleared by PT and Speech and Swallow. Occupational
Therapy had some concern for pt safety given TBI, but was
eventually cleared and sent home with regular safety checks by
the patients family.
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
Disp:*1 MDI* Refills:*0*
5. Clonidine 0.3 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
8. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours).
Disp:*360 Tablet(s)* Refills:*2*
9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Traumatic Brain Injury- Subdural Hemorrhage, Subarachnoid
Hemorrhage
Discharge Condition:
Stable
Discharge Instructions:
Take medications as perscribed, be sure to take you blood
pressure medications, if you fail to continue your medications
as directed you may develop severe and dangerous hypertension,
follow up as indicated below. Return to the Emergency
Department if you develop fevers > 101.5, Shortness of Breath,
Abdominal Pain, or other concerns.
Followup Instructions:
-Follow up with Neurosurgery, with Dr. [**Last Name (STitle) **], call ([**Telephone/Fax (1) 18865**] for an appointment regarding further management of your
intercranial bleed in 6 weeks, come to your appointment with a
recent repeat cat scan of your head, call ([**Telephone/Fax (1) 6713**] to
schedule an appointment for the scan.
-Follow up with Neurobehavoir, Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], call for
appointment [**Telephone/Fax (1) 1690**]
Follow up with Neurobehavior, with Dr. [**Last Name (STitle) **], call ([**Telephone/Fax (1) 1703**]
for an appointment regarding further management of your
Traumatic Brain Injury in [**12-15**] weeks.
Follow up with your Primary Care Physician as soon as possible
for Hypertension and Diabetes Management.
|
[
"250.00",
"401.9",
"873.0",
"V45.81",
"E960.0",
"291.0",
"428.0",
"852.06"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"96.72",
"96.04",
"99.07",
"86.59",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
3505, 3511
|
1848, 2565
|
368, 375
|
3624, 3632
|
836, 881
|
4017, 4814
|
2588, 3482
|
3532, 3603
|
3656, 3994
|
595, 595
|
274, 330
|
403, 482
|
890, 1825
|
609, 817
|
504, 519
|
535, 580
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,637
| 172,946
|
52640
|
Discharge summary
|
report
|
Admission Date: [**2199-3-10**] Discharge Date: [**2199-3-18**]
Date of Birth: [**2150-12-11**] Sex: M
Service: MEDICINE
Allergies:
Haldol / Perphenazine / Droperidol
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
agitation
Major Surgical or Invasive Procedure:
endotracheal intubation
peripherally inserted central venous catheter
History of Present Illness:
48yoM with h/o bipolar disorder and HTN, presented to [**Hospital1 18**] ED
[**2199-3-9**] with confusion and agitation to psychiatry, transferred
now to MICU with tachypnea, fever, tachycardia.
.
Patient initially presented to ED with pressured speech and
agitation after being found pacing and yelling in front of his
apartment. In ED T 100.6 HR 100 BP 184/95 RR 16 98%RA. He was
diagnosed with a UTI and treated with Cipro. CXR was
unremarkable. Lumbar puncture was bloody but without significant
WBC and negative gram stain. He was admitted to psychiatry
.
Today VS T 102.3 HR 106 BP 144/80 RR 40 96%RA. He was
complaining of low back pain and inability to urinate. Medical
consult was called and trasnferred patient to MICU. On arrival
patient was alert and responding appropriately to questions. He
complained of low back pain. He denied having bowel or bladder
incontinence, or lower extremity numbness. He also denied SOB,
chest pain, abdominal pain
Past Medical History:
PSYCHIATRIC HISTORY:
As above, pt. with long h/o bipolar disorder and multiple
inpatient admissions. See HPI for details.
Pt. stopped medications; psychiatrist on vacation.
Pt. with recent inpatient admissions to [**Hospital1 882**] and [**Hospital1 336**]. Pt.
has h/o assaults when manic. Pt. denies current HI/SI. Pt.
reports h/o x1 suicide attempt by overdose 20 years ago.
PAST MEDICAL HISTORY:
HTN
s/p asystole x 2 during ECT at [**Hospital 882**] hospital last year
tardive dyskinesia from Risperdal
EPS from Haldol
ALLERGIES (INCLUDE REACTION, IF KNOWN):Trilafon = N.M.S.
SUBSTANCE ABUSE HISTORY (INCLUDE HISTORY OF D.T.'S, WITHDRAWAL
SEIZURES, BLACKOUTS, DETOX TREATMENT, I.V. USAGE):
Pt. has a h/o some alcohol abuse but no known recent history. No
h/o detox. Pt. smokes cigarettes.
Social History:
Pt. never married, no children. Lives alone in geriatric section
8 housing.
Pt. finished H.S. and took courses at vocational program at BU
Center for [**Hospital 7637**] Rehabilitation, but did not complete two
internships due to illness.
Family History:
Mother = bipolar
Physical Exam:
On Arrival to MICU:
T 101.4 HR 106 BP 148/88 RR 31 100%4Lnc
Gen: tachypneic, alert, moderately agitated
HEENT: PERRL, anicteric, MMM, OP clear
Neck: no LAD, JVP not appreciated
CV: tachy, regular rhythm, no murmurs
Resp: CTAB
Abd: +BS, soft, NT, ND, obese
Back: tender to palpation
Ext: no edema, 2+ radials and DPs bilaterally
Neuro: A&Ox3, CN II-XII intact, strength 5/5 throughout,
sensation intact to touch
Pertinent Results:
[**2199-3-10**] CTA chest/abd:
1. 1.8 cm low density left renal lesion which is not completely
a cyst and is indeterminate, further evaluation with MRI is
recommended.
2. Bibasilar airspace opacities which may be secondary to
atelectasis versus aspiration versus infection, clinical
correlation is recommended.
3. No CT evidence of pyelonephritis. No evidence of
intra-abdominal abscess.
4. No evidence of pulmonary embolism.
Brief Hospital Course:
In brief, the patient is a 48 male with bipolar disorder, HTN
presenting with agitation, fever and respiratory distress.
.
1. Fever/tachycardia/tachypnea/leukocytosis: The patient
initially presented with symptoms consistent with acute mania.
Following admission to the psychiatry service, he developed
notable tachypnea, fever, and tachycardia. The patient had been
started on ciprofloxacin for a UTI prior to the admission. He
was transfered to the ED and subsequently to the MICU for
management of the potential sepsis. The patient was intubated
for respiratory distress/airway protection. Microbiology data
revealed coag negative staph on the day of evaluation in the ED.
He received ceftriaxone and vancomycin as empiric therapy. A
TTE (although limited) showed normal MV and AV w/o vegetations.
Follow-up blood cultures were negative. The patient
self-extubated without complication and by time of discharge was
breathing and oxygenating normally on room air. The likely
original source was a UTI followed by manic episode from
medicine non-adherence then aspiration pneumonitis that
resolved. He received a total course of empiric antibiotics of 9
days.
2. Bipolar disorder: The patient was followed by the psychiatry
service throughout his hosptial stay. He was not actively manic
during his stay on the medicine service. He was discharged on a
modified regimen of anti-psychotics and mood stabilizer
medication compared to his prior regimen. He will follow-up
with his primary psychiatrist within one week from discharge and
begin a partial hospitalization program following discharge.
.
3. CARDIAC: The patient had no chest pain during or prior to the
admission but had with EKG evidence of old anteroseptal infarct.
He had 3 sets of negative cardiac enzymes. A TTE revealed
preserved BiV function. His LDL was at goal. His blood
pressure was controlled with beta-blockade. He was started on
low-dose aspirin therapy. In follow-up with his new PCP he can
be considered for ETT to evaluated for reversible ischemic
myocardium.
.
4. Elevated Transaminases: Incidental note was made of mild
transaminase elevation which should be repeated as an outpatient
and evaluated as needed.
.
5. Renal Lesion: Incidental note of renal mass was made on the
CT scan of the torso. The lesion should be follow-up with MRI
to better characterize.
6. F/E/N: The patient received a low sodium diet and
electrolytes were repleted as needed.
7. PPx: The patient received SC heparin, PPI
.
8. Code: Full
.
9. Communication: mother [**Name (NI) **] [**Name (NI) 1124**] [**Telephone/Fax (1) 108639**]
Sister-also [**Name (NI) **] [**Known lastname 1124**] [**Last Name (NamePattern1) 108640**]: [**Telephone/Fax (1) 108641**]
.
10. Dispo: The patient was discharged to home with primary
psychiatrist follow-up, referral to partial hospitalization and
referral to initiate new primary medicine care.
Medications on Admission:
Zyprexa 20mg daily
Seroquel 150mg QHS
Lithium 1800mg QHS
Discharge Medications:
1. Lithium Carbonate 600 mg Capsule Sig: One (1) Capsule PO at
bedtime.
Disp:*30 Capsule(s)* Refills:*2*
2. Olanzapine 10 mg Tablet Sig: Two (2) Tablet PO at bedtime.
Disp:*60 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
4. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
UTI
Bipolar disorder type I
Aspiration Pneumonitis
.
Secondary:
Hypertension
Discharge Condition:
good. tolerating oral medications. afebrile with stable vital
signs.
Discharge Instructions:
You were evaluated and treated for a UTI and an aspiration
pneumonitis which resolved. Your symptoms of mania when you
came to the hospital could have been exacerbated by the medical
condition that you had. It is essential that you take all of
your medications as prescribed to prevent relapses of your
bipolar symptoms.
Please take the medications as they are prescribed to you. The
bipolar medicines have changed, you should only take the
medicines as they are prescribed to you.
Please make and attend the recommended follow-up appointments as
described below.
.
If you develop any new or concerning symptom particularly
agitation, excessive energy, talkativeness, chest pain, or
shortness of breath; please seek medical attention.
You have been referred to [**Hospital3 **] at [**Hospital3 **]
[**Hospital 1225**] Medical Center to initiate general medical care. The
number is [**Telephone/Fax (1) 250**]. Please call to schedule an appointment
with the first available provider.
[**Name10 (NameIs) **] should tell your new medicine doctor that you should have
your LFTs checked periodically while you are on your
medications.
Please also discuss with your new primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 108642**] testing of a kidney mass that you have on a scan done
this time.
Followup Instructions:
1. Primary psychiatry: Dr. [**Last Name (un) 108643**] will call you to
schedule a follow-up appointment this week. His phone number is
[**Telephone/Fax (1) 108644**].
2. Partial Hospitalization Program - Intake appointment: [**Hospital 1680**]
[**Hospital **] Hospital at [**Street Address(2) **]. in [**Location (un) **]. The appointment
is with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2199-3-19**] at 9:30 am.
3. Primary Care Physician: [**Name10 (NameIs) **] have been referred to [**Hospital **] at [**Hospital3 **] [**Hospital 1225**] Medical Center to initiate
general medical care. The number is [**Telephone/Fax (1) 250**]. Please call
to schedule an appointment with the first available provider.
[**Name10 (NameIs) **] should tell your new medicine doctor that you should have
your LFTs checked periodically while you are on your
medications. Please also discuss with your new primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) 108645**] testing of a kidney mass that you have on a
scan done this time.
|
[
"585.9",
"507.0",
"401.9",
"518.81",
"427.89",
"305.1",
"038.19",
"788.20",
"995.92",
"790.4",
"599.0",
"296.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6900, 6906
|
3377, 6281
|
306, 378
|
7036, 7107
|
2926, 3354
|
8470, 9541
|
2461, 2479
|
6389, 6877
|
6927, 7015
|
6307, 6366
|
7131, 8447
|
2494, 2907
|
257, 268
|
406, 1366
|
1789, 2187
|
2203, 2445
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,275
| 169,132
|
27473
|
Discharge summary
|
report
|
Admission Date: [**2198-9-18**] Discharge Date: [**2198-9-25**]
Date of Birth: [**2135-3-5**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 4277**]
Chief Complaint:
Right femur renal cell cancer lesion
Major Surgical or Invasive Procedure:
[**2198-9-19**] - Curettage and Bone grafting R femur renal cell cancer
lesion.
History of Present Illness:
Ms. [**Known lastname 23333**] has been treated for renal cell carcinoma in the
femur in the
past. Her original femur fixation was done at an outside
institution and she presented with a nonunion. We did an
exchange nailing of this and she initially had some
improvement in her symptomatology. However, she started to
develop increasing pain and noticeable bone resorption at the
fracture site. She underwent needle biopsy of this area and
it did reveal recurrence of the metastatic renal cell
carcinoma. At the same time though, she was undergoing
treatment for a newly developed thoracic spine lesion and had
unfortunately also recently suffered a myocardial infarction.
However, the femur lesion continued to progress and was
causing significant pain and decrease in her quality of life
as she could no ambulate. Discussed were the risks,
benefits and alternatives of this surgical procedure in
detail and she wished to proceed.
Past Medical History:
Renal Cell CA s/p nephrectomy and IM nailing right femur, CAD
with MI and stent placement, Hypertension, CHF, and arthritis
Social History:
She has two children. She is not a smoker. She
drinks very occasionally. She lives at home.
Family History:
Uncle had a GI cancer, unknown. The great aunt
on her father's side of the family had either a colon cancer or
an ovarian cancer, again unknown.
Physical Exam:
NAD
Pulse regular
RLE: incision w/out E/I/D, thigh soft, Firing [**Last Name (un) 938**]/TA/GC, SITLT
in DP/SP/T, 2+ DP
Brief Hospital Course:
63 y/o female with
Discharge Disposition:
Home With Service
Facility:
VNA of Care [**Location (un) 511**], [**Location (un) 50909**],RI
Discharge Diagnosis:
Renal cell CA lesion in right femur s/p curettage and
cementation
Discharge Condition:
Stable
Discharge Instructions:
Please call if you develop any fevers > 101.4, redness around
incision, or drainage from the wound.
You may weight bear as tolerated on the right lower extremity.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 4224**] [**Last Name (NamePattern4) 4225**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2198-10-1**] 1:15
Completed by:[**2198-10-2**]
|
[
"428.0",
"E878.8",
"198.5",
"401.9",
"998.11",
"285.1",
"V10.52",
"E849.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"77.85",
"99.29",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2005, 2101
|
1962, 1982
|
335, 417
|
2211, 2220
|
2432, 2619
|
1654, 1802
|
2122, 2190
|
2244, 2409
|
1817, 1939
|
259, 297
|
445, 1378
|
1400, 1525
|
1541, 1638
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,300
| 150,128
|
2187
|
Discharge summary
|
report
|
Admission Date: [**2128-7-15**] Discharge Date: [**2128-7-23**]
Date of Birth: [**2061-11-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 9824**]
Chief Complaint:
Rigors
Major Surgical or Invasive Procedure:
1. Tunneling line removal
2. RIJ Tunneling
History of Present Illness:
Pt is a 66F with complex medical history significant for DM2,
HTN, ESRD and h/o of multiple HD line infections, transferred to
medicine from the ICU where she had been recovering from proteus
bacteremia and sepsis. Per report, pt was in her normal state of
healthy until [**2128-7-15**], when she went in for dialysis through
Right IJ tunneling line and developed rigors one hour into the
procedure. She was given 250mg Vancomycin x 1, blood cultures
were apparently collected and she was referred to the [**Hospital1 18**] ED
for further management.
.
In the ED initial VS were noted to be HR 123, BP 156/88, RR 28,
Sat 83% on RA. She was triggered for her hypoxia, her hypoxia
improved to 98% on 4L. She further developed hypotension to the
70s, and was started on Levophed. Initial labwork was notable
for WBC 9.6 (86%N), Hgb/Hct 12.6/42. Chem panel showed BUN/Cr
30/5.7, and CXR showed mild vascular congestion. Subsequently
5/6 bottles grew pansensitive GNR, speciated to be proteus. He
was started on vanc/aztreonam/tobramycin initially, changed to
cipro on [**7-18**] following speciation and sensitivity. HD line has
been pulled and culture final report shows no growth. Infectious
workup have been negative thus far: 1) CT initially showed
increase in bile duct size from 7 to 10mm on CT, concerning for
early obstruction, but MRCP that was unremarkable (no stenosis,
stone, dilation). 2) TTE was of poor quality due to poor body
habitus, and could not definatively r/o veg
.
Pt has been off of levophed since [**7-18**] 4PM. Pt has been
hemodynamically stable. She was dialyzed today ([**7-20**])via a
temporary right femoral groin line. She needs a new tunneled HD
line for permanent access by IR prior to discharge. However, her
INR is 3.6 today. She has not gotten any vitamin K, need to have
INR <1.5 tunneling line to be placed.
Past Medical History:
1. CAD (nonobstructive on cath [**2119**], normal ETT [**7-/2124**])
2. Mod AS
3. IDDM2
4. Hypertension
5. Hypercholesterolemia
6. ESRD [**2-25**] HTN, DM on HD x9 years (TuThSa)
7. Severe renal osteodystrophy
8. H. Pylori s/p treatment in [**2124-3-23**]
9. Gastritis
10. Severe osteoarthritis
11. [**1-25**]+ AR, [**1-25**]+ MR
12. Hx of Back Abscess
13. Multiple HD line infections
14. s/p total abdominal hysterectomy/BSO [**2112**]
15. Status post C-section
16. s/p R knee subtotal medial meniscectomy and subtotal lateral
meniscectomy with medial femoral chondroplasty [**2126-1-8**]
17. Pelvic fracture, minimally displaced, managed conservatively
[**10-31**]
18. Chronic SCL Vein thrombosis on Coumadin
Social History:
Married and lives with husband, 2 children who live nearby,
former home health aid. Smokes <[**1-25**] ppd x 40 years, quit in [**3-2**]
after being hospitalized for influenza. no ETOH, no drugs.
Received the influenza and pneumococcal vaccines
Family History:
Premature CAD in brothers and mother. Daughter with kidney
disease. Siblings with DM, CAD, HTN, CVA, no cancer.
Physical Exam:
Admission:
PHYSICAL EXAM:
Vitals: T 101.8 BP 140/93 HR 82 RR 12 O2100%
General: Alert, dysoriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorly
CV: Regular rate and rhythm,
Abdomen: soft, non-tender, non-distended,
Ext: warm,no edema
Discharge:
Physical Exam
VS:100.5, 99.7, 72-88, 112-160/60-80, 180-20, 96-99% RA
GEN: Obese woman lying comfortably in bed. AOx3. Well-appearing.
NAD.
HEENT: NCAT, Anicteric sclera, Dry oropharynx, adentulous, MMM
CV: RRR, nl S1, S2, III/VI systolic ejection murmur
RESP: crackles b/l in middle and lower lobes.
ABD: Obese, +BS, soft, nondistended, nontender
Pertinent Results:
Admission Labs:
[**2128-7-15**] 09:20AM BLOOD WBC-9.6# RBC-3.85* Hgb-12.6 Hct-42.0
MCV-109* MCH-32.7* MCHC-30.0* RDW-16.1* Plt Ct-212
[**2128-7-15**] 09:20AM BLOOD Neuts-86* Bands-0 Lymphs-6* Monos-7 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2128-7-15**] 08:35PM BLOOD PT-14.6* PTT-26.8 INR(PT)-1.3*
[**2128-7-15**] 09:20AM BLOOD Glucose-201* UreaN-30* Creat-5.7*# Na-136
K-4.6 Cl-92* HCO3-20* AnGap-29*
[**2128-7-15**] 08:35PM BLOOD Calcium-8.6 Phos-4.8*# Mg-1.7
Discharge Labs:
[**2128-7-23**] 06:35AM BLOOD WBC-7.3 RBC-3.27* Hgb-11.0* Hct-35.5*
MCV-108* MCH-33.7* MCHC-31.1 RDW-16.1* Plt Ct-288
[**2128-7-23**] 06:35AM BLOOD PT-16.2* PTT-26.0 INR(PT)-1.4*
[**2128-7-23**] 06:35AM BLOOD Glucose-85 UreaN-22* Creat-5.6* Na-132*
K-5.0 Cl-93* HCO3-29 AnGap-15
[**2128-7-23**] 06:35AM BLOOD Calcium-9.0 Phos-3.2 Mg-1.9
Miscl:
[**2128-7-20**] 03:12AM BLOOD calTIBC-163* Ferritn-750* TRF-125*
Microbiology:
[**2128-7-15**] 9:20 am BLOOD CULTURE
**FINAL REPORT [**2128-7-21**]**
Blood Culture, Routine (Final [**2128-7-21**]):
PROTEUS MIRABILIS. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final [**2128-7-16**]):
Reported to and read back by DR. [**First Name (STitle) 5478**] [**Name (STitle) 11643**] PAGER#
[**Serial Number 11644**] @ 0152
ON [**2128-7-16**].
GRAM NEGATIVE ROD(S).
*All followup culture growth negative [**Date range (1) 11645**]
Imaging:
1. Chest Portable AP ([**2128-7-15**])
PORTABLE AP VIEW OF THE CHEST: Right-sided dual-lumen dialysis
catheter tip
terminates in the upper SVC. There are low lung volumes. The
heart size is
normal. The aorta remains tortuous and calcified. Increased
pulmonary
vascular markings is suggestive of vascular congestion. No focal
consolidation, large pleural effusion, or pneumothorax is
identified. No
acute osseous finding is seen.
2. CT with Contrast Abd & Pel ([**2128-7-16**])
-No intra-abdominal or intrapelvic fluid collection or abscess.
No
pulmonary consolidations.
-Severe stenosis of the right brachiocephalic vein and SVC
around catheter
resulting in extensive lateral and posterior chest wall
collateral flow mostly through the azygos vein. Chronic
occlusion of the left IJ, subclavian and
brachiocephalic veins.
-Cholelithiasis. Mild intrahepatic bile duct dilation and a 10
mm CBD
increased from [**2126**]. This raises concern for choledocholithiasis
and early
obstruction though papillary stenosis is a consideration.
-Chronic renal failure with cystic changes likely secondary to
chronic
dialysis. Right upper pole AML as before.
-Hepatic steatosis.
3. MRI Abd without contrast ([**2128-7-18**])
-Normal tapering common bile duct. No evidence of
choledocholithiasis or
ampullary stenosis. No intrahepatic bile duct dilatation.
-Small pancreatic cystic lesions, the largest within the head of
pancreas
measuring 8 mm. Interval follow-up in 12 months recommended to
ensure
stability.
-Bilateral cystic lesions in both kidneys could reflect lithium
nephropathy.
Please correlate with exposure hostory.
-Incidental angiomyolipoma noted in the upper pole of the right
kidney.
-Hemosiderosis of the liver and spleen.
4. Echo ([**2128-7-19**])
Suboptimal image quality due to body habitus. Left ventricular
systolic function is probably normal, a focal wall motion
abnormality cannot be excluded. Mild LVOT gradient is seen. The
right ventricle is not well seen. There is aortic stenosis that
is probably mild to moderate. Mild aortic regurgitation is seen.
No vegetation seen but image quality means endocarditis cannot
be excluded. If clinically suggested, the absence of a
vegetation by 2D echocardiography does not exclude endocarditis.
Brief Hospital Course:
History:
66F with ESRD on HD, CAD with rigors after HD admitted to MICU
for septic shock with blood cx growing proteus (unknown source).
Swiftly afebrile and stable on cipro IV, with negative follow up
blood cultures. New right IJ tunnelled HD line placed and
discharged to rehab.
Active Problem [**Name (NI) **]:
1. Proteus bacteremia: Pt presented with fever, rigors,
hypotension and hypoxia. 5/6 bottles grew pansensitive GNR,
speciated to be proteus. She was started on
vanc/aztreonam/tobramycin initially, changed to cipro on [**7-18**]
following speciation and sensitivity. Afebrile since initiation
of antibiotic. All surveillance cultures negative to date.
Source of infection is unclear. Culture from tunnelled catheter
was negative. CT and MRI of abdomen and pelvis have been
nonrevealing. SHE WILL NEED COMPLETE HER COURSE CIPROFLOXACIN.
2. ESRD on HD -> Has long history of complicated access with
multiple line infection. Right IJ tunnelled line initially
pulled at admission due to suspicion of infectious source. R
femoral catheter placed as temporary access. Right IJ line
placed on [**7-22**] after SVC stenosis was treated by angioplasty.
Patient has known left Upper DVT with stenosis on coumadin 7.5mg
at home, this was held periprocedurally and restarted without
bridge.
3.Hx of UE DVT -> Managed on 7.5mg coumadin at home. INR was
subtherapeutic at admission. However, IRN became suprathereutic
at 3.6 during hospital stay. Coumadin was held for 2 days with
0.5mg of Phytonadione([**7-21**]) with INR goal of 1.5 in preparation
for RIJ tunnelled cath placement. Coumadin restarted on [**7-22**] at
home dose (7.5mg) following tunnelling line placement.
Inactive Problem [**Name (NI) **]:
1. CAD (nonobstructive on cath [**2119**], normal ETT [**7-/2124**]) -
continued home meds
2. Mod AS, [**1-25**]+ AR, [**1-25**]+ MR - stable
3. IDDM2 - continued home meds
4. Hypertension - continued home meds
5. Hypercholesterolemia - continued home meds
6. Severe renal osteodystrophy - continued home meds.
7. Gastritis - continued home meds
9. Severe osteoarthritis - - continued home meds. Patient
received multiple one-time dosese of oxycodone
Transfer of Care:
1. Proteus [**Name (NI) 11646**] Pt transition to Ciprofloxacin with
dosing of 500mg qday until her last day ([**2128-7-28**]). If spikes,
high suspicion of infection, please culture blood, low threshold
for starting antibiotics, especially vancomycin (recent
percutaneous procedure).
2. Dialysis bridge- Outpatient dialysis schedule is T/Th/Sat.
However, she will be dialyzed today prior to discharge to rehab
due to facility request of dialysis on M/W/F. She will need one
additional, bridging dialysis prior to going back on the
T/Th/Sat schedule prior to d/c from rehab.
3. Chronic UE DVT- follow INR. INR at discharge was 1.4. Please
follow INR to ensure ultimate goal of [**2-26**]. Please communicate
with outpatient coumadin clinic regarding any changes
([**Telephone/Fax (1) 250**])
4. Please schedule PCP appt on discharge.
5. Patient has pancreatic cyst that requires 12 month f/u ([**Month (only) **]
[**2129**])
Medications on Admission:
Renagel 3200mg TID with meals
Celexa 20mg daily
Nepro bottle TID
Senna 1 tab [**Hospital1 **] PRN
Humulin N 3u qHS
Nystatin powder
Nystatin cream
Clonidine 0.2mg [**Hospital1 **]
Omeprazole 20mg daily
Simvastatin 40mg daily
Calcitriol 0.5mg [**Hospital1 **]
Lisinopril 20mg daily
Gabapentin 300mg qHS
Klonopin 0.25mg [**Hospital1 **] PRN
Colace 100mg TID PRN
SSD 1% topical cream daily
Oxycodone-Acetaminophen 5/325mg 1-2 tabs TID PRN
Warfarin 7.5mg daily
Flonase 50mcg 2 sprays each nostril daily
Nizoral 2% Shampoo
Discharge Medications:
1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*7*
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. sevelamer carbonate 800 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
8. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
10. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for fever.
11. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for fungal infxn.
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. pramoxine-mineral oil-zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal PRN () as needed for hemorrhoids.
15. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
16. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
17. Humulin N 100 unit/mL Suspension Sig: Three (3) units
Subcutaneous at bedtime.
18. Senna Lax 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
Tablet(s)
19. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
20. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO twice a day.
21. Klonopin 0.5 mg Tablet Sig: half Tablet PO twice a day as
needed.
22. Colace 100 mg Capsule Sig: One (1) Capsule PO three times a
day.
23. SSD 1 % Cream Sig: One (1) application of thin layer Topical
once a day.
24. Flonase 50 mcg/Actuation Spray, Suspension Sig: Two (2)
sprays Nasal once a day.
25. Nizoral 2 % Shampoo Sig: One (1) Topical once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Nursing & Therapy Center, [**Location 1268**]
Discharge Diagnosis:
Primary Diagnosis:
1. Proteus sepsis
Secondary Diagnosis:
1. CAD (nonobstructive on cath [**2119**], normal ETT [**7-/2124**])
2. Mod AS
3. IDDM2
4. Hypertension
5. Hypercholesterolemia
6. ESRD [**2-25**] HTN, DM on HD x9 years (TuThSa)
7. Severe renal osteodystrophy
8. H. Pylori s/p treatment in [**2124-3-23**]
9. Gastritis
10. Severe osteoarthritis
11. [**1-25**]+ AR, [**1-25**]+ MR
12. Hx of Back Abscess
13. Multiple HD line infections
14. s/p total abdominal hysterectomy/BSO [**2112**]
15. Status post C-section
16. s/p R knee subtotal medial meniscectomy and subtotal lateral
meniscectomy with medial femoral chondroplasty [**2126-1-8**]
17. Pelvic fracture, minimally displaced, managed conservatively
[**10-31**]
18. Chronic SCL Vein thrombosis on Coumadin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mrs. [**Known lastname **],
It was a pleasure to be part of your care during your hospital
stay at [**Hospital1 69**]. You were admitted
after developing rigor during dialysis and was found to have
proteus bacteremia, which means you had an infection that had
spread to your blood. You intially developed hypotension and
hypoxia due to the infection. You were admitted to the intensive
care unit. Your right internal jugular tunneling catheter was
removed due to concern that it may be the source of your
infection. However, the bacterial culture from the catheter was
negative. We placed a temporary dialysis catheter in your right
femoral area. You were started on an IV antibiotic
(ciprofloxacin) given on the days of your dialysis. After
starting the antibiotic, your blood cultures have been negative
for any bacteria. Once you were stable and no longer needed
support to maintain your blood pressure, you were transferred
from the intensive care unit to the medicine floor for further
care. Before sending you home, we removed the temporary dialysis
line and placed a permanent tunneling line in the right internal
jugular. Before the procedure, we had to stop your blood
thinning medicine (coumadin) to make sure that you did not bleed
during the procedure. You tolerated the procedure well. We
restarted you on the coumadin after the procedure. We will
switched to an oral antibiotics once you leave this hospital.
New medication you will go home with is:
1. Ciprofloxacin 500mg everyday for 7 days: This is the
antibiotic that you will take for 7 more days for treatment of
the infection.
Followup Instructions:
Department: [**Hospital1 706**]
When: WEDNESDAY [**2128-7-28**] at 1 PM
With: [**Year (4 digits) 706**] [**Telephone/Fax (1) 327**]
Building: [**Hospital Ward Name **] CLINICAL CENTER [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Click Add Appointment to add this appointment to Recommended
Follow-Up.
Department: [**Hospital Ward Name 706**]
When: WEDNESDAY [**2128-7-28**] at 1:25 PM
With: [**Year (4 digits) 706**] [**Telephone/Fax (1) 327**]
Building: [**Hospital Ward Name **] CLINICAL CENTER [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Click Add Appointment to add this appointment to Recommended
Follow-Up.
Department: [**Hospital 2039**] CARE CENTER
When: WEDNESDAY [**2128-7-28**] at 3:00 PM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 2041**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2128-7-23**]
|
[
"276.1",
"285.21",
"V45.11",
"356.9",
"785.52",
"995.92",
"585.6",
"293.0",
"276.2",
"112.0",
"V58.61",
"453.75",
"530.81",
"611.0",
"V49.86",
"275.09",
"038.49",
"496",
"250.40",
"428.0",
"403.91",
"577.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
14118, 14207
|
8307, 11425
|
279, 323
|
15023, 15023
|
4056, 4056
|
16836, 17881
|
3213, 3326
|
11993, 14095
|
14228, 14228
|
11451, 11970
|
15206, 16813
|
4536, 8284
|
3367, 4037
|
233, 241
|
351, 2197
|
14287, 15002
|
4072, 4520
|
14247, 14266
|
15038, 15182
|
2219, 2934
|
2950, 3197
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,058
| 103,209
|
42329+42330
|
Discharge summary
|
report+report
|
Admission Date: [**2175-7-25**] Discharge Date: [**2175-7-26**]
Date of Birth: [**2112-2-11**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Name13 (STitle) **] presented to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for dyspnea on exertion,
lower extremity edema, 2 days of worsening productive cough.
Also with PND, nausea, denies chest pain. He is scheduled for
MVR/TVR and CABG with Dr. [**Last Name (STitle) **] on [**2175-7-31**].
.
He reports that he has had a cough which is productive of white
sputum which has been very persistent for the past day and did
not improve with NyQuil. The patient reports that he thought he
had pneumonia so he came to the ED. He feels like he has "a
tickle in my throat" that he can't clear. He also reports that
he has a tightness in his back, which is C7-T2 area, which he
reports is a "tightness" and feels different from the back pain
that he had during his presentation during the last
hospitalization, which was sharper. The patient does endorse
paryoxysmal nocturnal dyspnea and orthopnea, but he cannot
clarify it is due to discomfort from lying where his neck hurts
him or if it is because he feels SOB. He says he has been
compliant with his medications. He also reports DOE but this is
unchanged from his baseline and is felt to be due to his severe
MR/TR. As well, he does not endorse LE edema.
.
In the ED, initial vitals were 98.4 93-125/46-73 82-88 20 100%
RA 108.6kg.
Labs and imaging significant for a BNP of 336, negative
troponins and WBC of 22. CXR without acute cardiopulmonary
process and UA was negative.
Patient given Lasix 20mg IV once and dextromethamorphan,
Tessalon Perles, he felt that his cough improved with these
interventions.
.
On arrival to the floor, patient had ongoing productive cough,
did endorse ongoing "tightness" in the superior aspect of his
back and otherwise felt well.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
palpitations, syncope or presyncope.
Past Medical History:
severe MR/TR
CAD with small LAD
EF 50-55%
atrial fibrillation (paroxysmal)
alcohol abuse
chronic leukocytosis (WBC 15-16)
Hypertension
Hyperlipidemia
Psoriasis
Diverticulitis
s/p sigmoid resection [**2175-5-19**]
Social History:
lives with girlfriend in [**Name (NI) **]. Maintenance worker.
-Tobacco history: quit 7 yrs ago. [**11-20**] ppd for 40 yrs
-ETOH: [**3-24**] drinks nightly, wine/beer/liquor, no history of
withdrawal symptoms. last drink Sunday [**7-9**]
-Illicit drugs: none
Family History:
Mother, died of lymphoma age 81. Father, with DM died of
alzheimers ag 84. Broather, throat cancer age 64.
No family history of heart disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.9 BP 104/60 HR 77 RR 12 O2 sat 98% RA
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.
CN II-XII intact.
NECK: no cervical lymphadenopathy, no thyroid nodules or
thyromegaly appreciated. Neck veins not appreciated due to body
habitus. No carotid bruits.
CARDIAC: irregularly irregular. No m/r/g.
LUNGS: CTAB, no crackles, wheezes or rhonchi. Resp were
unlabored, no accessory muscle use.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Trace edema in LE bilaterally. No c/c. No femoral
bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right:DP 1+ PT 1+
Left: DP 1+ PT 1+
DISCHARGE PHYSICAL EXAM:
afebrile, tachycardia to 100 with atrial fibrillation which
resolved spontaneously to HR of 80s-90s. BP 98-113/56-66.
No pericardial rub appreciated. No crackles or wheezes in the
lungs bilaterally.
No LE edema.
Pertinent Results:
ADMISSION LABS:
[**2175-7-25**] 05:20PM BLOOD WBC-16.9* RBC-3.84* Hgb-10.9* Hct-32.6*
MCV-85 MCH-28.5 MCHC-33.5 RDW-14.6 Plt Ct-328
[**2175-7-25**] 05:20PM BLOOD PTT-47.2*
[**2175-7-25**] 05:20PM BLOOD Plt Ct-328
[**2175-7-25**] 05:20PM BLOOD Glucose-101* UreaN-16 Creat-1.2 Na-141
K-5.0 Cl-104 HCO3-28 AnGap-14
[**2175-7-25**] 05:20PM BLOOD Calcium-9.6 Phos-5.5* Mg-2.4
PERTINENT LABS AND STUDIES:
CXR [**2175-7-25**]: In comparison with study of [**7-19**], the cardiac
silhouette may be slightly larger without definite pulmonary
vascular congestion. Probable mild pleural effusion and
atelectatic changes at the bases on the left. The increasing
cardiac size with little change in pulmonary vascularity raises
the possibility of pericardial effusion
ECHOCARDIOGRAM: [**2175-7-25**]: Focused study to assess pericardial
effusion.
There is a small to [**Month/Day/Year 1192**] sized pericardial effusion. There
are no echocardiographic signs of tamponade.
Compared with the prior study dated [**2175-7-14**] (images reviewed),
the amount of pericardial effusion has increased (previously
trivial). It appears circumferential, but predominantly located
along the infero-lateral wall of the LV.
DISCHARGE LABS:
[**2175-7-26**] 06:00AM BLOOD WBC-18.1* RBC-3.75* Hgb-10.7* Hct-31.7*
MCV-85 MCH-28.5 MCHC-33.7 RDW-14.2 Plt Ct-392
[**2175-7-26**] 06:00AM BLOOD Glucose-115* UreaN-17 Creat-1.1 Na-137
K-4.9 Cl-103 HCO3-25 AnGap-14
[**2175-7-26**] 06:00AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.2
Brief Hospital Course:
63yo male with past medical history of severe MR [**First Name (Titles) **] [**Last Name (Titles) **] who is
scheduled for surgery on [**2175-7-31**], here with productive cough for
1-2 days and pressure in his scapulae.
.
ACUTE ISSUES:
# Cough: productive of white sputum, patient is afebrile. CXR
without signs of pneumonia. Treated with
dextromethamorphan-guiafenesin, tessalon perles for symptomatic
control and had improvement of symptoms with this.
.
# Pericardial effusion: the patient has worsening positional
back pain, which is potentially consistent with pericarditis,
among other etiologies, including MSK. No cardiac rub
appreciated. He has a known pericardial effusion which was
considered to be insignificant, he did not undergo
pericardiocentesis during the prior hospitalization.
Cardiomegaly has worsened on his CXR (3cm difference), which is
concerning for worsening pericardial effusion. No signs of
tamponade--blood pressure stable, no JVD appreciated (pulsus not
assessed as patient looked very stable). Repeat echocardiogram
performed and showed that the effusion had increased but was
still small. The cardiac surgery team was updated on the new
finding.
.
# Leukocytosis: seen during prior hospitalization and stable
from prior hospitalization at 15-20. ID saw him during prior
hospitalization and cleared him for surgery. The patient's UA
was negative, his CXR was not concerning for pna, and bacterial
blood and urine cultures were pending at time of discharge.
.
CHRONIC ISSUES:
# CORONARIES: patient with known CAD in the LAD. Questionable
plan for CABG during MR/TR on Monday [**2175-7-31**]. Continued on
simvastatin, lisinopril, ASA, metoprolol.
.
# PUMP: borderline CHF 50-55%, appears euvolemic at this time.
Maintain on home dose of Lasix 20mg Daily. Discussed at length
the importance of fluid restrictions to 1500mL per day, taking
Lasix.
.
# RHYTHM: paroxysmal afib, on dabigatran. Rate control on
metoprolol succinate and diltiazem, patient does become
tachycardic with heart rate to low 100's but remains
asymptomatic and will return to atrial fibrillation in the
70-80s. No cardioversion scheduled because of plan for cardiac
surgery next week ([**2175-7-31**]).
.
# History of alcohol abuse, last drink prior to previous
hospitalization on [**2175-7-9**]. Continued on thiamine, B12, folic
acid, MVI
ISSUES OF TRANSITIONS IN CARE:
PENDING STUDIES:
- blood cultures x2
- urine culture
CODE STATUS: FULL CODE (CONFIRMED)
CONTACT: [**Name (NI) **] [**Name (NI) 91703**] (girlfriend) [**Telephone/Fax (1) 91702**]
Medications on Admission:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
2. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
3. aspirin 325 mg Tablet daily
4. furosemide 20 mg Tablet daily
5. multivitamin One tablet PO DAILY
6. folic acid 1 mg Tablet 1 Tablet PO DAILY
7. thiamine HCl 100 mg Tablet One Tablet PO DAILY
8. metoprolol succinate 100 mg Tablet ER DAILY
9. cyanocobalamin (vitamin B-12) 50 mcg Tablet PO DAILY
10. Diltzac ER 240 mg Capsule once a day.
11. dabigatran etexilate 150 mg Capsule PO twice a day.
12. trazodone 25 mg Tablet PO HS as needed for insomnia.
.
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
9. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
10. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
11. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
12. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
Disp:*100 ML(s)* Refills:*0*
13. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*15 Capsule(s)* Refills:*0*
14. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
primary: viral upper respiratory infection; paroxysmal atrial
fibrillation
secondary: severe mitral valve regurgitation; severe tricuspid
valve regurgitation; pericardial effusion; coronary artery
disease; dyslipidemia; hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Name13 (STitle) **],
You were admitted to the hospital for a cough. It is felt that
this cough is most likely just a simple virus. You do not have a
pneumonia. Reasons to return to the hospital would include
development of a fever, which is a temperature of greater than
100.5 degrees. You have also complained of some back
pressure/tightness, and this current pain is not because of your
heart. It is most likely due to a muscle strain because you have
been lying down so much recently. If you cannot tolerate this
pain, you may take Tylenol. Do not take Advil, Ibuprofen, Motrin
or other NSAIDs as they will interfere with your Aspirin, which
is very important for you.
It is of the utmost importance that you DO NOT DRINK ALCOHOL. DO
NOT SMOKE CIGARETTES.
Please note that the following changes have been made to your
medications:
- NO major changes, however, you may use Tessalon Perles,
Dextromethomorphan-guaifenesin (which is Mucinex) as needed for
your cough.
- Please continue to take your medications as directed during
your last hospitalization. The following medications you MUST
take daily: Aspirin, Simvastatin, Lisinopril, Lasix, Metoprolol,
Diltzac, Dabigatran. Your multivitamin, thiamine, B12, folic
acid, and trazadone are very important too.
Followup Instructions:
Your cardiac surgery is on [**2175-7-31**] at 6 am with Dr. [**Last Name (STitle) **].
Admission Date: [**2175-7-31**] Discharge Date: [**2175-8-4**]
Date of Birth: [**2112-2-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2175-7-31**] - 1. Mitral valve repair with a 28 mm [**Doctor Last Name 405**]
annuloplasty band. 2. Tricuspid valve repair with a 28 mm
[**Company 1543**] annuloplasty ring.
History of Present Illness:
Awoke w/ acute shortness of breath after having a productive
cough of white sputum for few days and presented to [**Hospital1 2519**] on [**7-10**]. Poor bedside peak flows, so treated with
inhaled bronchodilators. WBC 19.7 with left shift -> Zosyn and
levofloxacin, steroids. TnI <0.06 x2, BNP 159, CTA no pulm
embolus; small-[**Month/Year (2) 1192**] pericardial effusion (larger than 1
month ago), bibasilar atelectasis. Night sweats for 2 weeks.
Subsequently developed atrial fibrillation, but DCCV and
anticoagulation both deferred due to pericardial effusion. 25-30
pound weight loss in setting of npo and slowly advanced diet
during time of sigmoid diverticulitis surgery.
Past Medical History:
Severe Mitral and tricuspid regurgitation
Coronary artery disease with small LAD
EF 50-55%
Atrial fibrillation (paroxysmal)
Alcohol abuse
Chronic leukocytosis (WBC 15-16)
Hypertension
Hyperlipidemia
Psoriasis
Diverticulitis
s/p sigmoid resection [**2175-5-19**]
Social History:
lives with girlfriend in [**Name (NI) **]. Maintenance worker.
-Tobacco history: quit 7 yrs ago. [**11-20**] ppd for 40 yrs
-ETOH: [**3-24**] drinks nightly, wine/beer/liquor, no history of
withdrawal symptoms. last drink Sunday [**7-9**]
-Illicit drugs: none
Family History:
Mother, died of lymphoma age 81. Father, with DM died of
alzheimers ag 84. Broather, throat cancer age 64.
No family history of heart disease.
Physical Exam:
Pulse:111 AFIB (NEW) Resp: 18 O2 sat: 94% RA
B/P Right:150/80 Left:
General:
Skin: Dry [x] intact [] OTHER : recent abd incision w/ small pin
hole opening w/ scant serosang drainage
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs; crackles at bases bilaterally
Heart: RRR [] Irregular [x] Murmur [x] grade _III/VI at apex
and left sternal border
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] Other: obese
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +2 cath site Left:+2
DP Right:+1 Left:+1
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right:+2 Left:+2
Carotid Bruit Right: none Left: radiating
Pertinent Results:
[**2175-7-31**] ECHO: PRE-BYPASS:
1-The left atrium is elongated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium or left atrial
appendage.
2-The right atrium is markedly dilated. [**Month/Day/Year **] to severe
spontaneous echo contrast is seen in the body of the right
atrium.
3-There is mild symmetric left ventricular hypertrophy with
normal cavity size. Overall left ventricular systolic function
is normal (LVEF>55%).
4-The right ventricular free wall is hypertrophied. with normal
free wall contractility.
5-There are simple atheroma in the aortic arch.
6-There are both simple & complex atheroma noted in the
descending thoracic aorta.
7-There are three aortic valve leaflets. No aortic regurgitation
is seen.
8-The mitral valve leaflets are mildly thickened. Mild to
[**Month/Day/Year 1192**] ([**11-20**]+) mitral regurgitation is seen. The MR was
essentially unchanged with provocative maneuvers including fluid
challenge, phenylephrine administration & trendelenberg
positioning.
9-The tricuspid valve leaflets are mildly thickened. [**Month/Day (2) **] to
severe [3+] tricuspid regurgitation is seen.
Dr. [**Last Name (STitle) **] was notified at the time of the study.
POSTBYPASS:
1.The patient is AV paced on phenylephrine & epinephrine
infusions.
2. The biventricular function is unchanged from prebypass
evaluation.
3. There is a well seated annuloplasty ring in the mitral
position. There is mild MS noted.
4. There is a well seated annuloplasty ring in the tricuspid
position. Gradients are appropriate.
5. The aorta remains intact.
[**2175-7-31**] 11:48AM BLOOD WBC-18.1* RBC-2.77*# Hgb-7.8*# Hct-23.3*#
MCV-84 MCH-28.1 MCHC-33.4 RDW-14.6 Plt Ct-404
[**2175-8-4**] 06:05AM BLOOD WBC-10.7 RBC-3.22* Hgb-9.2* Hct-27.5*
MCV-85 MCH-28.5 MCHC-33.4 RDW-14.7 Plt Ct-544*
[**2175-7-31**] 11:48AM BLOOD PT-22.8* PTT-63.3* INR(PT)-2.1*
[**2175-8-4**] 06:05AM BLOOD PT-25.0* INR(PT)-2.4*
[**2175-7-31**] 01:32PM BLOOD UreaN-12 Creat-1.1 Na-140 K-4.8 Cl-108
HCO3-24 AnGap-13
[**2175-8-4**] 06:05AM BLOOD Glucose-90 UreaN-23* Creat-0.9 Na-137
K-4.3 Cl-98 HCO3-28 AnGap-15
[**2175-8-3**] 06:20AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.4
Brief Hospital Course:
Mr. [**Known lastname 74255**] was admitted to the [**Hospital1 18**] on [**2175-7-31**] for surgical
management of his mitral and tricuspid valve disease. He was
taken to the operating room where he underwent repair of both
his mitral and tricuspid valves. Please see operative note for
details. Postoperatively he was taken to the intensive care unit
for monitoring. He required multiple blood products for
bleeding. Hemostasis was achieved. Later on postoperative day 0,
he awoke neurologically intact and was extubated. On
postoperative day one, he was transferred to the step down unit
for further recovery. Mr. [**Known lastname 74255**] was gently diuresed towards
his preoperative weight. The physical therapy service was
consulted for assistance with his postoperative strength and
mobility. He remained in atrial fibrillation consistent with his
preoperative status and Coumadin was restarted. Chest tubes and
epicardial pacing wires were removed per protocol. Physical
therapy worked with him during his post-op course for strength
and mobility. He continued to make steady progress and on
post-op day four was discharged to [**Hospital **] [**Hospital **] Rehab with
the appropriate medications and follow-up appointments.
Medications on Admission:
1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
9. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
10. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
11. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
12. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough. Disp:*100
ML(s)* Refills:*0*
13. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*15 Capsule(s)* Refills:*0* 14. dabigatran etexilate 150 mg
Capsule Sig: One (1) Capsule PO BID (2 times a day).
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 DAILY
(Daily).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Cepacol Sore Throat 15-3.6 mg Lozenge Sig: One (1) Mucous
membrane four times a day as needed for throat.
8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
10. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 weeks.
13. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: dose
to change daily for goal INR 2-2.5.
14. Outpatient Lab Work
Labs: PT/INR for AFib, Coumadin
Goal INR 2-2.5
First draw: Saturday, [**8-5**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
Mitral and tricuspid regurgitation
Coronary artery disease
Past medical history:
Pericarditis
Atrial fibrillation (paroxysmal)
Alcohol abuse
Chronic leukocytosis (WBC 15-16)
Hypertension
Hyperlipidemia
Psoriasis
Diverticulitis
s/p sigmoid resection [**2175-5-19**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema - 1+
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**]
**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) **], [**2175-9-6**] 1:15
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**], [**8-22**] at 10:30am
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 22552**] in [**2-21**] weeks [**Telephone/Fax (1) 4475**]
**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 AFib, Coumadin
Goal INR 2-2.5
First draw: Saturday, [**8-5**]
Following d/c from rehab, Dr. [**Last Name (STitle) 22552**] will manage coumadin/INR
Results to phone [**Telephone/Fax (1) 4475**], attn: [**Doctor First Name **], for Dr. [**Last Name (STitle) 22552**]
fax: [**Telephone/Fax (1) 29683**]
Completed by:[**2175-8-4**]
|
[
"397.0",
"424.0",
"465.9",
"401.9",
"423.1",
"V15.82",
"424.2",
"276.7",
"423.9",
"414.01",
"423.0",
"427.31",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.14",
"35.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
20767, 20840
|
16968, 18204
|
12352, 12530
|
21148, 21322
|
14773, 16945
|
22210, 23087
|
13819, 13963
|
19470, 20744
|
20861, 20920
|
18230, 19447
|
21346, 22187
|
5486, 5760
|
13978, 14754
|
12293, 12314
|
12558, 13240
|
4287, 5469
|
10496, 10608
|
7290, 8339
|
20942, 21127
|
13541, 13803
|
4038, 4251
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,247
| 131,014
|
51271+59328
|
Discharge summary
|
report+addendum
|
Admission Date: [**2146-7-4**] Discharge Date: [**2146-7-10**]
Date of Birth: [**2066-2-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ampicillin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Presyncopal episodes and dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2146-7-4**] Aortic Valve Replacement w/ 19mm St. [**Male First Name (un) 923**] Porcine
History of Present Illness:
80 y/o female with long h/o PSVT and AS followed by serial
echo's who has been having pre-syncopal episodes along with
dyspnea on exertion. Most recent echo and cath showed severe
Aortic Stenosis.
Past Medical History:
Aortic Stenosis, Hepatitis C, PSVT, Varicose veins s/p
stripping, Macular degeneration, Osteoporosis, s/p
Tonsillectomy, s/p Total abdominal hysterectomy, s/p Umbilical
hernia repair and abdominoplasty, s/p Spinal fusion and
laminectomy, s/p Bilateral cataract surgery
Social History:
Retired lab tech. Denies tobacco use. Also denies ETOH use in 20
yrs.
Family History:
Brother died of CHF at age 75.
Physical Exam:
VS: 76 130/70 5'2" 113#
Gen: NAD
Skin: Ecchymosis right leg/groin
HEENT: PERRLA, EOMI, OP benign
Neck: Supple, FROM, -JVD
Chest: CTAB -w/r/r
Heart: RRR 3/6 SEM w/ radiation to carotids
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, 2+ edema
Neuro: Grossly intact, MAE, right foot drop
Pertinent Results:
[**7-4**] Echo: PREBYPASS: No atrial septal defect is seen by 2D or
color Doppler. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are complex (>4mm) atheroma in the descending thoracic aorta.
The aortic valve leaflets are severely thickened/deformed. There
is severe aortic valve stenosis (area <0.8cm2). Mild to moderate
([**12-22**]+) aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Mild (1+) mitral regurgitation is seen.
POSTBYPASS: LV systolic function appears hyperdynamic. RV
systolic function remains normal. There is a well seated, well
functioning bioprosthesis in the aortic position. There is trace
valvular AI. MR now appears trace. Otherwise no changes compared
to prebypass.
[**2146-7-4**] 02:00PM BLOOD WBC-9.2# RBC-3.11*# Hgb-9.6*# Hct-28.9*#
MCV-93 MCH-31.0 MCHC-33.4 RDW-15.1 Plt Ct-199
[**2146-7-7**] 06:55AM BLOOD WBC-4.6 RBC-2.98* Hgb-9.4* Hct-27.9*
MCV-94 MCH-31.5 MCHC-33.6 RDW-15.5 Plt Ct-160
[**2146-7-4**] 02:00PM BLOOD PT-14.3* PTT-83.9* INR(PT)-1.2*
[**2146-7-4**] 03:19PM BLOOD PT-14.7* PTT-92.3* INR(PT)-1.3*
[**2146-7-4**] 03:19PM BLOOD UreaN-12 Creat-0.4 Cl-117* HCO3-23
[**2146-7-7**] 06:55AM BLOOD Glucose-105 UreaN-12 Creat-0.4 Na-133
K-5.1 Cl-100 HCO3-32 AnGap-6*
[**2146-7-8**] 06:35AM BLOOD WBC-5.4 RBC-3.14* Hgb- [**Last Name (LF) **],[**Known firstname **]
[**Medical Record Number 106377**] F 80 [**2066-2-24**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2146-7-6**] 3:19
PM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2146-7-6**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 106378**]
Reason: r/o ptx after chest tube removal
[**Hospital 93**] MEDICAL CONDITION:
80 year old woman with s/p avr
REASON FOR THIS EXAMINATION:
r/o ptx after chest tube removal
Final Report
HISTORY: Chest tube removal, to evaluate for pneumothorax.
FINDINGS: In comparison with the study of [**7-4**], the various
tubes have been
removed. Specifically, there is no evidence of pneumothorax.
Atelectatic
changes persist at the left base.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: WED [**2146-7-6**] 5:09 PM
Imaging Lab
9.8* Hct-29.8* MCV-95 MCH-31.1 MCHC-32.7 RDW-15.7* Plt Ct-177
[**2146-7-8**] 10:25AM BLOOD PT-12.6 PTT-27.5 INR(PT)-1.1
[**2146-7-8**] 06:35AM BLOOD Glucose-131* UreaN-12 Creat-0.4 Na-132*
K-4.5 Cl-99 HCO3-26 AnGap-12
Brief Hospital Course:
Mrs.[**Known lastname **] was a same day admit after undergoing all
pre-operative work-up as an outpatient. On [**7-4**] she was brought
to the operating room were she underwent a aortic valve
replacement. Please see operative report for surgical details.
Following surgery she was transferred to the CVICU in stable
condition. Within 24 hours she was weaned from sedation, awoke
neurologically intact and extubated. On post-op day one
beta-blockers and diuretics were initiated and she was
transferred to the telemetry floor for further care. On post-op
day two she had an episode of atrial fibrillation which
appropriately responded to beta blockers and she converted to
normal sinus rhythm. She had further episodes of atrial
fibrillation and amiodarone and coumadin were initiated,INR GOAL
2-2.5, however, she converted to normal sinus rhythm and coumdin
was stopped upon discharge with INR 1.1. Physical therapy
worked with her on strength and mobility. She was ready for
discharge to rehab on POD 6. She has been instructed on follow
up with her PCP, [**Name10 (NameIs) **] and Dr.[**Last Name (STitle) **] after her discharge
from rehab.
Medications on Admission:
Atenolol 12.5mg qd, Protonix 40mg qd, Calcium 600 + D [**Hospital1 **],
Selenium 200 qd, Vit B6, Vit C, Magnesium, Ocuvite, Zinc,
[**Last Name (LF) 106379**], [**First Name3 (LF) **]-3
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. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg twice a day for 7 days then decrease to 400mg
daily for 7 days then decrease to 200mg daily until follow up
with cardiologist.
Disp:*60 Tablet(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Packet Sig: One (1) PO twice a day
for 3 days.
Disp:*6 * Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Location 106380**]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
PMH: Hepatitis C, PSVT, Varicose veins s/p stripping, Macular
degeneration, Osteoporosis, s/p Tonsillectomy, s/p Total
abdominal hysterectomy, s/p Umbilical hernia repair and
abdominoplast, s/p Spinal fusion and laminectomy, s/p Bilateral
cataract surgery
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule all appointments
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 9751**] in [**1-23**] weeks
Dr. [**Last Name (STitle) 2696**] after discharge from rehab
**Staples to be dc'd on Wed [**7-13**] or Thurs [**7-14**] by
VNA/Rehab
Name: [**Last Name (LF) 8268**],[**Known firstname 1911**] Unit No: [**Numeric Identifier 17330**]
Admission Date: [**2146-7-4**] Discharge Date: [**2146-7-10**]
Date of Birth: [**2066-2-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ampicillin
Attending:[**First Name3 (LF) 741**]
Addendum:
Pt did not go to rehab on Percocet, but on Ultram instead.
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. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg twice a day for 7 days then decrease to 400mg
daily for 7 days then decrease to 200mg daily until follow up
with cardiologist.
Disp:*60 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
7. Potassium Chloride 20 mEq Packet Sig: One (1) PO twice a day
for 3 days.
Disp:*6 * Refills:*0*
8. Ultram 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) 776**] & Islands - [**Location (un) 777**]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
PMH: Hepatitis C, PSVT, Varicose veins s/p stripping, Macular
degeneration, Osteoporosis, s/p Tonsillectomy, s/p Total
abdominal hysterectomy, s/p Umbilical hernia repair and
abdominoplasty, s/p Spinal fusion and laminectomy, s/p Bilateral
cataract surgery
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) 1477**]
Followup Instructions:
Please call to schedule all appointments
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) **] in [**1-23**] weeks
Dr. [**Last Name (STitle) 2283**] after discharge from rehab
**Staples to be dc'd on Wed [**7-13**] or Thurs [**7-14**] by
VNA/Rehab
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2146-7-10**]
|
[
"362.50",
"733.00",
"V45.4",
"285.9",
"070.70",
"736.79",
"424.1",
"427.31",
"458.29",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"88.72",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9353, 9467
|
4035, 5184
|
321, 413
|
9813, 9820
|
1386, 3225
|
10332, 10722
|
1034, 1066
|
8208, 9330
|
3265, 3296
|
9488, 9792
|
5210, 5396
|
9844, 10309
|
1081, 1367
|
237, 283
|
3328, 4012
|
441, 639
|
661, 931
|
947, 1018
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,446
| 128,379
|
9039
|
Discharge summary
|
report
|
Admission Date: [**2192-12-15**] Discharge Date: [**2192-12-20**]
Date of Birth: [**2108-6-1**] Sex: F
Service: MEDICINE
Allergies:
Bacitracin
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
Upper GI bleed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84 F with history of HTN, HL, CAD, depression, pulm HTN,
pulmonary fibrosis, h/o GIB presents with dizziness and possible
melena. Her hematocrit was noted to be decreased at 30 from her
baseline of 35.
.
In the ED inital vitals were, 96.9 59 140/78 20 100% 6L. Found
to be orthostatic (supine: 112/57 HR 117, sitting: 104/58 HR
125), sitting up triggered her to feel dizzy. Labs in the ED
were notable for BUN of 38, WBC of 18.8 with 94.1% PMNs, HCT of
30.2 and Plts of 246. NG lavage returned coffee grounds, which
cleared after 500 cc of lavage. Guaiac was positive. She was
given a bolus of IV PPI and placed on a drip. GI evaluated the
patient in the ED and advised admission to the MICU. Vitals on
transfer were 98.6 99 135/82 20 100% on 6L.
.
On arrival to the ICU, the patient is comfortable and without
additional complaints. Of note the patient was recently started
on ciprofloxacin 2 days ago for urinary frequency and dysuria.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies Denies nausea, vomiting, diarrhea,
constipation.
Past Medical History:
- severe pulmonary fibrosis with exertional dyspnea and resting
and exertional hypoxemia, FVC 1.08 33% and FEV1 0.96 49%
- pulmonary hypertension with biventricular dilatation.
- DMII
- HTN
- HL
- CAD
- severe lower back pain
- depression
- hiatal hernia
- small left upper lobe nodule
- thyroid nodule
- h/o pontine stroke ([**2186**]) - residual mild left hemiparesis
Social History:
She lives in [**Hospital1 392**] with her daughter [**Name (NI) **]. She has been a widow
since [**2159**]. She worked as an appraiser for the IRS until age 78,
a job she really enjoyed. She retired at the time of her stroke.
She has two daughters, one, [**Name (NI) **], who accompanies her lives in
[**State 350**], and another who lives in [**State 5887**]. She has a
son who lives in [**Name (NI) 12000**]. She smoked only for 10 years and quit
many years ago. She has one alcoholic beverage per night
([**Location (un) 21601**], scotch, or glass of wine). Denies TB exposure. She
has a dog but no other pets.
Family History:
Noncontributory
Physical Exam:
VS: T: 98, P: 102, BP: 128/83, RR: 22, O2 sat 98% on 6LNC
GENERAL: comfortable-appearing
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly,
RESPIRATORY: able to speak in full sentences, diffuse dry
crackles
HEART: RRR, no MRG, nl S1-S2.
ABDOMEN: Soft/NT/ND, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, moving all
extremities and able to sit up independently, no apparent focal
deficits on limit exam.
On Discharge:
GENERAL: comfortable-appearing
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly,
RESPIRATORY: able to speak in full sentences, diffuse dry
crackles
HEART: RRR, no MRG, nl S1-S2.
ABDOMEN: Soft/NT/ND, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, moving all
extremities and able to sit up independently, no apparent focal
deficits on limit exam.
Pertinent Results:
Admission Labs:
[**2192-12-15**] 12:10PM BLOOD WBC-18.8*# RBC-2.94* Hgb-9.7* Hct-30.2*
MCV-103* MCH-33.1* MCHC-32.2 RDW-13.6 Plt Ct-246
[**2192-12-15**] 09:30PM BLOOD WBC-13.7* RBC-2.51* Hgb-8.4* Hct-25.6*
MCV-102* MCH-33.6* MCHC-33.0 RDW-13.9 Plt Ct-193
[**2192-12-16**] 04:00AM BLOOD WBC-10.1 RBC-2.61* Hgb-8.5* Hct-26.0*
MCV-100* MCH-32.6* MCHC-32.8 RDW-14.7 Plt Ct-166
[**2192-12-15**] 12:10PM BLOOD Neuts-94.1* Lymphs-2.7* Monos-2.0 Eos-1.1
Baso-0.1
[**2192-12-15**] 09:30PM BLOOD PT-10.9 PTT-22.6* INR(PT)-1.0
[**2192-12-15**] 12:10PM BLOOD Glucose-205* UreaN-38* Creat-0.9 Na-139
K-4.6 Cl-97 HCO3-31 AnGap-16
[**2192-12-15**] 12:10PM BLOOD ALT-24 AST-29 AlkPhos-68 TotBili-0.4
[**2192-12-15**] 09:30PM BLOOD Calcium-8.7 Phos-2.3* Mg-1.7
CXR [**2192-12-15**]
Coarse bilateral interstitial opacities are consistent with
patient's
known interstitial lung disease. There is minimally increased
prominence of pulmonary vasculature and heart size compared to
prior, possibly secondary to slightly lower lung volumes and/or
interval hydration/fluid overload. Mild congestive heart failure
cannot be excluded. No pleural effusion or pneumothorax is seen.
Underlying interstitial lung disease slightly limits evaluation
for pneumonia, but no new large opacities are detected. Aortic
calcification is again seen. A nasogastric tube traverses below
the diaphragm, distal tip not well seen.
[**2192-12-18**] 03:27AM BLOOD WBC-9.6 RBC-3.36* Hgb-11.0* Hct-32.1*
MCV-96 MCH-32.6* MCHC-34.1 RDW-15.8* Plt Ct-137*
[**2192-12-18**] 03:27AM BLOOD Glucose-107* UreaN-17 Creat-0.7 Na-140
K-3.7 Cl-104 HCO3-33* AnGap-7*
UGI [**2192-12-17**]
DOUBLE CONTRAST UPPER GI: Contrast passed freely from the
esophagus into a
large hiatal hernia and into the stomach. The esophagus was
normal in shape and contour. There are no ulcerations,
strictures, or webs. There were multiple tertiary contractions
noted. There was normal gastric mucosa seen in the large mixed
hiatal hernia. In the body, antrum, and pylorus, the gastric
mucosa appeared normal. There was no evidence of masses or
ulcerations. The study was somewhat limited due to patient's
inability to be repositioned. Contrast passed from stomach into
the duodenum. The duodenum was normal in course and caliber,
without any mucosal abnormalities.
IMPRESSION:
1. Large hiatal hernia.
2. Mild esophageal dysmotility.
3. No evidence of large masses or ulcerations to explain the
patient's GI
bleed, although this was a somewhat limited study.
.
[**2192-12-20**] 07:47AM BLOOD WBC-9.3 RBC-3.20* Hgb-10.3* Hct-31.1*
MCV-97 MCH-32.0 MCHC-32.9 RDW-15.9* Plt Ct-124*
[**2192-12-15**] 09:30PM BLOOD Neuts-92.7* Lymphs-3.8* Monos-2.6 Eos-0.8
Baso-0.1
[**2192-12-20**] 07:47AM BLOOD Glucose-118* UreaN-23* Creat-0.6 Na-143
K-3.7 Cl-106 HCO3-29 AnGap-12
[**2192-12-15**] 12:10PM BLOOD ALT-24 AST-29 AlkPhos-68 TotBili-0.4
[**2192-12-20**] 07:47AM BLOOD Calcium-8.5 Phos-2.3* Mg-1.9
Brief Hospital Course:
84 F with history of HTN, HL, CAD, depression, pulm HTN,
pulmonary fibrosis, h/o GIB presents with dizziness and possible
melena.
.
#. GIB - likely upper GI bleed given coffee grounds seen on
lavage and reports of melena. Her BUN was high with normal
creatinine, which is also suggestive of UGIB. The patient was on
prednisone, meloxicam and aspirin which in combination
predisoses her to PUD and gastritis. The patients severe IPF and
pHTN makes EGD of particularly high risk of causing respiratory
failure. Further if intubated her pulmonary disease would make
her at high risk of not being extubatable. Therefore favored
conservative management without EGD. HCT was checked Q6H. She
was initially started on a PPI drip. She required 1 unit PRBC
for decrease in HT to 25. Repeat HCT was 29. Upper GI barium
swallow did not identify mass or ulcer responsible for her UGIB.
Her hematocrit remained stable and she was called out to the
general medical floor. While on the floor, her HCT was stable in
the mid 30s and she was deemed stable for discharge. She was
discharged on a [**Hospital1 **] dose of pantoprazole.
#. UTI - UA in ED without any persistent signs of UTI. Urine
culture was sent. She was continued on cipro to complete a 7 day
course. She was not sent home with any antibiotics.
#. Leukocytosis - WBC of 18.8, predominantly neutrophils. Not
febrile. UA without signs of persistent UTI. CXR without any
overt signs of pneumonia. Likely related to oral steroids and
stress reaction from GI bleed. No sign of pneumonia on CXR.
#. Pulmonary fibrosis - history of severe IPF, complicated with
pulmonary hypertension. Patient has baseline exertional dyspnea
and resting and exertional hypoxemia. She was continued on her
home prednisone regimen. She was started on liquid bactrim ss
10mL daily for PCP [**Name Initial (PRE) 1102**].
#. DMII - held metformin while inpatient and she was given
insulin sliding scale.
#. HTN - not on any antihypertensives at home. BP was monitored.
Given her clinical picture, we decided that the patient would
benefit from b-blockage. She was started on metoprolol 12.5 [**Hospital1 **].
She tolerated the dose and was sent home on this regimen.
#. Back pain - On fentanyl, dilaudid, cyclobenzaprine and
lidocaine patch at home. She would likely benefit from a pain
medicine counsult as an outpatient. She was continued on
lidocaine patch and cyclobenzaprine, standing tylenol 1000mg Q6H
and dilaudid PO as needed for pain.
#. CAD: continued on ASA and simvastatin
#. Depression: stable. Continued on mirtazapine and escitalopram
# Code: Extensive discussion with patient and daughters
confirmed DNR/DNI status
Medications on Admission:
- home oxygen 6 L/min at rest and sleep and 8L/min with exertion
- portable oxygen - pulm fibrosis; rest ra sat 84%
- meloxicam 7.5 mg [**Hospital1 **] (stopped on [**12-13**])
- acetaminophen 1000 mg TID:PRN back pain (stopped on [**12-13**])
- cyclobenzaprine 10 mg HS
- escitalopram 20 mg daily
- lidocaine 5 % (700 mg/patch) daily
- metformin 2,000 mg QAM and 1,000 mg QPM
- mirtazapine 15 mg daily
- prednisone 20 mg daily
- simvastatin 20 mg daily
- aspirin 81 mg
- calcium carbonate-vitamin D3 1200 mg-800 unit daily
- ferrous sulfate 325 mg QOD
- sodium chloride nasal mist spray daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
10. sulfamethoxazole-trimethoprim 200-40 mg/5 mL Suspension Sig:
Ten (10) ML PO DAILY (Daily).
Disp:*200 ML(s)* Refills:*2*
11. 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*
12. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-15**] Sprays Nasal
QID (4 times a day) as needed for congestion.
13. metformin 1,000 mg Tablet Sig: Two (2) Tablet PO QAM.
14. metformin 1,000 mg Tablet Sig: One (1) Tablet PO qpm.
15. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO every other day.
16. calcium carbonate-vit D3-min 1,200 mgcalcium -1,000 unit
Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Upper gastrointestinal bleed
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 10113**], you presented to the hospital with new dizziness
and melena in your stools. You were admitted to the ICU where
they found that your hematocrit, a measure of your blood level,
was low. You were given a unit of blood and your NSAIDs for pain
control were stopped. You were also started on a proton pump
inhibitor to stop the acid in your gut from worsening your
bleeding. Your blood levels then became stable and you were
deemed safe to be transfered to the general floor. On the floor,
we monitored your hematocrit and deemed you stable and healthy
for discharge to home with services.
Here are the changes we have made to your home medications:
.
STOP meloxicame or any other NSAIDs (advil, motrin, ibuprofen,
etc...)
Start Pantoprazole 40mg by mouth twice a day
Start the liquid form of bactrim daily (or you can stay with the
pillform). However take one or the other and not both.
Start metoprolol 12.5 mg by mouth twice a day
.
Here is a list of your current medications:
.
- home oxygen 6 L/min at rest and sleep and 8L/min with exertion
- portable oxygen - pulm fibrosis; rest ra sat 84%
- acetaminophen 650 mg Q6H:PRN back pain
- escitalopram 20 mg daily
- lidocaine 5 % (700 mg/patch) daily
- metformin 2,000 mg QAM and 1,000 mg QPM
- mirtazapine 15 mg daily
- prednisone 20 mg daily
- simvastatin 20 mg daily
- aspirin 81 mg
- calcium carbonate-vitamin D3 1200 mg-800 unit daily
- ferrous sulfate 325 mg QOD
- sodium chloride nasal mist spray daily
- metoprolol 12.5 mg PO BID
- pantoprazole 40 mg PO BID
- bactrim liquid form 10mL daily
Followup Instructions:
Please contact Dr. [**First Name (STitle) **] to schedule a follow up in the next
few days.
Department: PULMONARY FUNCTION LAB
When: FRIDAY [**2193-2-1**] at 11:10 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: FRIDAY [**2193-2-1**] at 11:30 AM
With: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: FRIDAY [**2193-2-1**] at 11:30 AM
Completed by:[**2192-12-20**]
|
[
"300.00",
"250.00",
"414.01",
"416.8",
"280.0",
"V58.65",
"V49.86",
"E935.9",
"438.20",
"518.89",
"V15.82",
"311",
"533.40",
"515",
"V46.2",
"401.9",
"288.60",
"553.3",
"272.4",
"E932.0",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11431, 11482
|
6601, 9265
|
287, 293
|
11555, 11555
|
3667, 3667
|
13342, 14128
|
2518, 2536
|
9910, 11408
|
11503, 11534
|
9291, 9887
|
11738, 12398
|
2551, 3120
|
12416, 12725
|
3134, 3648
|
1280, 1478
|
233, 249
|
12746, 13319
|
321, 1261
|
3683, 6578
|
11570, 11714
|
1500, 1871
|
1887, 2502
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,843
| 194,808
|
36505
|
Discharge summary
|
report
|
Admission Date: [**2194-3-21**] Discharge Date: [**2194-3-25**]
Date of Birth: [**2121-11-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
new onset diabetes, confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 72 yo M with HTN, hyperlipidemia, who presents with
altered mental status. According to his son, he has not been
feeling very well over the last week; he later recalled that his
father had been polyuric, polydipsic. There were no no obvious
fever, chills, HA, cardiopulmonary symptoms, or abd pain n/v. He
had not traveled anywhere recently. He works in [**Location (un) **] and lives
with his family.
.
On the day of admission, he was taking the bus when he was found
to be mumbling and not making sense, repeatedly stating his
wife's name and telephone number. He was found to be 220/110
with HR 80s and blood sugar 575. On arrival to the [**Name (NI) **], Pts BP
improved to the 140s-150s. Pt spiked a temp to 101. He was pan
cultured. CT head neg. LP neg (elevated protein). Pt given 2g
CTX and labetolol and started on insulin gtt for FSBG ibn 500s.
Pt also with hyponatremia and renal failure. Despite a
translator, he continued to repeat his name and wife's phone
number.
.
In the unit, Insulin drip was continued. MRI of the head was
done with no findings on preliminary report.
Past Medical History:
HTN
Hyperlipidemia
Social History:
married with 2 children. From [**Country **] originally. Works at garage.
No smoking, EtOH, or recreational drugs
Family History:
Non-contributory
Physical Exam:
VS: 99.0, 59, 121/76, 17, 96%ra
Gen: awake and alert, creole speaking. states his name
HEENT: EOMI, PERRL, anicteric sclera, MMM, OP clear. Poor
dentition
Neck: supple, no LAD
Heart: RRR no m/r/g
Lungs: CTAB no wheezes, rales, or crackles
Abd: soft, NT/ND +BS no rebound or guarding
Ext: warm, well perfused, no pitting edema
Skin: no obvious rashes
Neuro: awake and alert. Speaks in creole. States name. Fully
responsive. CNII-XII intact. strength preserved in all
extremities. gross sensation intact. No nystagmus
================================
Not significantly changed at time of discharge
Pertinent Results:
admission:
.
[**2194-3-21**] 05:43PM BLOOD WBC-5.4 RBC-5.76 Hgb-16.2 Hct-50.0 MCV-87
MCH-28.1 MCHC-32.4 RDW-13.8 Plt Ct-230
[**2194-3-21**] 05:43PM BLOOD PT-13.9* PTT-24.0 INR(PT)-1.2*
[**2194-3-21**] 05:43PM BLOOD Fibrino-448*
[**2194-3-21**] 08:00PM BLOOD Glucose-549* UreaN-20 Creat-1.6* Na-127*
K-4.3 Cl-89* HCO3-23 AnGap-19
[**2194-3-22**] 04:03AM BLOOD ALT-20 AST-21 LD(LDH)-254* CK(CPK)-331*
AlkPhos-121* TotBili-0.5
[**2194-3-22**] 04:03AM BLOOD CK-MB-7 cTropnT-<0.01
[**2194-3-22**] 03:12PM BLOOD CK-MB-6 cTropnT-<0.01
[**2194-3-22**] 04:03AM BLOOD Calcium-10.1 Phos-3.9 Mg-1.9
[**2194-3-21**] 05:43PM BLOOD Lipase-29
[**2194-3-22**] 04:03AM BLOOD VitB12-510 Folate-7.6
[**2194-3-22**] 09:29AM BLOOD %HbA1c-14.7*
[**2194-3-22**] 04:03AM BLOOD TSH-0.56
[**2194-3-23**] 07:05AM BLOOD Cortsol-2.8
[**2194-3-21**] 05:53PM BLOOD Glucose-GREATER TH Lactate-2.3* Na-130*
K-4.3 Cl-87* calHCO3-24
.
MRI/MRA: No significant abnormalities on MRA of the head
.
NCHCT: Chronic small vessel ischemic changes without
intracranial
hemorrhage or edema.
.
discharge:
[**2194-3-25**] 06:35AM BLOOD WBC-5.2 RBC-5.16 Hgb-14.7 Hct-43.7 MCV-85
MCH-28.4 MCHC-33.6 RDW-13.9 Plt Ct-241
[**2194-3-25**] 06:35AM BLOOD Glucose-100 UreaN-23* Creat-1.3* Na-138
K-4.2 Cl-101 HCO3-29 AnGap-12
Brief Hospital Course:
72 yo M with HTN, hyperlipidemia, who presents with altered
mental status, hyperglycemia, and hyponatremia. Initially
managed with insulin drip in the MICU. Presentation c/w
new-onset DM. Discharged on Lantus 20mg qam and a QID sliding
scale with close follow-up scheduled at the [**Hospital **] clinic.
.
NEW ONSET DMII: Presentation c/w new-onset DMII. Good BS control
on the day of discharge with a weight-based regimen (50% long
acting, 50% SSI). We have had difficulty with insulin teaching
[**1-6**] language barrier & poor vision. Pt's daughter was also
taught and [**Name (NI) 269**] was provided for further teaching.
- Lantus 20 daily + SSI ([**7-26**] with meals & [**1-12**] qhs)
- consider initiating oral hypoglycemics in outpt setting
- follow-up arranged within 2 days of discharge at [**Last Name (un) **]
- lisinopril 5mg daily started
- A1C= 14
.
Altered Mental Status: Unclear etiology. Pt fully alert and
oriented now, but was initially confused while in the MICU. No
focal signs to suggest stroke, and head CT/MRI/MRA unremarkable.
He did have a low-grade fever in ED. LP unremarkable. No growth
on urine or blood cultures. CXR unremarkable. [**Month (only) 116**] have been HHS
vs/ DKA given high glucose and initial ketones. Was very HTNive
initially, raising concern for hypertensive encephalopathy.
Hyponatremia mostly pseudohyponatremia which soon resolved.
Initial Tox screen negative. No obvious offenders on home
medication list.
- TSH, B12, folate all normal; RPR negative
- at the time of d/c, family said he was at his baseline mental
status
.
HTN: Came in extremely HTNive, but this largely resolved and BP
in the 140-150/80 range. Cont HCTZ, metoprolol. Added
lisinopril.
.
Renal Failure NOS: Unclear baseline. U/A negative for protein.
No obvious infection. Cr= 1.3 at the time of d/c.
.
--FOLLOW UP: Appointments made for pt at [**Last Name (un) **] w/in two days of
d/c. Message left for PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1355**] at [**Hospital 8**] Hospital.
Medications on Admission:
HCTZ 25mg daily
Atenolol 25mg daily
Simvatatin 40mg daily
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. FreeStyle Lite Strips Strip Sig: One (1) strip In [**Last Name (un) 5153**]
four times a day.
Disp:*1 month supply* Refills:*3*
5. Insulin Syringe 1 mL 28 X 1 Syringe Sig: One (1) syringe
Miscellaneous four times a day.
Disp:*1 month supply* Refills:*2*
6. Lantus 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous once a day: at breakfast.
Disp:*1 month supply* Refills:*2*
7. Humalog 100 unit/mL Solution Sig: 8-20 units Subcutaneous
four times a day: as per sliding scale.
Disp:*1 month supply* Refills:*2*
8. Lisinopril 5 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:
New Onset Diabetes Mellitus
=============
Hypertension
Hyperlipidemia
Discharge Condition:
Medically stable for discharge.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted directly to the Intensive Care Unit at [**Hospital1 18**]
for confusion. You were diagnosed with Diabetes. We have
started you on insulin and you and your family members have been
taught how to administer it. It is very important that you take
all of the insulin which you prescribe because you will become
very ill if you do not do this. You will be provided with
instructions for your insulin.
None of your previous medications have been changed. You should
continue to take them as you did previously. The only new
medications you should take are insulin and lisinopril.
Appointments have been made for you at the [**Hospital **] clinic (listed
below). Please keep these appointments and try to attend with an
english-speaking family member.
Followup Instructions:
The following appointment have been made for you at the [**Hospital **]
Clinic:
[**3-28**], 3pm with a Clinical Educator at the [**Hospital **] Clinic ([**Last Name (un) 19749**]) [**Telephone/Fax (1) 2384**]. You will then have an appointment
immediately after with Dr. [**Last Name (STitle) 3617**].
Please call and make an appointment with your PCP within one
week.
Completed by:[**2194-3-25**]
|
[
"585.2",
"250.40",
"403.90",
"584.9",
"276.1",
"272.4",
"780.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
6584, 6642
|
3609, 4484
|
345, 352
|
6756, 6790
|
2316, 3586
|
7639, 8039
|
1667, 1685
|
5745, 6561
|
6663, 6735
|
5662, 5722
|
6814, 7616
|
1700, 2297
|
5447, 5636
|
276, 307
|
380, 1477
|
4499, 5436
|
1499, 1520
|
1536, 1651
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,427
| 179,222
|
25612
|
Discharge summary
|
report
|
Admission Date: [**2125-7-30**] Discharge Date: [**2125-8-4**]
Date of Birth: [**2101-12-9**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
This is a 21 year old female who fell down a flight of stairs
and was found at the bottom with possible head trauma. Witnesses
did not recall any seizure-like activity.
On later questioning the patient reported having lost 25 pounds
over the past month while taking Brazilian diet pills, with
accompanying orthostasis, polydypsia, polyuria and dry mouth.
She said she fell down the stairs in the context of presyncope
and she believes she lost consciousness. She had no other
syptoms prior to admission; no URI symptoms, UTI symptoms,
shortness of breath, palpitations, chest pain, history of
siezures, or focal neurologic complaints.
Past Medical History:
None
Social History:
occassional EtOH
No tob/drugs
Family History:
CVA (father)
no h/o seizure/sudden death
Physical Exam:
VS T98.6 P80 BP104/70R20 98%RA
Gen: well-appearing, asking to go home
Chest: Clear bilaterally
CV: Regular rate and rhythm
Abd: Soft, nontender, nondistended
Ext: Well perfused
Pertinent Results:
CT head: right putamen bleed vs calcification
MRI: head: small calcification in putamen, inflammation vs
infection
MRA, MRV: negative
CT abd/pelvis: 1.6cm fatty lesion in liver
CT C-spine: negative
ECG: normal (24 hour tele)
Carotid US: normal
Serum/urine tox: normal
Brief Hospital Course:
Upon arrival the patient was responsive only to painful stimuli
and was intubated for a GCS of 10 and respiratory difficulty.
There were no obvious signs of trauma on evaluation and no
fractures or internal injuries were identified. There was no
evidence of bowel or bladder incontIn the ED she had some
episodes of activity not entirely consistent with but concerning
for seizure. Neurology and Neurosurgery were consulted and
evaluated the patient in the ED.
The patient was admitted to the Trauma ICU and self-extubated
later that day, remaining stable afterwards. On the following
day she had some episodes of tachypnea and/or apnea with return
of flickering eye movements, and she was re-intubated.
The patient was extubated without problems and monitored on
telemetry in the ICU for another day with no events. She was
transferred to the floor on telemetry and again had no return of
apneic or hypoxic events. Her electrolytes remained within
normal limits and she had no other complaints.
She was evaluated by Medicine as well as Neurology and
Neurosurgery, with no clear etiology found and a normal EEG. The
most likely explanation at the time of discharge was
drug-induced orthostasis combined with anxiety-associated
hyperventilation. The patient was encouraged to follow up with
her physician or the Trauma Surgery clinic and to return to an
ER if any symptoms returned. She was also encouraged to avoid
diet pills and have adequate food and liquid intake, along with
taking slow deep breaths when anxious.
Medications on Admission:
Diet pill
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Syncopal event, likely in setting of drug-induced orthostatic
hypotension
Apneic episode
Discharge Condition:
Good
Discharge Instructions:
You should call a physician or come to ER if you have loss of
consciousness, fevers, chills, nausea, vomiting, shortness of
breath, chest pain, tingling, numbness, seizures, weakness, or
any other questions or concerns.
Do not take diet pills.
Take slow deep breaths if you start to feel anxious.
Otherwise you may resume all your normal activities.
Followup Instructions:
Call your primary care physician for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 702**] appointment in
1 week. You will need a repeat head CT at that time.
If you do not have a primary care physician you may call the
Trauma Surgery clinic ([**Telephone/Fax (1) 2359**]) for a follow up
appointment.
|
[
"305.90",
"276.7",
"458.0",
"780.2",
"306.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
3263, 3269
|
1651, 3174
|
322, 348
|
3402, 3409
|
1358, 1358
|
3810, 4128
|
1104, 1146
|
3234, 3240
|
3290, 3381
|
3200, 3211
|
3433, 3787
|
1161, 1339
|
274, 284
|
376, 1013
|
1367, 1628
|
1035, 1041
|
1057, 1088
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,808
| 105,963
|
3559
|
Discharge summary
|
report
|
Admission Date: [**2149-8-15**] Discharge Date: [**2149-9-2**]
Date of Birth: [**2084-1-3**] Sex: M
Service: [**Doctor First Name 147**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
abdominal pain with nausea/vomiting
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy with subtotal colectomy, lysis of
adhesions, and repair of ventral hernia.
2. Revision of colostomy.
History of Present Illness:
Pt is a 60 yo white male w/ Hx significant for colon cancer, s/p
two bowel resections, including a colostomy, who presented to
[**Hospital1 18**] on [**8-14**] with C/O crampy abdominal pain and enlarging
parastomal hernia x 1 day.
Past Medical History:
Colon CA
s/p Bowel resections x 2 with Colostomy
Mechanical Mitral Valve
Parastomal hernia
Small Bowel Obstruction
NIDDM
Social History:
Pt denies tobacco, etoh, and illicit drug use.
Family History:
CAD
Physical Exam:
VS: 99.0, 76, 144/78, 16, 98 RA
Gen: alert, oriented, well-nourished male, no distress
HEENT: PERRLA, CN II-XII intact; no JVD or lymphadenopathy
Chest: CTA x 2
Cardio: RRR without murmur
Abd: Nondistended, Stoma pink, hypo-active BS, soft, diffuse
mild TTP without guarding or rebound. Non reducible parastomal
hernia
Ostomy: pink. Guiaic positive.
Brief Hospital Course:
Pt presented [**8-14**] with C/O crampy abdominal pain and enlargement
of parastomal hernia x 1 day. KUB revealed multiple air fluid
levels, and CT abd/pelvis revealed a mid small bowel obstruction
with transition point at mid abd wall in upper portion of hernia
sac. Pt admitted to surgery service. Pt started and maintained
on IV heparin drip.
[**8-15**], with obstruction not resolving, pt underwent exploratory
with subtotal colectomy, lysis of adhesions, and repair of
ventral hernia with mesh. Pt tolerated procedure well, and was
transferred to SICU. Pt remained intubated on propafol drip
posteroperatively, to prevent respiratory complications
secondary to major abd procedure.
[**8-16**], pt remained in stable condition, intubated on propafol
drip. Pt required aggressive fluid resuscitation for low urine
output.
[**8-17**], pt continued to remain stable and intubated. Hematocrit
remained stable, and pt continued to require large amounts of IV
fluids.
[**8-18**], stoma noted to not be viable, and pt taken to OR for
colostomy revision. Pt tolerated procedure well, and was
transferred to SICU in stable condition.
[**8-19**], Pt was weaned from propafol drip and ventilator, and pt
extubation. Pt tolerated extubation well.
[**8-20**], pt continued to tolerate extubation well, and was
transferred to the floor. Pt continued on 10 mg Coumadin for
mechanical mitral valve to achieve INR of 2.5-3.5.
[**8-21**], pt continued to remain in stable condition, and physical
therapy began working with pt, to get him OOB to chair. Pt
began clear liquids, which he tolerated well. Surgical wounds
and ostomy continued to appear well-healing.
[**8-22**], pt's diet advanced to full liquids, which he tolerated
well. He continued working with PT. Ostomy output was good and
wounds appeared well-healing.
[**8-23**], Pt continued with physical therapy and incentive
spirometry. Diet was advanced to regular, which was tolerated
well. HR noted to be tachy into 110s in a-fib- pt put on
telemetry.
For the next several days, pt continued to remain stable,
tolerating regular diet and working w/ PT. HR remained
elevated, and pt remained without cardiac symptoms.
Metoprolol was increased, and a cardiology consult was obtained.
Cardiology felt that pt's elevated HR may be due to decreased
HCT of 26.9. Pt was transfused 2 uprbcs on [**8-30**], and hematocrit
rose. Pt's HR stabilized over the few days.
On [**8-29**], with pt's HR elevated, pt complained of chest
tightness. EKG obtained and reviewed with cardiology was
negative for any acute ischemic process. CTA obtained to R/O
pulmonary embolism, revealed no pulmonary emboliism. Chest
tightness soon subsided, and once again, pt's HR stabilized to
normal.
Over his hospital course, Mr. [**Known lastname 16254**] required increasing doses of
Coumadin to achieve an INR of 2.5-3.5. At home, he reportedly
requires between 10-15 mg/day of Coumadin to maintain
therapeutic INR. During the last several days of [**Hospital **] hospital
stay, he required doses of 17.5mg/day, and 20 mg/day of coumadin
to achieve INR of 2.5-3.5.
On [**9-2**], Mr. [**Known lastname 16254**] continued to tolerate a regular diet. His
wounds continued to appear well-healing and his stoma output
continued to be good. His INR finally acheived the therapeutic
level of 3.0, and he was discharged to home in good condition.
Medications on Admission:
Metformin 250 mg PO TID
Glyburide 1.25 mg PO TID
Warfarin 10-15 mg PO once daily
Metoprolol 150 mg PO once daily
Lipitor 20 mg PO once daily
Discharge Medications:
Metformin 250 mg PO TID
Glyburide 1.25 mg PO TID
Metoprolol XL 200mg PO once daily
Coumadin 17.5 mg PO once daily
Lipitor 20 mg PO once daily
Discharge Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) 189**] [**Last Name (NamePattern1) 269**]
Discharge Diagnosis:
Small Bowel Obstruction
s/p Exploratory Laparotomy, Lysis of adhesions, repair of
parastomal hernia
Discharge Condition:
Stable
Discharge Instructions:
Keep wounds clean.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] within one week after discharge
by telephone to set up appointment. Dr.[**Name (NI) 6433**] phone # is:
[**Telephone/Fax (1) 6439**]. Pt needs to follow-up with his primary care
physician for coumadin management, etc. within one to two days
after discharge.
|
[
"250.00",
"V10.06",
"E878.6",
"V43.3",
"401.9",
"552.20",
"569.69",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.43",
"54.59",
"47.09",
"45.75",
"53.69",
"45.73",
"99.15",
"99.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
5138, 5240
|
1383, 4781
|
368, 499
|
5383, 5391
|
5458, 5772
|
985, 990
|
4972, 5115
|
5261, 5362
|
4807, 4949
|
5415, 5435
|
1005, 1360
|
293, 330
|
527, 760
|
782, 904
|
920, 969
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,446
| 168,605
|
9689+9705
|
Discharge summary
|
report+report
|
Admission Date: [**2101-9-1**] Discharge Date: [**2101-9-8**]
Date of Birth: [**2049-6-12**] Sex: M
Service: MEDICINE
CHIEF COMPLAINT: Change in mental status.
HISTORY OF PRESENT ILLNESS: This is a 52-year-old male, with
a history of bipolar disorder on lithium, who was transferred
from an outside hospital with a diagnosis of lithium toxicity
for emergent hemodialysis. The patient was admitted into the
Medical Intensive Care Unit at [**Hospital1 **]
Hospital. From there, he was transferred to the general
medicine service to the floor.
The patient had a syncopal episode at home on [**2101-9-1**]. He
was brought by the EMTs to an outside hospital Emergency
Department. He was found to have a pulse of 44, tremors,
increased potassium to 6.3, creatinine 1.7, and lithium
level was 3.3. He received 2 liters of normal saline,
thiamine, folate, multivitamin, Kayexalate, calcium chloride,
Insulin, and bicarb at the outside hospital in [**Location (un) 620**]. The
patient noted 3 days of decreased PO intake, lethargy. He
did not recall any syncopal episode, or who had brought him
to the Emergency Department. His lithium bottle had the
appropriate number of meds in it. He denied any fevers,
chills, shortness of breath, chest pain, or abdominal pain.
He also denied any dysuria. He denied suicidality.
PAST MEDICAL HISTORY:
1. Bipolar disorder.
2. Diabetes mellitus
3. GERD.
4. Sleep apnea.
5. Former alcohol and drug use.
MEDICATIONS ON ADMISSION:
1. Lithium 300 mg qid.
2. Lisinopril 10 mg qd.
3. Lamictal 100 mg qd.
4. Protonix 40 mg qd.
5. Nadolol 20 mg [**Hospital1 **].
6. Tylenol 500 mg tid prn.
7. Seroquel 300 mg qhs.
9. Loperamide.
10.Insulin NPH/ regular 32 units/28 units [**Hospital1 **]
ALLERGIES: Unknown.
SOCIAL HISTORY: Past history of alcohol abuse with last use
9 years ago. History of tobacco use.
PHYSICAL EXAM: On admission at the Medical Intensive Care
Unit, the patient was afebrile with a temperature of 99.5,
blood pressure 134/44, heart rate 51, respiratory rate 20,
satting 94% on room air. He was alert, oriented x 2 to
himself and the date. He had occasional short tremors of his
extremities. His sclerae were anicteric. Pupils equal,
round and reactive to light. Extraocular muscles intact.
His oropharynx was clear, and his mucous membranes were dry.
His neck was large and unable to appreciate JVD. His chest
was clear to auscultation bilaterally. His heart was
bradycardic with a regular S1, S2, and II/VI systolic
ejection murmur heard at the right base. His abdomen was
obese, soft, tender in the left lower quadrant. His
extremities had no clubbing, cyanosis or edema. His cranial
nerves II through XII were intact. He had equal strength
bilaterally in his upper and lower extremities. He had
clonus in his lower extremities. His patellar reflexes were
2+ bilaterally.
LABORATORIES: Electrolytes from [**Hospital3 628**]: Sodium
130, potassium 6.3, chloride 105, bicarb 17, BUN 50,
creatinine 1.7, glucose 172. CBC from the outside hospital:
White blood cell count 11.2, hematocrit 32.4, platelets 175.
His toxicology screen was positive for tricyclics.
HOSPITAL COURSE: Upon admission to the [**Hospital3 **] Medical
Intensive Care Unit, his white blood cell count was 10,
hematocrit 32.7, platelets 174. His sodium was 137,
potassium 5.5, chloride 111, bicarb 18, BUN 42, creatinine
1.4, glucose 162.
STUDIES: Head CT was negative for bleed or mass effect at
the outside hospital. An EKG done at the outside hospital
showed bradycardia with a rate of 49, without any acute ST
changes. Chest x-ray done at [**Hospital3 **] Hospital on the day
of admission was questionable for right lower lobe
atelectasis, infiltrate.
HOSPITAL COURSE BY SYSTEM AND PROBLEM - 1) LITHIUM
INTOXICATION: The patient's clinical picture, given his
tremor, bradycardia, clonus, and change in mental status, was
consistent with lithium intoxication. His lithium level on
admission was 3.3. The patient's creatinine was elevated, as
well, at 1.7. Given that the lithium would be renally
cleared, the creatinine explained his high level of lithium.
The patient was dialyzed, as per toxicology recommendations.
He was placed on IV fluids and monitored for signs of
diabetes insipidus throughout his hospital admission. His
lithium levels were continuously checked daily.
On hospital day #5, the patient's lithium level was 0.5. The
patient's mental status improved during his hospital
admission. By hospital day #5, he was alert and oriented x
3. His clonus, tremors and bradycardia had resolved during
his hospital stay.
Psychiatry was consulted who recommended that the lithium and
neurontin be held. They recommended repeating a CT of his
head to determine any degree of underlying neurologic disease
which may have contributed to his presentation. CT of the
head was done on hospital day #4 which was negative for any
signs of bleeding or mass effect. The patient was resumed on
his dosage of Seroquel.
2) ACUTE RENAL FAILURE: The patient's BUN and creatinine
steadily improved throughout his hospital course. He was
continued on IV fluids, and his ACE inhibitor was held for 4
days. He was closely monitored for signs of diabetes
insipidus which he did not develop. His electrolytes
normalized, and his creatinine improved to 0.8. The patient
was also closely followed by the renal service.
3) BIPOLAR DISORDER: The patient's lithium was continued to
be held until hospital day #5. He was restarted on his
Seroquel on hospital day #4. He was also continued on his
Lamictal.
4) HYPERKALEMIA: After dialysis, the patient's potassium
levels normalized. By hospital day #4, the patient's
potassium level was 4.4. His electrolytes were closely
monitored.
5) TYPE 1 DIABETES: The patient was continued on Insulin on
a regular Insulin sliding scale. His fingersticks were
monitored qid. His blood glucose level was well-controlled.
6) BRADYCARDIA: The patient's episodes of bradycardia prior
to admission and on the day of admission were likely due to
his lithium toxicity, and his daily regimen of beta blocker,
nadolol. The patient's nadolol was held and he was placed on
telemetry. The patient's EKGs were checked, but did not show
any acute changes. Telemetry was discontinued on hospital
day #5, since the patient did not experience anymore episodes
of bradycardia.
7) FLUID, ELECTROLYTES AND NUTRITION: The patient was
continued on a diabetic diet, and IV fluids were
administered. A Foley was placed to closely monitor urine
output. The Foley was then discontinued on hospital day #4.
On hospital day #5, the patient's symptoms had clearly
improved. He was alert and oriented x 3, and was able to
have a normal conversation. His neurologic symptoms of
tremors and clonus had resolved, as well. Psychiatry
recommended that the patient did not require inpatient
psychiatric treatment. They recommended that a follow-up
with a psychiatrist, Dr. [**Last Name (STitle) **]. [**Doctor Last Name **], after discharge from the
hospital. They did recommend that the patient be sent to
physical rehab for reconditioning.
In summary: Patient found to have lithium toxicity.
Precipitant may have been renal failure from dehydration from
gastroenteritis in the setting of ACE inhibition. The resultant
renal failure resulted in decreased lithium clearance and thus
toxicity. There was no evidence of intentional overdose.
The bradycardia was likely from a combination of lithium and
decreased clearance of nadolol ( beta blocker) which is renally
cleared. As of discharge his HR is in the 60-70 BPM range.
Nadolol can be restarted as outpatient.
His insulin regimen should be adjusted at rehab accordingly.
His mental status is near baseline. His ataxia continues to
improve on a daily basis. Head CT negateive for hematoma of
other abnormality. Expect gait to improve over time. We have
decided to hold his Lithium for a few more days as his gait
improves. Would restart the lithium in the near future.
He will discharged on essentially the same meds as on admission
else lithium and nadolol. Of note he is taking nadolol for a
tremor presumed secondary to lithium. This too can be restarted
as an outpatient.
groin eccyhmosis- from femoral central line.
Patient's lithium should be restarted in the near future.
Please call patient's psychiatrist to discuss reinstitution of
lithium Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 32741**]
DISCHARGE MEDICATIONS:
protonix 40 mg po qd
lamotrigine ( Lamictal) 100 mg po qd
lisinopril 10 mg po qd
quetiapine ( seroquel) 300 mg qhs
NPH insulin 20 units / regular insulin 15 units [**Hospital1 **] SQ
cc:[**Last Name (STitle) 32742**]
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1775**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1776**]
Dictated By:[**Name8 (MD) 4955**]
MEDQUIST36
D: [**2101-9-7**] 10:47
T: [**2101-9-7**] 09:51
JOB#: [**Job Number 32743**]
Admission Date: [**2101-9-2**] Discharge Date: [**2101-9-8**]
Date of Birth: [**2049-6-12**] Sex: M
Service: GENERAL SURGERY
ADDENDUM TO DISCHARGE SUMMARY OF [**2101-9-7**]: Over the past 24
hours, the patient has not had any events. His mental status
continues to be improving. He continues to be alert and
oriented to time, place and person. His clonus and tremor
have resolved. His ambulation has improved, as well. Based
on the patient's current status and his level of improvement,
the patient will be discharged to a rehab facility today for
further assistance with ambulation.
DISCHARGE CONDITION: Stable.
DISCHARGE TO: Rehab facility.
DISCHARGE DIAGNOSES:
1. Lithium intoxication.
2. Delirium.
3. Acute renal failure.
DISCHARGE MEDICATIONS:
1. Lisinopril 10 mg po qd.
2. Lamotrigine 100 mg po qd.
3. Pantoprazole 40 mg po qd.
4. Seroquel 300 mg po q hs.
5. The patient is to continue on his Insulin regimen as prior
to admission.
DISCHARGE INSTRUCTIONS:
1. The patient is to call his doctor for any changes in
mental status, tremors, shortness of breath, or other
worrisome symptoms.
2. He is to make a follow-up appointment with a psychiatrist,
Dr. [**Last Name (STitle) **], at ([**Telephone/Fax (1) 32780**] after discharge from the rehab
facility.
3. His lithium to be held at present and is to be restarted
on an outpatient level, as the patient's inability to
ambulate improves.
4. His nadolol has been held for bradycardia. This is to be
restarted as an outpatient, as well.
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1775**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1776**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2101-9-8**] 10:07
T: [**2101-9-8**] 10:10
JOB#: [**Job Number 32781**]
|
[
"530.81",
"427.89",
"584.9",
"276.7",
"250.00",
"276.5",
"296.7",
"599.7",
"780.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
9641, 9682
|
9703, 9766
|
9789, 9979
|
1494, 1769
|
3179, 8496
|
10003, 10824
|
1885, 3161
|
157, 183
|
212, 1346
|
1368, 1468
|
1786, 1869
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,862
| 149,988
|
3522
|
Discharge summary
|
report
|
Admission Date: [**2143-11-16**] Discharge Date: [**2143-11-29**]
Date of Birth: [**2084-8-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
[**2143-11-20**] AVR ( 27 mm CE Magna-Ease pericardial)
History of Present Illness:
(per records, girlfriend)
This patient is a 59 year old male with a PMH of chronic pain,
HTN, HLD, IVDA who initially presented to his PCP several days
ago with cough/ congestion seen by PCP and started on a z-pack
for concern of bronchitis but he has not been taking the
antibiotics. His girlfriend states that he has been slowly
decling over the past few weeks. He takes large amounts of
oxycontin and dilaudid at baseline and she has noticed that her
pain medications have gone missing too. He has also been using
heroine, last use [**11-15**]. Has been noted to have minimal PO
intake, occasionally drooling, noted to have increased lethargy.
Lethargy and cough have been worsening over the last 5 days. On
[**11-15**], he developed shortness of breath and diffuse rhonchi
which worsened over afternoon. Pt became somnolent, minimally
responsive and tachpneic in his PCP [**Name Initial (PRE) 3726**]. EMS was called by
PCP and found him altered with O2 saturation 85%.
.
On arrival to BD [**Location (un) 620**], his VS were T 97.3 HR: 89 BP: 117/50
Resp: 20 O(2)Sat: 82% RA 100% NRB. CXR showed question of CHF
vs. PNA. He was given vanc/zosyn/flagyl for presumed pneumonia.
He became more somnolent and was intubated at BIDN. Sedation was
Fent/Versed gtt. Labs were significant for hct 22, trop T 0.152,
BNP elevated 63k. EKG showed TWI in V2-V4. Stools guaiac
negative and he was transfused one unit PRBCs. There was no
report of bleeding. He was given Aspirin PR. Transferred by
[**Location (un) 7622**]. On arrival to [**Hospital1 18**], his HCT was 25. EKG showed T
wave inversions in V2-V4. His most recent VS prior to transfer
to the MICU were: T 99.3 P 78, BP 99/31 CVP 20, vent settings
FiO2 100, Peep 5, Tidal Volume 550.
.
On the floor, patient was intubated, minimally sedated.
.
Review of sytems:
Per HPI, unable to fully obtain.
Cardiac surgery was consulted for AV vegetation and AI after
echo obtained.
Past Medical History:
- Hypertension.
- Anxiety.
- Chronic Back pain/ leg pain
- Questionable history of prior MI.
- IVDA- heroin- last injection [**11-15**]
(benzodiazepine and opiate +)
- Hepatitis C
Social History:
uses heroine, last used [**11-15**]. lives in [**Location 86**] with his
girlfriend. Smokes 2 ppd. Denies any alcohol. [**Country 3992**]
veteran.
Family History:
(per OMR) Father died at age 81 from an aneurysm in his leg.
Mother is living and had a lower extremity blood clot. Two
brothers and sisters with no history of CAD or diabetes.
Physical Exam:
Admission:
105 kg 73"
Vitals: AF BP: 135/37 P: 59 R: 29 O2: 100%
General: intubated, sedated
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: rhonchorous breath sounds throughout, decreased breath
sounds over right lung field
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: surgical scar in RUQ, soft, non-tender, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
GU: foley in place
Ext: raised, erythematous papular rash over back, bilateral
knees, elbows, shoulders, LE with chronic venous statis changes
and diffuse skin defects
Neuro: intubated, sedated, moving all extremities
Pertinent Results:
Conclusions
PREBYPASS: The left atrium is moderately dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is mildly dilated. Right ventricular chamber size and
free wall motion are normal. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque. There are large vegetations on the
aortic valve. There is no aortic valve stenosis. Severe (4+)
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve. Severe (4+) mitral regurgitation is seen due to
restricted mitral valve leaflets. No masses or vegetations are
seen on the tricuspid valve, but cannot be fully excluded due to
suboptimal image quality. Severe [4+] tricuspid regurgitation is
seen. There is no pericardial effusion. No clot in LAA. Slightly
dilated coronary sinus.
These finding were discussed with the surgical team.
POSTBYPASS: Normal LV function with LVEF > 55% and not segmental
wall motion abnormalities. Normally functioning aortic valve
prosthesis. Moderate to severe MR [**First Name (Titles) 151**] vena contracta > 7.0 mm
but PA pressures were much less ( mean PA pressrures [**12-2**]
systemic) and the TR was much less (mild to moderate). No
dissection seen after aortic cannula removed. These findings
were discussed with surgical team.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16164**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2143-11-20**] 15:59
[**2143-11-28**] 07:50AM BLOOD WBC-5.3 RBC-3.56* Hgb-8.6* Hct-28.1*
MCV-79* MCH-24.3* MCHC-30.7* RDW-21.8* Plt Ct-252
[**2143-11-15**] 11:30PM BLOOD WBC-16.8* RBC-3.55* Hgb-7.0* Hct-25.6*
MCV-72* MCH-19.7* MCHC-27.3* RDW-20.4* Plt Ct-284
[**2143-11-24**] 01:46AM BLOOD PT-13.3* PTT-31.1 INR(PT)-1.2*
[**2143-11-16**] 05:03AM BLOOD PT-18.9* PTT-27.9 INR(PT)-1.8*
[**2143-11-29**] 03:48AM BLOOD Glucose-100 UreaN-73* Creat-3.3* Na-133
K-4.3 Cl-99 HCO3-27 AnGap-11
[**2143-11-15**] 11:30PM BLOOD Glucose-133* UreaN-92* Creat-2.4* Na-140
K-5.5* Cl-111* HCO3-18* AnGap-17
[**2143-11-29**] 03:48AM BLOOD ALT-14 AST-22 LD(LDH)-421* AlkPhos-52
TotBili-0.5
Brief Hospital Course:
Mr. [**Known lastname 16165**] is a 59 year old male with a past medical history of
chronic pain, hypertension, HLD, IV drug abuse who initially
presented with bacteremia, endocarditis, and renal failure. His
blood cultures grew pansensitive enterococcus in the blood from
an outside hospital, which were the likely cause for septic
emboli and vegetations. An MRI of his head showed multiple
emboli. He was intially given vancomycin and zosyn but then was
switched to ampicillin and gentamicin. Patient with large
pneumonia seen on CXR. CT showed 5-cm right upper lobe
consolidation consistent with pneumonia secondary to septic
embolus. He required mechanical ventilation with pressure
support on the ARDSnet protocol. His renal status worsened and
he was started on CVVH. He developed a rash which was biopsied
and was thought to likely be septic vasculitis.
He was referred to cardiac surgery after a cardiac
catheterization and underwent an aortic valve replacement with
an [**Doctor Last Name **] 27-mm pericardial tissue valve ,Debridement of left
aortic annular abscess with Dr. [**Last Name (STitle) **] on [**11-20**].CROSS-CLAMP
TIME:70minutes.PUMP TIME:88 minutes. Aortic Valve OR culture=
(+)Enterococcus. He was transferred to the CVICU in fair
condition on titrated milrinone, levophed, vasopressin and
propofol drips. He underwent CVVHD to help remove fluid. By
post-operative day three enough fluid was removed that he was
able to be extubated. His chest tubes and epicardial wires were
removed per protocol. A PICC was placed and he was transferred
to the surgical step down floor. The infectious disease service
recommended that he complete 6 weeks of ampicillin and
ceftriaxone from the day of surgery-last day [**2144-1-1**]. The
remainder of his postoperative course was essentially
uneventful. He continued to progress and was cleared by Dr.[**Last Name (STitle) **]
for discharge to [**Hospital **] Rehabilitation on POD#9.All follow up
appointments were advised.
Medications on Admission:
oxycontin 60 mg po BID
Dilaudid 8 mg po 6 times a day
Xanax
Clonidine
Folic Acid
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed
Release (E.C.)(s)
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
5. methadone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. ampicillin sodium 2 gram Recon Soln Sig: One (1) Recon Soln
Injection Q8H (every 8 hours): last dose on [**2144-1-1**] .
11. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours): last dose on [**1-1**], [**2143**].
12. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 4339**]
Discharge Diagnosis:
aortic insufficiency s/p AVR
enterococcal endocarditis
acute renal failure
Hepatitis C
hypertension
acute diastolic heart failure
NSTEMI
anxiety
chronic back pain/leg pain,
? h/o prior MI
IVDA (heroin - last injection [**11-15**])
pneumonia
septic brain emboli
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema .............
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **], Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2144-1-2**] at 1:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2143-12-10**]
10:00
Infectious disease: [**Name6 (MD) 14621**] [**Last Name (NamePattern4) 14622**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2143-12-30**] at 10:00
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 5404**] in [**3-5**] 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**
Laboratory monitoring required: CBC c diff, chem-7, LFTs
Frequency: Weekly
Infectious Disease attending visit: [**2143-12-10**]
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
All questions regarding outpatient antibiotics should be
directed
to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**]
Completed by:[**2143-11-29**]
|
[
"729.5",
"070.54",
"785.51",
"449",
"272.4",
"338.29",
"280.9",
"584.5",
"305.1",
"511.9",
"397.0",
"401.9",
"486",
"447.6",
"414.01",
"785.52",
"396.3",
"428.31",
"276.1",
"038.0",
"410.71",
"724.5",
"518.81",
"300.00",
"421.0",
"275.41",
"304.00",
"415.19",
"412",
"041.04",
"434.11",
"428.0",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"86.11",
"88.56",
"39.95",
"96.72",
"37.22",
"38.95",
"34.91",
"88.72",
"35.21",
"96.6",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9344, 9391
|
5886, 7882
|
334, 392
|
9695, 9880
|
3647, 5863
|
10804, 11927
|
2732, 2913
|
8014, 9321
|
9412, 9674
|
7908, 7991
|
9904, 10781
|
2928, 3628
|
273, 296
|
2236, 2346
|
420, 2218
|
2368, 2549
|
2565, 2716
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,347
| 150,914
|
16719+16761
|
Discharge summary
|
report+report
|
Admission Date: [**2161-12-15**] Discharge Date: [**2135-2-21**]
Date of Birth: [**2085-11-29**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 47303**] is a 76-year-old
female with a past medical history significant for
hypertension, DM and diverticulitis who presented to an
outside hospital with exertional dyspnea, chest pain with
progressive worsening in the setting of a two day history of
fatigue and and GI bleed. Hematocrit was 20.2 with guaiac
positive stools. Found to have a non-Q wave MI with a
troponin of 9.2, CK of 152. Several episodes of substernal
pain and EKG changes. Was transfused and continued to have a
GI bleed.
On [**12-10**] underwent a positive packed red blood cell scan with
evidence of mid transverse colon bleeding. Mesenteric angio
revealed no definitely bleeding, however empiric IV
vasostriction [**Doctor Last Name 360**] was infused in the middle colon.
On day of transfer she developed substernal chest pain with
EKG changes revealing a 1 to 2 mm ST segment changes. She
was started on aspirin, IV Lopressor and Nitro with
resolution of chest pain. She was asked to be transferred
and was transferred to the [**Hospital1 188**] on [**2161-12-15**] for cardiac catheterization revealing
severe three vessel disease not amendable to interventional
cardiology with normal left ventricular systolic function.
She had LAD 80% mid and 80% OM2, left circumflex 60% and 80%
OM2. RCA was 95% occluded.
The patient was taken to the Operating Room on [**2161-12-17**] for
a coronary artery bypass graft times three with LIMA to lad,
SVG to OM, SVG to PDA with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. On
postoperative day #1, she was in the Intensive Care Unit and
was volume requiring, however she was slightly confused and
moving all four extremities. She was doing well. She remained
in the Intensive Care Unit and
postoperative day #2, she was transfused one additional unit
for a hematocrit 25 which raised her appropriately to 28.9.
Beta blocker was begun and diuresis was begun.
Lopressor was increased to 25 b.i.d. and
she was transferred to the floor on 12/[**2160**].
On postoperative day #3, she did well on the floor. Chest
tube and wires were discontinued. Rehab screens and PT was
consulted. It was felt the patient should go to rehab and on
[**12-22**] the patient was discharged home. Of note, it was
noticed that her hematocrit was steadily decreasing and at
this point is 26.3, however it is not hemodynamically
significant and she maintains a good blood pressure. She
does not have frankly melanotic stools.
The rest of the CT Surgery Team was made aware of this
particularly Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] and patient after this
consultation was felt clear for discharge.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. b.i.d. times 10 days.
2. KCL 20 mEq p.o. b.i.d. times seven days.
3. Aspirin 325 mg once a day.
4. Ibuprofen 600 mg p.o. q. eight hours p.r.n.
5. Percocet 5/325 mg tablets one to two q. four hours p.r.n.
Pain.
6. Colace 100 mg p.o. b.i.d.
7. Glyburide 5 mg p.o. b.i.d.
8. Protonix 40 mg p.o. b.i.d.
9. Iron Sulfate 325 mg p.o. b.i.d.
10. Lopressor 37.5 mg p.o. b.i.d. held for heart rate less
than 65 or systolic blood pressure less than 110.
11. Regular insulin sliding scale 150 to 200 given two units,
201 to 250 give four units, 251 to 300 to give six units.
Page 1 was done and patient was felt stable for discharge to
follow up with Dr. [**Last Name (STitle) **] and follow up with her PCP.
DR [**First Name4 (NamePattern1) 1112**] [**Last Name (NamePattern1) **] 02.229
Dictated By:[**Name8 (MD) 16758**]
MEDQUIST36
D: [**2161-12-22**] 11:00
T: [**2161-12-22**] 12:05
JOB#: [**Job Number 36800**]
Admission Date: [**2161-12-15**] Discharge Date:[**2161-12-22**]
Date of Birth: [**2085-11-29**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient was admitted to [**Hospital1 1444**] on [**2161-12-15**] for
cardiac catheterization and subsequent coronary artery bypass
graft.
She presented from an outside hospital where she presented
with exertional dyspnea and chest pain in the setting of
progressive lower gastrointestinal bleed. Her hematocrit had
been 20, and she was transferred here after transfusion at
the outside hospital.
Here, her catheterization revealed severe 3-vessel disease.
Left anterior descending artery with 80%, second obtuse
marginal with significant stenosis, right coronary artery
with 95% at the middle. Ejection fraction was normal.
PAST MEDICAL HISTORY:
1. Diabetes.
2. Hypertension.
3. Diverticulitis.
4. Cholecystectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
SOCIAL HISTORY: No smoking or ethanol abuse.
HOSPITAL COURSE: She was taken to the operating room on
[**2161-12-17**] for a coronary artery bypass graft times
three and then transferred to the Cardiothoracic Intensive
Care Unit postoperatively where she had an ongoing
crystalloid requirement, and her cardiac drips were weaned.
On postoperative day one, she did well. Her chest tubes were
taken out. She was diuresed and a beta blocker was begun.
On postoperative day two, we increased Lopressor to 25 mg and
continued Lasix. .................... was discontinued and
one unit of blood was given for a hematocrit of 25. She was
transferred from the Intensive Care Unit to the floor.
On postoperative day three, on [**12-20**], Foley and wires
were taken out. Physical [**Hospital **] rehabilitation screening
was begun.
On [**12-21**], on postoperative day four, she was afebrile
with some loose stool. A Clostridium difficile was sent
which was negative. Her stools were not bloody.
On [**2161-12-22**], she was afebrile. Her hematocrit was
26.3. Her blood urea nitrogen and creatinine were 20 and
0.6. All of her incisions were clean and dry. Her lungs
were clear. Her belly was soft, and she had no lines or
drains. She was sent to rehabilitation. She was seen and
examined by the cardiothoracic surgery team. Her
laboratories were discussed with other members of the
cardiothoracic surgery team.
DISCHARGE DISPOSITION: The patient was discharged.
MEDICATIONS ON DISCHARGE: (Her discharge medications were)
1. Lasix 20 mg p.o. b.i.d. (times 10 days).
2. Potassium chloride 20 mEq p.o. b.i.d. (times 10 days).
3. Aspirin 325 mg p.o. q.d.
4. Percocet as needed for pain.
5. Colace 100 mg p.o. b.i.d.
6. Glyburide 5 mg p.o. b.i.d.
7. Ibuprofen 600 mg p.o. t.i.d.
8. Iron sulfate 325 mg p.o. t.i.d.
9. Lopressor 37.5 mg p.o. b.i.d. (hold for a heart rate of
less than 65 or a blood pressure of less than 110).
10. A regular insulin sliding-scale; from 150 to 200 give 2
units; from 201 to 250 give 4 units, from 251 to 300 give 6
units, for over 300 call the house officer.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**MD Number(1) 5226**]
Dictated By:[**Name8 (MD) 16758**]
MEDQUIST36
D: [**2161-12-22**] 15:46
T: [**2161-12-22**] 15:55
JOB#: [**Job Number 47361**]
|
[
"414.01",
"410.71",
"562.10",
"401.9",
"272.0",
"250.00",
"429.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"37.22",
"36.12",
"88.56",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
6224, 6253
|
2861, 3952
|
6280, 7166
|
4775, 4775
|
4841, 6200
|
3981, 4614
|
4636, 4748
|
4792, 4822
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,207
| 155,740
|
3224
|
Discharge summary
|
report
|
Admission Date: [**2190-5-15**] Discharge Date: [**2190-6-3**]
Date of Birth: [**2149-8-5**] Sex: F
Service: MEDICINE
Allergies:
Benzocaine
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Right pleural effusion
Major Surgical or Invasive Procedure:
PICC line placement
Pleurocentesis
Aborted bronchoscopy
History of Present Illness:
Mrs. [**Known lastname **] is a 40 year old previously healthy woman with a
history of depression and anxiety presenting with right pleural
effusion after laproscopic cholecystectomy performed at an
outside hospital. 16 days prior to admission to the medicine
team patient was admitted to [**Hospital3 **] with RUQ
abdominal pain. She was given the diagnosis of cholescystitis
and had laproscopic cholesectomy. Post-op it was noted that she
had developed a "low output bile leak picked up by JP tube". 12
days prior to admission, she then had ERCP with sphincterotomy.
It was then reported that the JP output decreased and was then
removed. 11 days prior to presentation Mrs. [**Last Name (STitle) **] still complained
of RUQ, had a fever of 103.2 and became hypoxic A chest CT was
preformed that showed bilateral pleural effusions and bilateral
PNA with no intra-abdominal abnormalities. VQ scan for plumary
embolis was negative. 10 days prior to admission patient was
started on Zosyn for PNA. 6 days prior she had a repeat chest
CT that showed larger right pleural effusion with partial
collapse of RLL and smaller left pleural effusion. Pt reports
that she was disatisified with the level of care and service
that she was recieving from [**Hospital3 **], so 4 days prior
to medicine admission, she was transfered to [**Hospital1 **] surgery team
where her temperature ranged from 97.8-102.8 and her right
pleural effusion became worse.
At the time of interview patient complained of constant, diffuse
abdominal pain, [**11-22**], that radiated to her lower back. She
also stated that she had SOB with exerction accompanied with
sharp pain in her sternum and right upper portion of her chest.
When questioned she denied having the pain when she inhaled.
Patient was at times an unreliable source due to her tendancy to
perseverate on old injuries, bizarre affect and she was
intermittently uncooperative with interviers (see MSE).
Past Medical History:
[**5-/2184**]-accident involving escalator requiring 5 orthopedic
surgeries that left her disabled only able to get around with a
walker/cruches/wheelchair; otherwise previously healthy denies
HTN, DM and cancers.
Social History:
Lives by herself in [**Location (un) **], MA in a "handicap" apartment; went
to [**State 15093**] where she recieved her bachelors,
worked as a financial consultant and teacher before accident;
widowed x 8 years was married for 3 years with no children.
ETOH-occasional
Tobacco-denies past or present use
Sexual history-denies history of STDs, denies sexual activity,
can't remember last pap smear, LNMP [**2190-5-2**]
Family History:
Parents died 20 years ago in accident, patient became tearful
and did not want to discuss their health or that of any other
family members.
Physical Exam:
VS: t 98.6 (98-98.6) BP 142/90 (140-142/70-90) P 82 (82-104)
RR 22 (22-26) O2sat 97% on non-rebreather (95-97% on NRB)
General: Obsese, disheveled woman lying in bed, in mild
respiratory distress
Skin: Bluish-[**Doctor Last Name 352**] macules on abdomen, otherwise unremarkable
HEENT: normal cephalic, atraumatic
Neck: not assesed
CV: Regular rhythm, nl s1 and s2 with no extra heart sounds or
murmurs, dorsalis pedial pulses palpated bilaterally
Resp: No breath sounds heard throughout right lung field, mild
wheezing heard over left lung field, no crackles appreciated
Abd: Obese, scars from laproscopic cholesectomy healed well;
hypoactive bowel sounds, no masses felt, non-tender on
palpation, non-distened
Ext: No muscle atrophy, swelling, patient walks with cane.
Strength and reflexes not assesed
Neuro: CN II-XII grossly intact
MSE: Patient was disheveled in apperance and seemed agitated
she would frequently comb and pull at her hair. Her behavior
was inconsistent towards interviewers at some points she be
cooperative and at other times she would become hostile.
Patient's speech was sometimes labored and slurred, but not
pressured. Her stated mood was not assesed, her affect was
bizarre and labile, she would start crying when talking about
her parents or her current medical condition and then the next
minute start laughing at a joke she made. She preseverates on
her accident that occured in [**2184**] and was tangential, it was
sometimes impossible to get her to directly answer a question.
Patient denies active SI/HI, however she frequently states that
she wishes that she could go home lie down and die, but states
that she does not want to try to kill herself because of her
catholic faith. Memory and concentration was not assesed.
Patient's insight is poor she believes that her accident in [**2184**]
is somehow the cause for her current medical condition.
Pertinent Results:
[**2190-5-16**] Admission Labs:
WBC-15.2*# RBC-3.88* Hgb-9.9* Hct-31.3* MCV-81* MCH-25.6*
MCHC-31.8 RDW-14.7 Plt Ct-369#
Glucose-117* UreaN-9 Creat-0.8 Na-142 K-2.8* Cl-99 HCO3-35*
AnGap-11
ALT-27 AST-33 AlkPhos-224* Amylase-24 TotBili-0.3 Lipase-34
Calcium-9.0 Phos-3.5 Mg-2.2
TotProt-7.4 Albumin-3.8 Globuln-3.6 Calcium-8.8 Phos-3.7 Mg-2.2
.
Cardiac enzymes:
[**2190-5-19**] 09:11PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2190-5-20**] 12:33AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2190-5-21**] 10:48AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2190-5-19**] 09:11PM BLOOD CK(CPK)-42
[**2190-5-20**] 12:33AM BLOOD ALT-26 AST-30 CK(CPK)-33 AlkPhos-193*
Amylase-28 TotBili-0.4
[**2190-5-21**] 10:48AM BLOOD CK(CPK)-45
.
Other:
GGT-181*
VitB12-433 Folate-10.0 calTIBC-205* Ferritn-655* TRF-158*
TSH-3.2 Free T4-1.1
.
[**2190-6-1**] Discharge Labs:
WBC-9.1 RBC-3.54* Hgb-8.8* Hct-27.3* MCV-77* MCH-24.8* MCHC-32.3
RDW-15.4 Plt Ct-305
Glucose-107* UreaN-8 Creat-1.3* Na-142 K-3.8 Cl-108 HCO3-24
AnGap-14
ALT-19 AST-22 AlkPhos-119* TotBili-0.2
Calcium-8.9 Phos-2.1* Mg-1.8
.
Micro:
No growth of pathogens noted in blood, urine, sputum, and
pleural fluid cultures. Stool was negative for C. difficile
toxin. Pleural fluid negative for malignant cells.
.
CT CHEST W/O CONTRAST [**2190-5-30**]
Moderate loculated right-sided effusion again noted with
interval decrease in component tracking along the major
fissure.There are multiple linear and patchy areas of
atelectasis as described above. A superimposed infectious
process cannot be entirely excluded.
.
CT CHEST W/O CONTRAST [**2190-5-24**]
1) Decrease of previously identified right-sided effusion with
continued markedly loculated moderate-sized right-sided
effusion. There has been reexpansion of the right lower lobe
with continued multifocal areas of atelectasis. While the
etiology of this loculated effusion is presumably due to
pneumonia, the radiologic differential diagnosis also includes
sequela of collagen vascular disease, malignancy, or TB if an
infectious etiology is not clearly established.
2) Left thyroid nodule as discussed previously.
.
CHEST (PA & LAT) [**2190-5-27**]
1. Continued right intrafissural loculated pleural effusion,
smaller, with right middle and lower lobe atelectasis.
2. Left lower lobe atelectasis and probable small loculated
pleural effusion.
3. Continued small right lateral apical loculated pleural
effusion.
.
CT ABDOMEN W/CONTRAST [**2190-5-20**]
1) No ascites or intra-abdominal fluid collection.
2) Interval marked decrease in right pleural effusion. Residual
bibasilar atelectasis.
Brief Hospital Course:
40 year old woman status post laparascopic cholecystectomy at
OSH complicated by bile leakage into peritoneum, status post
ERCP with sphincterotomy also at OSH, course complicated by
right lower lobe pneumonia and right pleural effusion.
.
RLL pneumonia/pleural effusion: Patient was transferred from the
surgical service to the medical service on [**2190-5-19**] with RLL
pneumonia, R pleural effusion x 5d, and fever spiking through
Zosyn. She was seen by intervental pulmonology on day of
transfer and they drained over 1400cc of bloody sterile
exudative pleural fluid. CXR post thoracentesis showed
persistent lower lung zone consolidation, decreased appearance
of right pleural effusion and persistent LLL atelectasis. She
was kept on Zosyn for a total of 18d including OSH, started on
Vanc by the Medicine team and kept on that for 5d total. She
stopped having fevers and antibiotics were then held as the
effusion was sterile and it was thought that her pneumonia was
likely fully treated. She remained afebrile x 5d, then started
spiking again. Since her R effusion was still present, she went
for a repeat CT scan that revealed, "decrease of previously
identified right-sided effusion with continued markedly
loculated moderate-sized right-sided effusion." Thoracic Surgery
felt that her effusion could be followed on an outpatient basis
and that her primary problem was her pneumonia, which was still
quite impressive. She went for repeat tap by IP, but they could
not see an area to tap on ultrasound, and decided to bronch her
instead with BAL. Upon receiving Hurricane spray, the patient
developed methemoglobinemia and required transfer to the MICU.
She received 200 mg of methylene blue with resulting improvement
in O2 sat and was able to be stably transferred back to the
general medicine service. Patient had no obvious source of
infection and did not have further fever during the hospital
course. Microbiology studies of sputum, blood, urine, pleural
fluid, and stool were unremarkable. While pneumonia was
suspected, it was also possible symptoms were related to marked
atelectasis for which the patient refused to use the incentive
spirometer and was mostly sedentary lying in bed. At time of
discharge, the patient's breathing had been stable on room air
with good oxygen saturation for several days. Per the thoracic
surgery service review, it was decided that outpatient follow up
was appropriate and the patient was discharged to home in her
usual state of health. She had been tolerating an oral diet and
mobile via wheelchair. Followup with thoracic surgery,
gastroenterology, and a PCP was recommended.
.
Abdominal pain: Initially, the pain was felt to be secondary to
bile leak and post-op inflammation, though the patient also has
an element of chronic abdominal pain that we do not know the
reason for. The epigastric pain was controlled with MS [**First Name (Titles) **] [**Last Name (Titles) 15094**]d down to 15mg [**Hospital1 **] with breakthrough PO morphine that was
successfully tapered, and was thought to be close to baseline
prior to discharge. She was started on reglan for chronic mild
nausea and did not have laboratory evidence of an active
hepatobiliary process.
.
Acute renal failure: From her baseline Cr 0.8 on [**2190-5-21**],
creatinine increased to 1.4 less than a week later in setting of
antibiotic therapy and dehydration; considered most likely
prerenal with FENa < 0.1%, Na<10. Creatinine returned to
baseline after rehydration with IVF.
.
Hypokalemia: Patient presented with low potassioum likely from
diarrhea and lasix used post-op. Potassium was repleted per IV.
.
Anemia, microcytic: Likely anemia of chronic disease; Fe 19,
TIBC 205, ferritin 655; and there was no folate or B12
deficiency. Oral iron supplementation was held. HCT fluctuated
daily and improved spontaneously; there were no signs of active
bleeding; and stools were guaiac negative. Patient refused blood
products for symptomatic relief.
.
Depression/Anxiety: Patient was continued on Seroquel, Klonopin
(cut dose in half), and Zoloft; SW as actively involved. At one
point during this admit, patient fired her entire medical team
and had to be switched to a new service. Frequently, patient was
difficult with the housestaff and refused multiple attempts for
visits by the psychiatry consultation service. Patient was
generally noncompliant at times with medical care and was noted
to have concerning behaviors such as defecating/urinating
in her room/shower. Patient's outpatient psychiatrist, Dr.
[**Last Name (STitle) 15095**], was contact[**Name (NI) **] for patient's outpatient medical regimen
and patient will follow up with him.
.
Thyroid nodule, left: Outpatient workup was recommended with
appointment for the thyroid nodule clinic.
.
Prophylactic measures included administration of a PPI, SC
heparin, bowel regimen, and anti-fungal cream to peritoneum.
.
Patient was full code.
Medications on Admission:
Zoloft 200mg
Klonopin 2mg
Seroquel 25mg [**Hospital1 **]
Discharge Medications:
1. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*1 1* Refills:*2*
2. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*1 1* Refills:*2*
3. Sertraline HCl 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Albuterol 90 mcg/Actuation Aerosol Sig: [**2-14**] Inhalation every
4-6 hours as needed for shortness of breath or wheezing.
Disp:*1 2* Refills:*0*
5. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: Two
(2) Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*1 1* Refills:*2*
6. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 1* Refills:*2*
7. Quetiapine Fumarate 25 mg Tablet Sig: Two (2) Tablet PO QHS
(once a day (at bedtime)).
Disp:*60 Tablet(s)* Refills:*2*
8. 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*
9. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
10. Morphine Sulfate 15 mg Tablet Sig: One (1) Tablet PO every
six (6) hours as needed for fever or pain for 7 days.
Disp:*30 Tablet(s)* Refills:*0*
11. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO QID
(4 times a day) as needed for nausea: take as needed before
meals.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
hypokalemia
pneumonia, hospital acquired
methemoglobinemia
chronic anemia
acute renal failure
thyroid nodule
dyspepsia
other:
s/p cholecystectomy and ERCP, s/p mutiple orthopedic surgeries
now on disability (ambulate with walker), morbid obesity,
depression
Discharge Condition:
good, in usual state of health, hemodynamically stable breathing
comfortably on room air, tolerating an oral diet, ambulating
with walker. Home services have been refused by the patient.
Discharge Instructions:
Please take your medications as prescribed. Please call your
doctor or go to the ED if you have worsening abdominal pain,
nausea, vomiting, shortness of breath, fevers, chills, or other
concerning symptoms.
Followup Instructions:
-Please follow up in the thoracic surgery clinic in [**4-16**] weeks to
evaluate your chronic lung fluid collection. Call Dr.[**Name (NI) 1816**]
office at ([**Telephone/Fax (1) 1504**] to make an appointment.
-Please follow up in the [**Hospital1 18**] gastroenterology clinic with Dr.
[**Last Name (STitle) 1940**]. Call the clinic at ([**Telephone/Fax (1) 2306**] within the next few
weeks to make an appoinmtment at your convenience.
-Please follow up with your primary care physician affiliated
with [**Hospital6 13753**] in [**2-14**] weeks. Call to make an
appoinment.
|
[
"285.9",
"584.9",
"518.0",
"707.9",
"511.9",
"789.00",
"311",
"278.01",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
14228, 14234
|
7704, 12628
|
292, 350
|
14536, 14724
|
5106, 5122
|
14980, 15561
|
3013, 3154
|
12735, 14205
|
14255, 14515
|
12654, 12712
|
14748, 14957
|
5943, 7681
|
3169, 5087
|
5467, 5927
|
230, 254
|
378, 2324
|
5138, 5450
|
2346, 2561
|
2577, 2997
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,390
| 158,369
|
30507
|
Discharge summary
|
report
|
Admission Date: [**2104-4-27**] Discharge Date: [**2104-4-30**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] year old man with history of seizures, prior CVA, bilateral
carotid endarterectomies, hypertension, prostate cancer, CAD s/p
NTEMI, presenting after syncopal episode at home.
Patient was having dinner with his family when he was noted to
slump down on his arm chair and becoming unresponsive. Drooling
was noted from the left side of his mouth. Patients grandson is
a police officer and reports not being able to find a pulse or
to arouse him. Patient did not receive CPR, EMS was called and
he was taken to nearby hospital.
At [**Hospital6 **], VS 211/120, HR 90, RR 26. Pt
given IV labetalol 10mg x 2 with BP 185/92 at time of transfer.
Non contrast head CT with preliminary read of no acute
intracraneal hemorrhage.
Pacer pads, brady to 15s hypertensive 200's/.100's. NSGY BP
goals less than 140, on nicardipine drip, lateral ST changes.
Needs repeat head CT in AM.
Per neurosurgery, no immediate intervention needed. Patient will
need repeat head CT in the morning. Although he received aspirin
325mg in ED, does not need platelets at this time. Asked to hold
any further aspirin and plavix.
Past Medical History:
[**2096**]- CVA with residual speech impairments
Seizure disorder, on tegretol
Bilateral Carotid Endarterectomy
Prostate Cancer treated with Casodex
Hypertension
Inguinal Hernia
Aortic Sclerosis
Arthritis
[**2100**]- Upper GI bleed
Psoriasis on elbows
Depression
BPH
Social History:
Lives with his daughter, retired, no services at home.
Independent with use of a cane, wife is in nursing home. Attends
daily meetings and is able to perform ADL's. No current alcohol
or drug use.
Family History:
Noncontributory
Physical Exam:
GENERAL: Pleasant, well appearing elderly man in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. (+) Tongue ecchymoses. Neck
Supple, No LAD, No thyromegaly. Bilateral scars over carotid
artery, no bruits.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. II/VI
Systolic crescendo murmur. No rubs or gallops.
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. Large inguinal hernia, partially
reducible, non tender or discolored. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: Bruise on posterior scalp, shoulder and arm.
NEURO: A&Ox3. Speech slurred, word finding difficulties (per
family at baseline) Appropriate. CN 2-12 grossly intact although
with poor effort on exam. Preserved sensation throughout. [**6-10**]
strength throughout. [**2-8**]+ reflexes, equal BL. Normal
coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2104-4-28**] 04:32AM BLOOD WBC-12.4* RBC-3.92* Hgb-12.4* Hct-35.9*
MCV-92 MCH-31.6 MCHC-34.5 RDW-12.5 Plt Ct-260
[**2104-4-26**] 07:35PM BLOOD Neuts-86.0* Lymphs-9.7* Monos-3.4 Eos-0.8
Baso-0.1
[**2104-4-28**] 04:32AM BLOOD PT-13.1 PTT-24.4 INR(PT)-1.1
[**2104-4-28**] 04:32AM BLOOD Glucose-150* UreaN-24* Creat-1.1 Na-136
K-4.1 Cl-101 HCO3-25 AnGap-14
[**2104-4-28**] 04:32AM BLOOD ALT-19 AST-45* CK(CPK)-1031*
[**2104-4-26**] 07:35PM BLOOD ALT-17 AST-22 LD(LDH)-232 CK(CPK)-154
AlkPhos-64 TotBili-0.2
[**2104-4-26**] 07:35PM BLOOD Lipase-27
[**2104-4-27**] 07:50PM BLOOD CK-MB-16* MB Indx-1.8 cTropnT-0.01
[**2104-4-28**] 04:32AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.1
[**2104-4-27**] 07:50PM BLOOD TSH-1.3
[**2104-4-26**] 07:35PM BLOOD Digoxin-0.9
[**2104-4-26**] 07:35PM BLOOD Valproa-<3.0*
[**2104-4-28**] 04:32AM BLOOD Carbamz-6.9
[**2104-4-28**] 04:56AM BLOOD Lactate-1.7
[**2104-4-27**] 04:06AM BLOOD Lactate-3.1*
[**2104-4-26**] 09:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2104-4-26**] 09:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
Blood cultures neg
CT head [**4-26**]:
1. Small foci of subarachnoid hemorrhage along the right falx
without
significant edema or mass effect.
2. Old left parietooccipital infarct with resultant
encephalomalacia.
CTA head [**4-26**]:
1. Stable appearance of small subarachnoid hemorrhage at the
right frontal
vertex.
2. No evidence of an aneurysm or arteriovenous malformation.
Please note
that conventional angiography would be more sensitive for small
arteriovenous malformation, particularly of the dural type.
CXR [**4-26**]: The heart is enlarged. Mediastinum is somewhat
prominent. There is central pulmonary vascular prominence
consistent with mild congestive failure.
Brief Hospital Course:
Mr. [**Known lastname 4643**] is a [**Age over 90 **]-year-old man with history of CVA,
hypertension, seizure disorder, CAS in left diagonal (occluded
RCA with non-jeopordized L to R collaterals), presenting with
breakthrough seizure, found to have small SAH, requiring short
ICU stay.
#. SYNCOPE: Most likely unifying explanation appeared to be
spontaneous SAH in the setting of hypertension leading to
seizure activity (as pt has evidence of tongue biting).
However, given sinus arrest while on tele, also concerning for a
bradycardic event. Each of these problems was worked up as
below. Final hypothesis was that syncope was caused by SAH vs
overmedication with beta blocker.
#. MALIGNANT HYPERTENSION: As above, likely cause of SAH. BP on
arrival was 190 systolic. Head imaging revealed new small
sub-arachnoid. In order to prevent re-bleed, patient was closely
monitored. Pt's BP was found to be in the 200s, prompting
nicardipine gtt. In the ICU, blood pressures continued to be
very labile (80s-180s), requiring boluses. Bp dropped to 78-85
sys 3 hr after nicardipine at one point. Urine output dropped
from 60-80 cc/hr to 15-25 cc /hr with this bp drop. Nicardipine
was changed to PO when on floor. Norvasc 5mg QD was started on
floor, but then dstopped when patinet became hypotensive to the
80's the evening the medication was started. Patient was
discharged on Metoprolol 25 [**Hospital1 **], Lisinopril 10mg QD.
#. BRADYCARDIA: In seeting of acute ICH and administration of
labetalol and metoprolol 25mg on patient therapeutic on digoxin.
Tracings from that time revealed up to 6 second pauses with
sinus arrest (no p waves). Cardiology agreed that pause was
likely due to multiple nodal agents and that no pacer was
indicated unless had more pauses. Atropine at the bedside and
pacing pads were on, but not needed. Pt has had HR in 70s for
duration of stay. Digoxin was stopped. Metoprolol 12.5 was
restarted after bradychardia resolved and no further pauses were
observed. Norvasc started but then stopped as explained above.
Patient was discharged on Metoprolol 25 [**Hospital1 **], Lisinopril 10mg QD.
#. SAH/SZ: Relatively small amount of blood at the right
frontocortex. Extensive parieto-occipital encephalomlalcia. Did
not need platelet transfusion. Repeat head CT with unchanged
small subarachnoid bleed, stable. Holding aspirin and plavix (ok
with cardiology). MRI was recommended, but pt noted to have
shrapnel in shoulder and MRI was canceled. Tegretol per
neurosurgery, who did not believe surgical intervention was
indicated. Aspirin was re-started on discharge; Plavix was held.
#CAD: Plavix and ASA were d/c'd on admission to ICU in the
context of the bleed. Statin was continued. Plavix was stopped
on discharge; ASA was continued on discharge.
#.ELEVATED CK: Multiple bruises on back and head suggest fall at
home. Pt has no renal failure currently. Receiving IVF. Will
continue to moniter CK q12.
#. ECG CHANGES: Patient had EKG with prolonged PR, but this is
his baseline. He was noted to have a single 6 second sinus
arrest in the ICU with sinus escape. Beta blockers were held. No
further arrests were observed. CE negative, no NSTEMI.
#. ERYTHEMATOUS HANDS: Pt was started on levofloxacin day of
admission, but this levofloxacin was d/c when these changes were
thought to be hyperpigmentaton changes, and no infection was
suspected.
.
# DISPO: Patient was cleared for discharge by PT. Close
follow-up with his cardiologist and PCP were arranged.
Medications on Admission:
tegretol 200mg [**Hospital1 **]
flomax .8mg
plavix,
sertraline 100
lopressor 25mg [**Hospital1 **]
simvastatin 80
finasteride
Digoxin 0.125
Bicalutamide 50mg
Aspirin 325mg
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*60 Capsule, Sust. Release 24 hr(s)* Refills:*0*
7. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Casodex 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day:
Please start this medicaiton one week from discharge.
Disp:*30 Tablet(s)* Refills:*0*
11. Please provide pt. with standard walker.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Association
Discharge Diagnosis:
PRIMARY:
1) Syncope
2) Hypertensive Emergency
3) Subarachnoid Hemorrhage
4) Seizure
Discharge Condition:
Good
Discharge Instructions:
You were admitted for syncope, hypertensive emergency,
subarachnoid hemorrhage and possible seizure. You underwent
brief observation in the ICU. You stabalized quickly and were
transferred to the floor where you did very well. You were
discharged in stable condition.
.
Please take all of the medications that we have prescribed as
written.
.
Please follow-up with your providors as recommended.
.
Please return to the hospital for chest pain, shortness of
breath, new syncope or loss of consciousness, apparent seizure,
changes in mental status, loss of motor function, changes in
vision, arm pain, jaw pain, or any other symptom that concerns
you.
.
It has been a pleasure serving you. We wish you the best.
Followup Instructions:
1) You should see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] within 10 days of discharge. We
phoned Dr.[**Name (NI) 29821**] office to try to set-up an appointment but
were not able to reach them before discharge. We left a message
asking them to please contact you to set up an appointment;
however, if you do not here back from them shortly, please
proactively call [**Telephone/Fax (1) 29822**] to set up a follow-up appointment.
Dr. [**Last Name (STitle) **] should check your creatinine at your visit, as well as
perform a diabetes work-up because your sugars were sometimes
high during this hospitalization. Dr. [**Last Name (STitle) **] can also counsel you
on neurology follow-up should he deem it necessary after your
bleed.
.
2) Dr.[**Name (NI) 5452**] office will be contactin you to set up an
appointment shortly.
.
3) Please follow-up with your primary neurologist at [**Hospital1 2025**] within
two weeks.
Completed by:[**2104-5-11**]
|
[
"412",
"311",
"414.01",
"430",
"272.4",
"401.9",
"438.11",
"780.39",
"426.6",
"V45.82",
"427.89",
"438.89"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9725, 9796
|
4840, 8336
|
270, 276
|
9924, 9931
|
3000, 4817
|
10689, 11667
|
1945, 1962
|
8559, 9702
|
9817, 9903
|
8362, 8536
|
9955, 10666
|
1977, 2981
|
223, 232
|
304, 1424
|
1446, 1715
|
1731, 1929
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,624
| 138,579
|
43870
|
Discharge summary
|
report
|
Admission Date: [**2117-1-21**] Discharge Date: [**2117-1-28**]
Date of Birth: [**2070-8-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Bright red blood in stools
Major Surgical or Invasive Procedure:
Upper endoscopy
Colonoscopy
Transfusion of platelets and fresh frozen plasma
History of Present Illness:
In brief, a 46-year-old man with etoh cirrhosis, varices s/p
banding in [**12-9**], HCV not on treatment, who initially presented
with a chief complaint of 3 days of BRBPR. Patient describes
finding blood in his underwear, not in the toilet bowl, only
when he wipes, and denies hematemesis or melena. No
fever/chills/nausea/vomiting
No CP or pressure. No shortness of breath or DOE. No abdominal
pain, but generally complains of malaise. No trauma or falls, no
LOC.
He is an active drinker and reports that he drinks up to a pint
of vodka per day. His ROS was + for feeling lightheaded and
dizzy. Patient ran out of his prescriptions 3 days prior to
admission.
.
In the ED, VS 97.3 95 147/90 20 96% RA. Two PIVs placed, 2L
NS given, Octreotide 50 mcg x 1 given, type and crossed, vit K
10 mg SC x 1, Cipro 400 IV x 1, Ativan 2 mg IV x 1. NGL showed a
small clot, not active bleeding in ED. Patient remained
hemodynamically stable and sent to the ICU for close monitoring.
He was started on the CIWA scale. Liver fellow was consulted
and an EGD was performed which showed no active variceal
bleeding, only portal gastropathy with friable mucosa. His HCT
remained stable overnight and he is called out today to be
monitored for etoh withdrawal and further monitoring of his GI
bleeding.
Past Medical History:
- Etoh cirrhosis, actively drinking, MELD 18
- HCV viral load is 436,000 international units. The patient
has not had a liver biopsy nor has the patient had any treatment
to date for his hepatitis C followed by Dr. [**Last Name (STitle) 497**] (last seen
[**12-9**]).
- EGD [**2115-12-23**] revealing varices at the lower third of the
esophagus, with two bands placed, and portal gastropathy.
- Grade 3 esophageal varices with multiple admissions for GIB,
banding in past
- Ethanol abuse with history of DTs.
- h/o Nephrolithiasis.
- MVA [**2113-5-4**] with two fractured lumbar vertebrae, torn
rotator cuff, and humeral head fracture.
- h/o coagulopathy, anemia (baseline Hct ~30), thrombocytopenia
- foot surgery
- facial reconstruction as a child
- leg cramps
- asthma
Social History:
The patient is single. Moved to cape and is living with friends.
Currently moving. He is actively drinking. Has long hx of etoh
abuse (since high school, with 1 6 month period of sobriety) and
withdrawl. He smokes 1 pack every 3 days, x 30+ years. He is not
working. He used to work as a carpenter. He denies IVDA x last
15 years, has used intranasal drugs within the past year or so,
+cocaine/heroin use in past; hx of incarceration in the past.
Family History:
He does not know much about his family history. He does not
know
of any liver disease or colon cancer.
Physical Exam:
VS: T: 96.9 BP:130/77 P: 77 RR: 12 O2 sat: 98% RA
GEN: NAD
HEENT: OP clear, dry, slightly icteric sclera, PERRLA, EOMI,
neck supple
Skin: slight jaundice, diffuse erythema on chest
CVS: nl S1 S1, RRR, no m/r/g
LUNGS: CTAB with scattered faint wheezes, no rales
ABD: soft, NT, distended, unable to palpate liver edge, +BS
EXT: warm, +3 edema to the knees, trace on thighs, diffuse
echymoses/petechia, +palmar erythema
NEURO: awake and oriented, drowsy, moves all four extremities
Pertinent Results:
Labs on admission:
wbc 5, Hgb 12.7, Hct 36.5, Plt 50,000
INR 1.9
creatinine 0.7
sodium 138
ALT 52, AST 207, total bili 5.5
amylase, lipase WNL
albumin 2.6
alcohol level 429
acetaminophen 7.1
.
Imaging:
CXR ([**1-21**]): No acute cardiopulmonary process.
.
Upper endoscopy ([**1-21**]): Varices at the lower third of the
esophagus
Granularity, friability, erythema, congestion and abnormal
vascularity in the whole stomach compatible with portal
gastropathy
Polyps in the second part of the duodenum
Otherwise normal EGD to second part of the duodenum
.
Colonoscopy ([**1-27**]): Grade 2 external hemorrhoids
Diverticulosis of the sigmoid colon
No rectal varices
Otherwise normal colonoscopy to cecum
.
Labs at discharge:
WBC 6.3, Hgb 9.7, Hct 29.8, Plt 90,000
INR 2.1
sodium 131
creatinine 0.8
ALT 26, AST 63, LDH 273, total bili 6.1
albumin 2.3
Brief Hospital Course:
Mr. [**Name13 (STitle) **] is a 46 year old male with acoholic cirrhosis,
hepatitis C, and known varices who presented with BRBRP and
spent one night in the ICU, moved to the floor after EGD which
showed portal gastropathy.
.
# GI bleed: The patient's initial presentation was concerning
given his history of varices. He was not found to have any
evidence of active variceal bleed. Following his endoscopy which
showed portal gastropathy, he continued to have bright red blood
in his stools. He was given FFP and platelets prior to
colonoscopy on the 24th. He did not require any transfusion of
packed red cells. His colonoscopy showed external hemorrhoids
and diverticulosis. His hematocrit remained stable, and he was
discharged without any symptoms of dizziness or lightheadedness.
- We continued his nadolol and proton pump inhibitor.
.
# Etoh Cirrhosis/HCV. The patient's alcohol level on admission
was > 400. His slight elevation in liver enzymes is likely
secondary to alcoholic hepatitis superimposed on chronic
cirrhosis/HCV. His LFTs and bilirubin were stable at discharge.
His INR remained elevated; he did receive FFP and platelets
prior to his colonoscopy.
- He received treatment with several days of pentoxyfylline but
this was discontinued prior to discharge.
- We continued his diuretic regimen with lasix and aldactone.
- We continued his lactulose.
- He will return on [**2117-2-12**] to see Dr. [**Last Name (STitle) 497**].
.
# Etoh abuse/withdrawl. The patient was placed on scheduled
valium when transferred to the floor. His need for prn valium
decreased, and this was discontinued. The scheduled valium was
weaned down during his stay. We maintained the patient on an
MVI, folate, and thiamine. He was interested in inpatient rehab
but did not have an acute inpatient need. He was discharged to
home with plan to follow up with Dr. [**Last Name (STitle) 497**].
.
# Hypokalemia: The patient's potassium was low following
admission; this was repleted as necessary.
.
# Pancytopenia. His white blood count normalized. His
thrombocytopenia is chronic; his platelets were 90,000 at time
of discharge. His anemia was stable following his endoscopy and
colonoscopy as above.
.
# FEN: Prior to discharge, the patient was tolerating a regular
diet. Nutrition evaluated the patient and recommended
nutritional supplements.
.
# PPx. He is to continue a PPI twice per day. He was ambulating.
He received lactulose for bowel regimen.
.
# Comm: [**Name (NI) 6961**] in [**First Name8 (NamePattern2) 745**] [**Last Name (NamePattern1) **] and [**Name (NI) **]
Tel: [**Telephone/Fax (1) 94194**]
.
# Code Status: full (confirmed with patient)
Medications on Admission:
- Albuterol Inh
- Neoril
- Doxepin 50 mg (TCA)
- folic acid 1 mg
- Nadolol 40 mg
- Fluticasone 50 mcg Aerosol, Spray [**1-5**] spray(s) to each nostril
daily
- Neurontin 300 mg t.i.d.
- Aldactone 50 mg
- Thiamine 100 mg
- Prilosec 20 mg b.i.d
- Lasix 20 mg daily
- Quinine 260 mg qHS
.
On transfer:
1. Nadolol 40 mg PO DAILY
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
3. Nicotine Patch 7 mg TD DAILY
4. Diazepam 5 mg PO Q2H:PRN CIWA >10
5. Pantoprazole 40 mg PO Q12H
6. Diazepam 10 mg IV ONCE Duration: 1 Doses
7. Phytonadione 5 mg PO DAILY Duration: 2 Days Order date: [**1-21**]
8. Diazepam 10 mg PO BID hold for sedation, RR <8
Hold for K > Order date: [**1-22**] @ 0201
9. Dolasetron Mesylate 12.5 mg IV Q8H:PRN nausea/vomiting
10. FoLIC Acid 1 mg PO DAILY
11. Furosemide 20 mg PO BID
12. Ipratropium Bromide Neb 1 NEB IH Q6H
13. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
14. Lactulose 30 ml PO TID titrate to [**3-7**] BMs daily
15. Spironolactone 50 mg PO DAILY
16. Thiamine HCl 100 mg PO DAILY
17. Multivitamins 1 CAP PO DAILY
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
8. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1) inhalation
Inhalation four times a day as needed for cough.
10. Doxepin 50 mg Capsule Sig: One (1) Capsule PO at bedtime.
11. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: [**1-5**] spray
to each nostril Nasal once a day.
12. Neurontin 300 mg Capsule Sig: One (1) Capsule PO three times
a day.
13. Lactulose 10 g/15 mL Syrup Sig: 15-30 MLs PO BID-TID:
Titrate amount to achieve at least [**3-7**] BMs daily.
Disp:*QS one month mL* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal bleeding likely secondary to grade two external
hemorrhoids
Diverticulosis of the sigmoid colon
Esophageal varices
Alcohol abuse
Alcoholic cirrhosis
.
Secondary:
Hepatitis C
History of nephrolithiasis
History of anemia and thrombocytopenia
Asthma
Discharge Condition:
Afebrile, normotensive, comfortable on room air
Discharge Instructions:
Please take your medications as prescribed. Please call your
doctor or return to the emergency room should you develop any of
the following: throwing up blood, nausea or vomiting with
inability to keep down liquids or medications, fever > 101,
chills, difficulty breathing, dizziness or passing out,
increased amount of bright blood in the stools, increased leg
swelling, abdominal pain, or any other concerns.
.
You have been evaluated for the blood seen in your stools. Your
endoscopy showed esophageal varices which did not appear to be
bleeding. You should continue to take omeprazole 20 mg twice
daily. Your colonoscopy showed hemorrhoids which are likely
causing the bright blood in your stools.
.
Please return on [**2-12**] to see Dr. [**Last Name (STitle) 497**].
Followup Instructions:
Please return to see Dr. [**Last Name (STitle) 497**] on [**2117-2-12**]. If there
are problems with this appointment, please call [**Telephone/Fax (1) 2422**].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2117-2-12**] 10:20
Completed by:[**2117-2-2**]
|
[
"211.2",
"284.8",
"070.70",
"286.7",
"455.5",
"571.1",
"562.10",
"456.21",
"276.8",
"291.81",
"571.2",
"305.1",
"303.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"96.34",
"99.07",
"45.13",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
9595, 9601
|
4513, 7168
|
340, 419
|
9909, 9959
|
3642, 3647
|
10780, 11125
|
3021, 3127
|
8258, 9572
|
9622, 9888
|
7194, 8235
|
9983, 10757
|
3142, 3623
|
274, 302
|
4363, 4490
|
447, 1744
|
3661, 4344
|
1766, 2540
|
2556, 3005
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,822
| 183,414
|
30017
|
Discharge summary
|
report
|
Admission Date: [**2138-2-27**] Discharge Date: [**2138-3-9**]
Date of Birth: [**2066-5-18**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Large L sided ICH
Major Surgical or Invasive Procedure:
intubated
hemodialysis
History of Present Illness:
Pt. is a 71 y/o with a hx of aneurysm and resultant L sided
stroke, stomach CA (active) and Colon CA (in remission) who is
transferred for further management of ICH. History is per pt's
family and OSH records, as pt. is intubated and sedated.
Pt. was in his USOH until [**2-24**]. That day he went to a coffee
shop and fell. His family was not present during the fall, and
is unsure if any seizure activity was noted. He was taken to
the ED where Head CT was performed and was negative, Neuro exam
was at baseline (R hemiparesis, but awake and alert). Dilantin
was checked and was subtherapeutic at 7.5. It was presumed that
the fall was [**2-14**] seizure and pt. was given a PO load and
discharged home in stable condition. His family reports that he
was fine between discharge and today.
Today he woke up in his USOH, but at around 10:30A his wife
heard him fall in the kitchen. She came in and found him on the
ground unconscious and called the paramedics. She reports that
he woke up in the ambulance and when he arrived in the ER was
back to normal. His initial neurologic exam is documented as
awake and alert, oriented to place and person, following
commands, with R hemiparesis. Dilantin was checked and was
10.7 (12:30) In the ED at around 2 PM he got up to go to the
bathroom and fell when he got out of bed, per family because his
legs were too weak to support him. On repeat exam he was more
drowsy, so Head CT was ordered, and showed a large L sided ICH
with interventricular extension and subfalcine shift.
Arrangements were made to transfer him to a tertiary care
facility. His mental status continued to deteriorate, and on
repeat exam his was arousable to sternal rub only. At around
17:00 he had a 10 minute GTC, which terminated with Ativan 2 mg
IV and Dilantin 400 mg IV. He was transferred here for further
care.
On arrival here he had a GCS of 7. Neurosurgery was consulted
emergently and Head CT was repeated (see read below) and showed
a 7 cm x 6.5 cm hemorrhage with extension to the lateral, 3rd,
and 4th ventricles. Neurosurgery felt that given the size of
the hemorrhage there was no utility in EVD placement. This was
discussed with family who agreed that they would not want EVD
placed at this time. Pt. was intubated and sedated with
Propofol and R femoral CVL was placed. Neurology was consulted
and patient admitted to neuro ICU.
Past Medical History:
- s/p aneurysm rupture 30 years ago with SAH and stroke, s/p
clipping, with residual R hemiparesis (arm > leg) and aphasia
- Seizure d/o since stroke
- Colon CA [**2121**], in remission
- Stomach CA, active
- ESRD on HD (TuThSat)
- DVT s/p IVC filter placement
- HTN
Social History:
Lives with wife, [**Name (NI) **] EtOH, no tobacco
Family History:
[**Doctor Last Name **] syndrome
Physical Exam:
(off propofol x 5 min)
BP- 115/69 HR- 86 RR- 15 O2Sat- 100% on CMV 500/15/5/100%
Gen: Lying in bed, intubated
HEENT: NC/AT, moist oral mucosa
Neck: supple
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: opens eyes briefly to sternal rub, regards
examiner, will inconsistently squeeze L hand on command but will
not open or close eyes on command
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. + Gag with manipulation of ETT. Will look left
and right when called. R facial droop with grimace.
Motor:
Normal bulk bilaterally. Decreased tone RUE and RLE, flaccid. No
observed myoclonus or tremor. Moves LUE and LLE briskly and
purposefully in response to pain, bends L knee to 90 degrees,
bend elbow to 45 degrees. Minimal flexion RLE to pain, extensor
posturing RUE to pain.
Sensation: Grimaces to pain all 4 extremities
Reflexes:
Slightly brisker in RUE and RLE (2+) than LUE and LLE (1+)
Toes upgoing on R, mute on L
Pertinent Results:
Color Yellow Appear Clr SpecGr 1.008 pH 9.0 Urobil Neg Bili
Neg
Leuk Neg Bld Neg Nitr Neg Prot 30 Glu Tr Ket Tr
RBC 0 WBC 0 Bact None Yeast None Epi 0
Trop-T: 0.12
137 97 28
------------< 147
7.8 30 5.5
(hemolyzed)
CK: 214 MB: 3
Ca: 8.9 Mg: 2.2 P: 5.4
WBC 10.4 Hgb 12.8 Plt 256 Hct 37.3 MCV 92
N:96.3 Band:0 L:3.0 M:0.6 E:0 Bas:0.1
Hypochr: NORMAL Anisocy: 1+ Macrocy: 1+
Comments: MANUAL
Plt-Est: Normal
PT: 12.0 PTT: 28.1 INR: 1.0
Head CT, prelim rads read:
A large intraparenchymal hemorrhage centered in the left frontal
lobe measuring 71 x 56 mm in greatest axial dimension, extending
to the temporal lobe and basal ganglia, superimposed on large
area of encephalomalacia in the left cerebral hemisphere.
Extension of blood is seen into the lateral ventricles, third
ventricle, and a small amount in the fourth ventricle.
Extra-axial blood is also seen along the inner table of the
skull
overlying the left anterior falx, left frontal lobe, and the
anterior parietal lobe and superior temporal lobe. It measures
6
mm in greatest axial thickness. The hemorrhage causes some mild
rightward shift of the septum pellucidum and other midline
structures, approximately 6 mm. The right cerebral hemisphere
is
notable for extensive hypovascular densities in the corona
radiata and centrum semiovale indicating chronic microvascular
change. In the right frontoparietal scalp, a hematoma is seen
about 10 mm. There is evidence of previous craniotomy on the
left, and two aneurysm clips in the region of the left middle
cerebral artery. No acute fractures are identified. Scattered
opacified ethmoid air cells are noted. There are small polyps
versus retention cysts in the maxillary sinuses, one measuring 7
mm in the left, one measuring 7 mm on the right. Cavernous
carotid arteries are partially calcified.
IMPRESSION:
1. Large left frontal intraparenchymal hemorrhage superimposed
on extensive encephalomalacic changes, with extension to the
ventricular system including the third and fourth ventricles.
2. 6-mm subdural hematoma overlying the left frontal, parietal,
and temporal regions. This may be related to the
intraparenchymal hemorrhage, or may be a separate event related
to the right-sided subgaleal hematoma.
Brief Hospital Course:
Patient was a 71 year old with history of aneurysm rupture and
resultant left-sided stroke, [**Doctor Last Name **] Syndrome with history of
stomach cancer (s/p XRT) and colon cancer (s/p resection) who
was transferred for further management of large intracranial and
subdural hemorrhage. The bleed was ~150 cc in volume on CT,
which put him at a 30 day mortality of >90%. On initial exam he
was arousable to sternal rub but did not follow commands, had a
R hemiparesis with some posturing to pain, and reactive pupils.
Given the size of his hemorrhage Neurosurgery consulted the
family and family declined an external ventricular drain.
Patient was admitted to the Neuro-ICU where his blood pressure
was controlled, neuro checks were performed every hour, he was
kept euthermic and euglycemic, his head was elevated and all
blood thinning products were held. He was also continued on
dilantin for seizure prophylaxis. A repeat head CT the
following morning showed no new bleeding. Renal team was
consulted and performed patient's routine hemodialysis. On
[**2-28**], family meeting was held to discuss goals of care. Full
code for now and reintubate if needed. Plan was to wean to
extubate patient that weekend. CTA of head did not show
extravasation of contrast but couldnot exclude bleeding from
clipped aneurysm site. Hemorrhage remained stable. R MCA 5mm
aneurysm seen at bifurcation. Over the weekend, patient became
less responsive despite holding propofol sedation and was not
moving his left side as he had done. Repeat head CT was
unchanged without any new bleeding involving the right
hemisphere to explain the new left-sided weakness. A subsequent
spine CT revealed possible metastatic lesion within the superior
facet of the right side of C3. There was no evidence of cord
compression above the level of C5-6. Below this level, shoulder
artifact precluded adequate evaluation. There was a slightly
rounded lucent lesion within the C7, also concerning for
metastatic deposit. A bone scan was inconclusive. Oncology
records from [**Hospital6 **] were obtained and Oncology and
Radiation oncology at [**Hospital1 **] were consulted. Patient's prognosis
was grim given diffuse metastatic disease and prior XRT of the
stomach precluding further XRT to recurring cancer and likely
only palliative chemotherapy. Per oncology, patient required
better functional status before undergoing such a therapy.
Furthermore, patient developed a ventilator associated pneumonia
and was not weanable off the ventilatory. Further famliy
meeting was held to discuss prognosis and family made decision
to extubate patient and pursue medical treatment but he would be
DNI/DNR. Patient was extubated and was made comfort measures by
family a few days later. Patient expired from respiratory
failure on [**2138-3-9**]. Family declined autopsy.
Medications on Admission:
Norvasc
Dilantin 300/400
Nephrocaps
PhosLo
Fluconazole 100 mg QD x 7 days, started [**2-21**], for fungal
infection in stomach per wife
Discharge Disposition:
Expired
Discharge Diagnosis:
Left frontal intracranial hemorrhage
Widely metastatic stomach cancer
ESRD on hemodialysis
Hypertension
Discharge Condition:
Deceased
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2138-3-22**]
|
[
"585.6",
"486",
"403.91",
"198.5",
"198.3",
"999.9",
"780.39",
"431",
"V10.05",
"151.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
9620, 9629
|
6582, 9433
|
334, 359
|
9776, 9926
|
4299, 6559
|
3151, 3185
|
9650, 9755
|
9459, 9597
|
3200, 3482
|
276, 296
|
387, 2777
|
3680, 4280
|
3521, 3664
|
3506, 3506
|
2799, 3067
|
3083, 3135
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,086
| 114,746
|
30597
|
Discharge summary
|
report
|
Admission Date: [**2138-12-26**] Discharge Date: [**2139-1-1**]
Date of Birth: [**2083-1-14**] Sex: M
Service: MEDICINE
Allergies:
Shellfish
Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
unresponsiveness, respiratory distress
Major Surgical or Invasive Procedure:
Picc line placement
History of Present Illness:
Mr. [**Known lastname 4401**] is a 55 year old man with history of COPD on 3L home
O2, hypertension, diabetes, history of stroke, hypertension, IV
drug use on chronic methadone, history of pancreatitis, history
of PE with IVC ([**2137**]) who was admitted to [**Hospital1 18**] on [**2138-12-27**] for
unresponsiveness and respiratory failure. He was found minimally
responsive at his long-term facility and brought to the ED,
where his O2sat was 71% on 3L NC. He was febrile to 101.6F in
the ED. He was initially given 2mg Narcan and placed on BiPap
with improvement in respiratory status. His respiratory rate
increased after the Narcan. CXR was performed which demonstrated
a RUL pneumonia. He received CTX, Flagyl, and Vancomycin. During
his stay in the ED, he became unresponsive at which time ABG was
7.10/168/356/56; he was again given Narcan with improvement. He
was then transferred to the MICU after moderate improvement.
.
In the MICU, he was initially treated with BiPAP and he was
continued on vancomycin and zosyn for his RUL pneumonia. He
received nebs and prednisone. His Utox was negative except for
opiates. He came off of BiPAP, was stabilized on 3LNC, afebrile,
and breathing comfortably, and was called out to the general
medical floor. His ABG improved to 7.37/77/153/46 at the time of
transfer.
.
Over the preceding days, patient required between 3-6LNC with O2
sats 89-91%. On the morning of transfer, his oxygen saturation
was noted to be low, between 70-mid 80s. He was given a
nebulizer treatment, after which he transiently improved. At
that time he was A+Ox3. A CXR was performed which was showed
improvement in RUL infiltrate. He then became more sedated and
was given 0.4mg ov Narcan with no improvement. At that time, ABG
showed 7.43/70/64/15. His saturation increased on a venti mask
(up to 96% sat), then trended down to 84%. Again, he recovered
spontaneously. He was then noted to be increasingly somnolent
and transiently unresponsive (with no movement and unrousable to
sternal rub); ABG at that time was 7.50/54/83/44. Patient was
then transferred to the MICU.
.
Upon arrival to the MICU, the patient is mentating without
difficulty. Alert and oriented x3. States he does not understand
why he needs to be in intensive care. He does remember having
low oxygen this morning but does not remember being unresponsive
or frequent attempted arousals. O2 sat is 86-91% on 6L O2. He
denies any chest pain, pleuritic chest discomfort, palpitations,
leg pain, cough, shortness of breath, diarrhea, constipation. He
does feel like his breathing is somewhat more difficult than at
home. He notes that he typically only wears his oxygen at night.
Past Medical History:
# Chronic obstructive pulmonary disease: On home O2
# Diabetes: [**3-7**] pancreatic surgery
# Hypertension
# Chronic pancreatitis, s/p Whipple
# Hepatitis C
# Peptic ulcer disease
# Anemia
# History of PE with IVC filter ([**3-/2137**])
# Possible CVA ([**2122**]): Reports he was comatose for two weeks and
has had memory problems since
# Seizure disorder
# Previous substance abuse
# Depression
Social History:
Lives in [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] retirement home. Brother and sister in
area. Originally from [**State 531**]. Former laborer. Previous alcohol
abuse, quit 13 years ago. Previous smoker 2 pks a day, duration
unknown, quit 2-3 years ago. Previous heroin abuse
Family History:
Unknown
Physical Exam:
PE: T: 98.7 BP: 138/79 HR: 93 RR: 14 O2 91% 6LNC
Gen: Pleasant, comfortable, no respiratory distress
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD, No JVD.
CV: RRR. Distant heart sounds. No appreciable murmurs, rubs or
[**Last Name (un) 549**]
LUNGS: Decreased breath sounds throughout but symmetric bilat.
Bilat wheezes
ABD: NABS. Healed midline surgical incision. Soft, ND. TTP in
epigastrum w/o rebound or guarding. No rigidity.
EXT: WWP, No clubbing. No edema. 2+ DP pulses BL
SKIN: No rashes/lesions.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Resting
tremor in LUE. Moving all extremities. Gait assessment deferred
Pertinent Results:
STUDIES:
.
ECG [**2138-12-29**]: NSR @ 88. LAD. Nl intervals. LAFB. Delayed RW
progression. Early repolarization changes in inf leads. Compared
to prior, no [**Month/Day/Year 65**] change.
.
CXR [**2138-12-29**]: writers read: improved consolidation in RUL.
.
CXR [**2138-12-28**]: There is interval improvement of the consolidation
within the right upper lobe. There is some atelectasis of the
right base. The cardiac silhouette and mediastinum is within
normal limits.
.
CXR [**2138-12-26**]: Right upper lobe pneumonia. Repeat radiography
following appropriate therapy recommended to document
resolution.
.
ECHO [**2138-12-5**]: The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). There is borderline right
ventricular hypertrophy. Right ventricular chamber size and free
wall motion are normal. The aortic root is moderately dilated at
the sinus level. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The pulmonary artery
systolic pressure could not be determined (probably at least
mildly elevated but Doppler measurements were technically
suboptimal). There is a trivial/physiologic pericardial
effusion.
Brief Hospital Course:
Mr. [**Known lastname 4401**] is a 55yoM with history of COPD on 3L home O2, DM,
HTN, chronic methadone use admitted with altered MS found to
have hypercapnea and pneumonia. The patient was initially
admitted to the MICU, then transferred to the floor. In the
MICU, he was initially treated with BiPAP and he was continued
on vancomycin and zosyn for his RUL pneumonia. He received nebs
and prednisone. His Utox was negative except for opiates. He
came off of BiPAP, was stabilized on 3LNC, afebrile, and
breathing comfortably, and was called out to the general medical
floor. His ABG improved to 7.37/77/153/46 at the time of
transfer.
.
Over the preceding days, patient required between 3-6LNC with O2
sats 89-91%. On the morning of transfer, his oxygen saturation
was noted to be low, between 70-mid 80s. He was given a
nebulizer treatment, after which he transiently improved. At
that time he was A+Ox3. A CXR was performed which was showed
improvement in RUL infiltrate. He then became more sedated and
was given 0.4mg ov Narcan with no improvement. At that time, ABG
showed 7.43/70/64/15. His saturation increased on a venti mask
(up to 96% sat), then trended down to 84%. Again, he recovered
spontaneously. He was then noted to be increasingly somnolent
and transiently unresponsive (with no movement and unrousable to
sternal rub); ABG at that time was 7.50/54/83/44. Patient was
then transferred back to the MICU.
.
Upon arrival to the MICU, the patient was mentating without
difficulty. Alert and oriented x3. O2 sat is 86-91% on 6L O2.
After further improvement in his respiratory status, he was
transferred back out the the floor on 3-4L O2.
Hospital Course by problem:
# altered mental status: waxing and [**Doctor Last Name 688**] on floor. Ddx
includes med induced, hypercarbia, seizure, infection,
toxic-metabolic encephalopathy. Patient was back to MS baseline
at time of admission to the MICU. Not clearly related to CO2 and
did not have evidence of worsening CO2 rentention from baseline.
Suspect significant contribution of psychoactive medications
including methadone, gabapentin, zyprexa, theophylline. Should
also consider seizure given question of seizure disorder
although no post ictal period and no obvious evidence of seizure
clinically. No evidence to suggest active infection either.
Intially methadone, zyprexa, gabapentin were held -> improved MS
with holding these medications. These medications have all been
resumed at time of discharge. A theophylline level was checked
and found to be subtherapeutic. His U/A was unremarkable. His
LFTs and pancreatic enzymes were found to be unremarkable.
.
# hypoxia: pt has a home O2 requirement but significantly
increased O2 requirement at presentation. Ddx includes
hypoventilation, PE, mucous plugging, pneumonia, V/Q mismatch
from COPD, CHF, cardiac ischemia. Hypoventilation could be
explained by altered MS [**First Name (Titles) **] [**Last Name (Titles) 72587**] despite improved MS.
Pneumonia appears improved on CXR. No evidence of collapse on
CXR to suggest mucous plugging. No evidence of CHF on exam or
CXR. Pt was ruled out for MI and no ischemic changes on ECG. PE
ruled out by CTA. O2 sats were maintained between 88-92% to
avoid CO2 retention.
# COPD: Pt has a baseline O2 requirement, ~ 3L O2 via nasal
cannula. Likely exacerbated by pneumonia. Pt was continued on
albuterol, spiriva, flovent and theophylline. Patient was given
prednisone and is now on a taper, currently day 2 of prednisone
20mg. He will continue for 3 additional days and then taper to
prednisone 10mg qday x 5 days.
# RUL Pneumonia - Initially thought to be a possible aspiration
PNA given unresponsiveness. Suspect some contribution of
pneumonitis given rapid resolution on CXR. No sputum Cx
available as dry cough. Afebrile without white count currently.
Treated with vancomycin and zosyn, now day [**8-16**]. Patient has a
PICC line in place for IV antibiotics.
.
# Diabetes: secondary to pancreatic resection. On NPH and ISS.
NPH was uptitrated while on prednisone, also patient with many
dietary indiscretions while in-house resulting in elevated BS.
Will discharge patient on NPH 15mg [**Hospital1 **] and sliding scale
insulin. As prednisone is tapered and stricter diet is resumed,
the patient will likely require less insulin.
.
# Hypertension: Patient was admitted off antihypertensives but
home regimen was supposed to consist of lisinopril 60mg daily,
HCTZ 25mg daily, clonidine patch 0.2mg daily, toprol XL 25mg
daily. Home regime was slowly re-initiated and patient is
discharged on his home regiment.
# Chronic abdominal pain: unclear etiology. Likely secondary to
abdominal surgery. Abdomen soft. Seems to be at patients
baseline. Pancreatic enzyme supplements continued.
.
# History of PE: Unclear circumstances but had IVC filter
placed, reportedly in 2/[**2137**]. IVC filtered confirmed by
abdominal CT. Had been on coumadin but was d/c'ed following
admission [**6-8**]. CTA w/o evidence of new PE. Patient received
subq heparin throughout this hospitalization.
.
# Hepatitis C. No active issues.
.
# Peptic ulcer disease. Not currently active. Continue PPI.
.
# Seizure disorder: Keppra continued throughout hospitalization.
Patient did not have an EEG.
# Previous IVDU on methadone - Patient has some nonspecific
aches/pains but no clear e/o withdrawal. Home dose Methadone 5
mg PO tid. Patient was restarted on his home dose of methadone
the day before discharge.
.
# Depression. No active issues. Continued buproprion,
citalopram.
The patient was evaluated by physical therapy and will be
discharged to a rehab bed at the [**Hospital3 1186**] with physical
therapy. He was discharged on hospital day #7 in stable
condition.
.
Medications on Admission:
Albuterol Nebs Q2H PRN
Fluticasone 2 puff INH [**Hospital1 **]
Buproprion 150mg PO BID
Citalopram 40mg daily
Olanzapine 5mg QHS
Levetiracetam 500mg TID
Ferrous Sulfate 325mg [**Hospital1 **]
Gabapentin 300mg [**Hospital1 **], 600mg QHS
Memantine 5mg daily
Methadone 5mg TID
Acetaminophen 325mg Q6H PRN
Colace 100mg [**Hospital1 **]
Dulcolax PRN
Amylase-Lipase-Protease 20,000-4,500,25,000 capsule TID with
meals
Theophylline 80mg/15mL [**Hospital1 **]
Insulin NPH 10 units QD
Tiotropium 18mcg one cap INH daily
Ipratropium 0.02% INH Q6H
Prilosec 20mg daily
Discharge Medications:
1. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. Bupropion 75 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a
day).
3. Citalopram 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
4. Levetiracetam 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3
times a day).
5. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Ferrous Sulfate 325 (65) mg Tablet [**Hospital1 **]: One (1) Tablet PO
DAILY (Daily).
9. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) [**Hospital1 **]: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
10. Theophylline 80 mg/15 mL Elixir [**Hospital1 **]: One (1) PO BID (2
times a day).
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Last Name (STitle) **]: One (1)
Inhalation Q4H (every 4 hours).
13. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Last Name (STitle) **]: One (1)
inhalation Inhalation Q2H (every 2 hours) as needed.
14. Hydrochlorothiazide 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY
(Daily).
15. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Last Name (STitle) **]:
One (1) Cap Inhalation DAILY (Daily).
16. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain, [**Last Name (STitle) **].
17. Ibuprofen 400 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q8H (every 8
hours) as needed.
18. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) inhalation
Inhalation Q6H (every 6 hours) as needed.
19. Prednisone 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily)
for 3 days.
20. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
21. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
[**Last Name (STitle) **]: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
22. Methadone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a
day).
23. Gabapentin 300 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
24. Gabapentin 300 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO HS (at
bedtime).
25. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
26. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
[**Last Name (STitle) **]: One (1) Intravenous Q8H (every 8 hours) for 7 days.
27. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Last Name (STitle) **]: One (1)
Intravenous Q 12H (Every 12 Hours) for 7 days.
28. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
29. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
30. Zyprexa 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO qHS.
31. Clonidine 0.2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
32. insulin
Humalog Insulin Sliding Scale per sliding scale provided.
NPH 15mg [**Hospital1 **] (breakfast/dinner)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
Pneumonia
COPD exacerbation
Diabetes
Secondary:
HTN
Chronic pancreatitis
HCV
PUD
Anemia
h/o PE with IVC filter
Seizure d/o
h/o substance abuse
Depression
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) **] > 100.4, shortness of breath,
chest pain, inability to tolerate food/liquids.
Followup Instructions:
1. Follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. She will see you at your
long term care facility.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**]
|
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"304.01",
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"311",
"518.81",
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
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15957, 16030
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|
309, 330
|
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4502, 6026
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16450, 16684
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3794, 3803
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3818, 4483
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231, 271
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7733, 7743
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358, 3034
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7758, 11780
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3056, 3456
|
3472, 3778
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,405
| 166,661
|
29741
|
Discharge summary
|
report
|
Admission Date: [**2185-12-22**] Discharge Date: [**2185-12-23**]
Date of Birth: [**2139-11-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
found unresponsive
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
46yoM with h/o ivdu, EtOH abuse found unresponsive in bathroom
after injecting heroin and brought to [**Hospital1 18**] ED. Patient was
administered Narcan by EMS and transiently aroused. On arrival
to [**Hospital1 18**] ED T 98.6 HR 86 BP 120/p RR 14 94%RA. There he
admitted to having used heroin that night. He subsequently
became tachycardic with irregular HR 180s. Narcan wore off, and
he again became sedated. At that point he was intubated for
airway protection. Following intubation his blood pressure
decreased to 86/45. He was given 6L NS prior to transfer to the
floor. On arrival he is sedated but arousable to voice,
responding to some but not all commands.
Past Medical History:
Heroin use
EtOH abuse
Hepatitis C - per ED record
Social History:
not known
Family History:
not known
Physical Exam:
PE: T 97.3 HR 71 BP 109/61 RR 14 99%
A/C Tv 600 RR 14 FiO2 100% PEEP 8
Gen: sedated, arousable to loud voice
HEENT: right pupul pinpt, reactive. left pupil surgical,
minimally reactive. MM dry. ETT
Neck: supple, JVP nondistended
CV: PMI nondisplaced, RRR, no mrg
Resp: bronchial left, CTA right
Abd: +BS, soft, NT, ND, no masses
Ext: BLE edema R > L, 2+ radial and DPs
Neuro: responded to command to open eyes, squeeze right hand
but not left, not respond to command to move toes. withdraws to
pain in all four extremities.
Pertinent Results:
CT HEAD WITHOUT CONTRAST: No priors for comparison available. No
hemorrhage, edema, shift of normally midline structures, or
infarction is apparent. Density values of the brain parenchyma
are within normal limits. There is mucosal thickening in the
ethmoid sinus and polypoid mucosal thickening in the left
maxillary sinus. No air-fluid levels are seen. The mastoid air
cells are clear. The surrounding soft tissue structures appear
unremarkable.
IMPRESSION: No evidence of hemorrhage or edema.
.
AP SUPINE CHEST: ETT terminates 8.5 cm above the carina. NG tube
terminates in the gastric fundus. There is cardiomegaly. No
definite pulmonary edema is seen. There are no effusions or
consolidations. There may be mild upper zone vascular
redistribution.
.
RIGHT LOWER EXTREMITY ULTRASOUND: [**Doctor Last Name **] scale and Doppler
son[**Name (NI) 1417**] of the right common femoral, superficial femoral, and
popliteal veins were performed. There is normal compressibility,
waveform, augmentation and flow. No intraluminal echogenic
material is identified.
IMPRESSION: No DVT in the right lower extremity.
.
[**2185-12-22**] 10:04PM BLOOD WBC-8.5 RBC-4.84 Hgb-14.5 Hct-42.8 MCV-88
MCH-29.9 MCHC-33.8 RDW-13.9 Plt Ct-257
[**2185-12-22**] 10:04PM BLOOD Plt Ct-257
[**2185-12-22**] 10:04PM BLOOD PT-11.5 PTT-24.3 INR(PT)-1.0
[**2185-12-22**] 10:04PM BLOOD Fibrino-247
[**2185-12-23**] 02:35AM BLOOD Glucose-98 UreaN-13 Creat-0.6 Na-147*
K-3.9 Cl-115* HCO3-23 AnGap-13
[**2185-12-22**] 10:04PM BLOOD CK(CPK)-1430* Amylase-48
[**2185-12-23**] 06:47AM BLOOD CK(CPK)-797*
[**2185-12-22**] 10:04PM BLOOD CK-MB-20* MB Indx-1.4 cTropnT-<0.01
[**2185-12-23**] 06:47AM BLOOD CK-MB-12* MB Indx-1.5 cTropnT-<0.01
[**2185-12-23**] 02:35AM BLOOD Albumin-2.9* Calcium-6.5* Phos-3.5 Mg-2.1
[**2185-12-22**] 10:04PM BLOOD ASA-NEG Ethanol-365* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2185-12-23**] 02:37AM BLOOD Type-ART pO2-162* pCO2-55* pH-7.27*
calTCO2-26 Base XS--2
[**2185-12-23**] 12:19AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2185-12-23**] 12:19AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2185-12-23**] 12:19AM URINE RBC-[**10-10**]* WBC-0-2 Bacteri-FEW Yeast-MOD
Epi-0
[**2185-12-23**] 12:19AM URINE bnzodzp-POS barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
Brief Hospital Course:
A/P: 45yoM with h/o ivdu, EtOH abuse, found unresponsive with
response to Narcan
.
# Mental status: patient unresponsive at first but with
reponse to Narcan, suggestive of opiate OD. Subsequent tox
screen positive for etoh, bzd, opiates. Intubated for airway
protection and sedated. Patient subsequently sobered from his
multiple intoxications. Received vitamin, thiamine, folate for
etoh. Extubated uneventfully the morning after. Patient's
mental status cleared, and he decided to leave AMA. He
verbalized an understanding of the risks of leaving, signed the
AMA form.
.
# Hypernatremia: free water deficit 4L. Hydrated with D5 [**11-22**]
NS at 150cc/hr overnight with improved values by the AM.
.
# Elevated CK: concerning for development of rhabdomyolysis
with ?fall in bathroom when unconscious. CK's trended down
thereafter with hydration.
.
# ?Pneumonia: patient felt to have possible early pneumonia vs.
pneumonitis, received Azithro in house and given 2 extra days
worth of pills for discharge (given the low likelihood that he
would fill scripts)
Medications on Admission:
None
Discharge Medications:
1. Azithromycin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
5. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation four times a day.
Disp:*1 MDI* Refills:*2*
6. Spacer
Please dispense one Spacer for MDI
Discharge Disposition:
Home
Discharge Diagnosis:
Hypercarbic respiratory suppression
Heroin overdose
EtOH abuse
Discharge Condition:
Stable
Discharge Instructions:
You have decided to leave against medical advice (AMA). Please
follow-up with a primary care physician. [**Name10 (NameIs) **] you need a PCP you
can call [**Telephone/Fax (1) 250**] to schedule an appointment at [**Hospital1 18**].
Please take the additional 2 days worth of Azithromycin for the
questionable pneumonia seen on your chest X-ray.
.
If you develop fever >101.3, shortness of breath, or any other
concerning symptom, please seek medical assistance.
Followup Instructions:
Please follow-up with a primary care physician. [**Name10 (NameIs) **] you need a
PCP you can call [**Telephone/Fax (1) 250**] to schedule an appointment at
[**Hospital1 18**].
|
[
"728.88",
"507.0",
"518.81",
"E980.0",
"965.01",
"305.1",
"780.09",
"070.70",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5817, 5823
|
4146, 4233
|
336, 349
|
5930, 5939
|
1760, 4123
|
6452, 6633
|
1176, 1187
|
5272, 5794
|
5844, 5909
|
5243, 5249
|
5963, 6429
|
1202, 1741
|
278, 298
|
377, 1059
|
4249, 5217
|
1081, 1133
|
1149, 1160
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,463
| 119,608
|
4650
|
Discharge summary
|
report
|
Admission Date: [**2172-1-14**] Discharge Date: [**2172-1-24**]
Date of Birth: [**2110-8-5**] Sex: M
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old
male who initially presented to the podiatry service after an
elective triple arthrodesis of the right foot. He was
initially admitted for pain control and was placed on
clindamycin postoperatively. He initially did well, but
began to develop some low blood pressures into the systolic
90s, which initially responded to IV fluid boluses. These
low blood pressures continued with systolics into the
70s-80s, which required several liters of fluid. He also
developed a temperature to 101, at which time blood cultures
were obtained which revealed [**1-8**] positive blood cultures with
gram-positive cocci. He also, at that time, had increasing
creatinine with a peak of 2.6, and began to develop a new
oxygen requirement. He was 92% on 2 liters nasal cannula.
He also developed some diarrhea, as well as some mental
status changes, and was thought to be encephalopathic. The
medical consult resident was [**Name (NI) 653**], and the patient was
then transferred to the medical team.
PAST MEDICAL HISTORY:
1. Hypertension.
2. CAD.
3. History of asthma.
4. History of osteoporosis.
5. GERD.
6. ?History of Crohn's disease, although there are no records
of tissue biopsy, and no previous history of diarrhea, or
abdominal surgeries.
7. Previous history of metastatic melanoma to the lung.
8. History of HIV with the last CD4 count of 595 in [**2171-6-4**].
9. History of cataracts.
10.History of low T4.
11.History of dilated cardiomyopathy secondary to IL-2
treatment for his melanoma. This cardiomyopathy later
resolved.
12.Peripheral neuropathy.
13.Hypertriglyceridemia.
14.Allergic rhinitis.
ALLERGIES:
1. Sulfa.
2. Cipro.
3. Penicillin.
MEDICATIONS ON TRANSFER:
1. Vancomycin.
2. Flagyl.
3. Tums.
4. Percocet.
5. Lisinopril.
6. Heparin subcu.
7. Imodium.
8. Testosterone patch.
9. Stavudine.
10.Lamivudine.
11.Abacavir.
12.Zyrtec.
13.Dipentum.
14.Allopurinol.
15.Gemfibrozil.
16.Nifedipine.
17.CR30 qd.
18.Protonix.
19.Synthroid.
20.Montelukast.
21.Gabapentin.
VITAL SIGNS ON TRANSFER: T-max 100.1, blood pressure ranging
between 72-100 systolic/50s, heart rate between 86 and 114,
respiration rate 20, satting 93% on [**1-5**]/2 liters nasal
cannula. Ins and outs - 4,400 in with 300 out. Bowel
movements x 6.
GENERAL APPEARANCE: The patient is older than stated age,
sleepy but arousable, in no apparent distress.
HEAD AND NECK EXAM: Anicteric. Mucous moist. No JVD noted.
LUNGS: Bilateral lower lobe crackles.
CARDIAC EXAM: Tachycardic with II/VI systolic ejection
murmur with radiation to the apex.
ABDOMEN: Soft, nontender, nondistended. There was no CVA
tenderness.
EXTREMITIES: Right lower extremity in a cast. No clubbing,
cyanosis or edema.
NEURO EXAM: He was alert, appears somewhat confused, with
notable asterixis on exam.
LABS ON TRANSFER: Notable for a white count of 11.4 down
from 14, hematocrit 33.1, MCV 104, platelets 192. Chem-7
with a sodium of 136, K 4.6, chloride 108, bicarb 16, BUN 54,
creatinine 2.6 up from 2.5, glucose 126, calcium 8.2, mag
1.9, phos 4.4. Coags were notable for an INR of 1.4. Blood
cultures at this time were notable for [**12-8**] gram-positive
cocci in pairs and clusters. Previous C. diff toxin was
negative. EKG appeared sinus with a rate of 114. No ST
elevation. No clear markers of ischemia or tamponade were
noted.
HOSPITAL COURSE - 1) INFECTIOUS DISEASE: The patient
appeared to be in sepsis which was likely due to globalized
sepsis from his Methicillin sensitive Staphylococcus aureus
which later grew out of his blood. The source of this was
somewhat unclear. It was initially thought to be related to
his foot surgery, although his foot appeared clean per
podiatry notes. He initially was placed on vancomycin,
Flagyl and gentamicin. He was transferred to the Intensive
Care Unit initially where he received several liters of IV
fluids, and antibiotics were continued. He did well and
maintained his blood pressure with improvement in his
creatinine and pulmonary status. He was transferred back to
the floor. While back on the floor, his gentamicin was DC'd.
He was afebrile the day of discharge, and follow-up cultures
continued to remain negative. He received a TTE and later a
TEE to evaluate for endocarditis, which showed no evidence of
thrombus or vegetation. A PICC line was placed for a 14-day
course of vancomycin, as the patient could not receive
penicillin derivatives or fluoroquinolones.
2) DIARRHEA: Based on his clinical history, there was a very
high suspicion for C. diff infection as the cause of the
patient's diarrhea. He had been on clindamycin as an
outpatient and was continued on clindamycin as monotherapy as
an inpatient. His clindamycin was DC'd, and he had numerous
C. diff studies for toxin A which were negative. A C. diff
toxin B assay was sent which was not available at the time of
discharge. He was treated empirically for C. diff colitis
with a 14-day course of Flagyl with gradual improvement in
his diarrhea.
3) CARDIOVASCULAR: During his initial presentation to the
medical team, the patient developed atrial fibrillation with
rapid ventricular response into the 150s. He was initially
given IV Lopressor and then po Lopressor with adequate
response while in the Intensive Care Unit, and his heart rate
was maintained. Approximately 3 days after the onset of his
atrial fibrillation, he was sent for TEE and was cardioverted
successfully. He was placed on Coumadin, became therapeutic,
and was discharged on a 6-week course of Coumadin, and to
have his INR checked at rehab.
4) RENAL: He developed what appears to be acute renal
failure secondary to sepsis, which resolved with the
resolution of his sepsis and aggressive IV fluid management.
5) PULMONARY: He had an initial O2 requirement which was
likely secondary to his sepsis. He did not have any evidence
of systolic congestive heart failure on echo, and his
transient O2 requirement was likely secondary to capillary
leak which later resolved. He did not require intubation
during his hospital course and was satting well on room air
at the time of discharge.
6) PODIATRY: His postop wound remained clean throughout his
hospital course, and he was discharged in a cast to be
followed up in [**4-10**] days, and to be changed by podiatry.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: Extended care facility.
DISCHARGE DIAGNOSES:
1. Staph aureus bacteremia.
2. Diarrhea possibly secondary to Clostridium difficile.
3. Triple arthrodesis of right foot.
4. Atrial fibrillation with rapid ventricular response status
post cardioversion.
5. Congestive heart failure.
6. Acute renal failure.
7. Sepsis.
8. Transient encephalopathy.
DISCHARGE MEDICATIONS:
1. Tylenol prn.
2. Abacavir 300 mg [**Hospital1 **].
3. Gabapentin 300 mg tid.
4. Montelukast 10 mg qd.
5. Lamivudine 150 mg [**Hospital1 **].
6. Levothyroxine 150 mcg qd.
7. Protonix 40 mg qd.
8. Gemfibrozil 600 mg [**Hospital1 **].
9. Allopurinol 30 mg qd.
10.Stavudine 40 mg q 12.
11.Testosterone 5 mg patch q 24 h.
12.Calcium carbonate 500 mg 1 tablet [**Hospital1 **].
13.Miconazole powder prn.
14.Flagyl 500 mg po tid for an additional 10 days.
15.Lidocaine ointment prn.
16.Regular insulin sliding scale.
17.Percocet [**12-6**] q 4-6 h prn.
18.Atenolol 75 mg qd.
19.Zinc oxide ointment prn.
20.Coumadin 3 mg po q hs. To have daily INR checks at rehab.
21.Loperamide 2 mg po q 12 prn diarrhea.
22.Vancomycin 1 gm q 12 for 14 days.
23.Dipentum.
FOLLOW-UP PLANS:
1. The patient was told to follow-up with Dr. [**Last Name (STitle) **] of
podiatry within 5-7 days after his discharge to change his
right leg cast.
2. He also was told to follow-up with his primary care
physician [**Name Initial (PRE) 176**] 1-2 weeks of discharge.
3. He was also given an appointment with Dr. [**Last Name (STitle) 19686**] of
infectious disease, [**3-11**].
DISCHARGE INSTRUCTIONS: He was given explicit instructions
to take all medications as prescribed and told to remain
nonweightbearing on his right lower extremity until his
follow-up appointment with Dr. [**Last Name (STitle) **]. He was told that if
he had any further episodes of fever, any lightheadedness,
severe leg pain, worsening diarrhea, or had any other
concerning symptoms, that he should seek immediate medical
attention.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Last Name (NamePattern1) 6289**]
MEDQUIST36
D: [**2172-1-24**] 11:05
T: [**2172-1-24**] 11:36
JOB#: [**Job Number 19687**]
|
[
"734",
"V08",
"427.31",
"008.45",
"995.92",
"428.0",
"584.9",
"038.11",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.61",
"81.12",
"38.93",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
6556, 6854
|
6877, 7629
|
8051, 8735
|
6482, 6535
|
7646, 8026
|
169, 1188
|
1872, 6467
|
1210, 1847
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,774
| 173,586
|
8554
|
Discharge summary
|
report
|
Admission Date: [**2141-3-8**] Discharge Date: [**2141-3-30**]
Date of Birth: [**2068-2-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Chest pain and abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 73 year old male with past medical history significant
for CAD s/p CABG and PCI to LCx, aortic stenosis, VT/VF arrest
s/p ICD, CHF (EF 20%) s/p BiV pacer, afib on coumadin, CRI and
diverticulosis who presents with 1 hour of chest pain similar to
anginal equivalent that radiated to abd and back. Assocated with
nausea. Took ntg tab w/o relief. No pleuritic chest pain. The
abd pain is LLQ predominant w/o radiation. He states that he has
had black stools on both of the last 2 days associated with
changed smell of the stools. He has had no bloody stool. The abd
pain usually is better after eating. There have been no new
foods and no sick contacts.
.
Of note the patient was recently in the [**Hospital1 18**] for abdominal pain
in [**1-20**]. At which time his labs were unremarkable. A CT abd
showed no acute pathology to explain his pain. He received IV
fluids and slowly advanced his diet to normal prior to
discharge.
.
In ED, initial vitals were 97.8 120/70 100 14 100%RA. Stools
brown and OB negative.
ECG was V-paced at 85bpm, cardiac enzymes were negative.
Patient given aspirin, nitro tabs, morphine.
.
On floor, patient was with decreasing chest pain but still with
nausea. The abdominal pain is also improved.
.
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, he
denies recent fevers, chills or rigors. he denies exertional
buttock or calf pain. his weight has been stable at
222-223pounds. His baseline function is 1 flight of stairs. All
of the other review of systems were negative.
.
Cardiac review of systems is notable for paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
.
Past Medical History:
CAD status post CABG with simultaneous aortic aneurysm repair
in [**2133**], history of stenting of the left circumflex artery [**2135**]
s/p VT/VF arrest, s/p ICD placement in [**2135**]
iCMP (EF 20%) s/p BiV pacer [**10-18**]
Chest wall cellulitis over pacer site [**3-19**] vs. ICD pacer
pocket infection
AFib (not anti-coagulated due to recurrent GI bleeds)
CKD Stage III b/l Cr. ~1.6
Hyperlipidemia
Asthma
Anxiety
Alzheimer's dementia
Hypothyroidism
Diverticulosis
GERD
s/p cholecystectomy
.
CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
Social History:
married, lives with wife. [**Name (NI) **] originally from [**Country 4754**]. No
history of smoking. Patient was a heavy drinker until 20 years
ago. No history of illicit drugs
Family History:
No family history of early MI, otherwise non-contributory.
Physical Exam:
On admission-
VS: 98.5 100/71 82 16 99%2L
wt. 222 lbs
GENERAL: WDWN obese male 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 8 cm.
CARDIAC: PMI laterally displaced. RR, normal S1, S2. [**2-17**]
systolic murmur at RUSB c/w AS. 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, minimal tender to LLSB. No HSM or tenderness. Abd
aorta not enlarged by palpation. No abdominal bruits. guiaiac
negative brown stool.
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 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Neuro:
-MS alert and oriented x3. coherent response to interview
-CN II-XII intact
-Motor moving all 4 extremities symmetrically.
-[**Last Name (un) **] light touch intact to face/hands/feet
Pertinent Results:
========
Labs
========
[**2141-3-30**] 11:51AM BLOOD Hct-27.8*
[**2141-3-30**] 11:51AM BLOOD PT-22.2* PTT-91.8* INR(PT)-2.1*
[**2141-3-30**] 04:09AM BLOOD WBC-9.2 RBC-2.92* Hgb-8.4* Hct-26.2*
MCV-90 MCH-28.8 MCHC-32.1 RDW-15.5 Plt Ct-255
[**2141-3-30**] 04:09AM BLOOD Glucose-193* UreaN-31* Creat-2.0* Na-132*
K-4.5 Cl-97 HCO3-27 AnGap-13
[**2141-3-11**] 06:37AM BLOOD WBC-6.5 RBC-4.10* Hgb-11.9* Hct-35.6*
MCV-87 MCH-29.1 MCHC-33.5 RDW-14.6 Plt Ct-144*
[**2141-3-10**] 05:15AM BLOOD WBC-7.4 RBC-4.16* Hgb-12.2* Hct-35.8*
MCV-86 MCH-29.2 MCHC-34.0 RDW-14.7 Plt Ct-136*
[**2141-3-9**] 05:15AM BLOOD WBC-8.7 RBC-4.14* Hgb-12.3* Hct-35.7*
MCV-86 MCH-29.7 MCHC-34.5 RDW-14.5 Plt Ct-145*
[**2141-3-8**] 06:45PM BLOOD WBC-9.2 RBC-4.44* Hgb-13.0* Hct-38.5*
MCV-87 MCH-29.2 MCHC-33.7 RDW-14.5 Plt Ct-193
[**2141-3-11**] 06:37AM BLOOD Glucose-86 UreaN-17 Creat-1.6* Na-140
K-4.0 Cl-103 HCO3-27 AnGap-14
[**2141-3-10**] 05:15AM BLOOD Glucose-72 UreaN-20 Creat-1.5* Na-138
K-3.8 Cl-103 HCO3-27 AnGap-12
[**2141-3-9**] 05:15AM BLOOD Glucose-86 UreaN-25* Creat-1.6* Na-140
K-4.4 Cl-102 HCO3-29 AnGap-13
[**2141-3-8**] 06:45PM BLOOD Glucose-95 UreaN-26* Creat-1.7* Na-138
K-4.3 Cl-100 HCO3-31 AnGap-11
[**2141-3-10**] 05:15AM BLOOD ALT-42* AST-47* AlkPhos-132* Amylase-112*
[**2141-3-9**] 05:15AM BLOOD LD(LDH)-276* CK(CPK)-86 Amylase-208*
[**2141-3-8**] 06:45PM BLOOD ALT-20 AST-30 CK(CPK)-96 AlkPhos-92
Amylase-137* TotBili-0.3
[**2141-3-11**] 06:37AM BLOOD Lipase-33
[**2141-3-10**] 05:15AM BLOOD Lipase-46
[**2141-3-9**] 04:05PM BLOOD Lipase-58
[**2141-3-9**] 05:15AM BLOOD Lipase-164*
[**2141-3-8**] 06:45PM BLOOD Lipase-124*
[**2141-3-9**] 05:15AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2141-3-8**] 06:45PM BLOOD cTropnT-<0.01
[**2141-3-8**] 06:45PM BLOOD Digoxin-0.7*
.
=========
Radiology
=========
CXR [**3-8**]
FINDINGS: PA and lateral views of the chest are obtained.
Three-lead pacer
device is unchanged with lead tips positioned in the expected
location.
Midline sternotomy wires are unchanged. Cardiomegaly is stable.
There is no
CHF or evidence of pneumonia. No pleural effusion or
pneumothorax is seen.
Osseous structures are intact.
IMPRESSION: No significant change with persistent cardiomegaly
and no evidence
of CHF or pneumonia.
.
RUQ U/S [**3-9**]
RIGHT UPPER QUADRANT ULTRASOUND: The liver appears unremarkable
in
echotexture and architecture, without focal liver lesion seen.
Flow in the
main portal vein is in normal hepatopetal direction. No intra-
or extra-
hepatic biliary ductal dilatation is noted, with the common duct
measuring 5
mm. Again the gallbladder is absent, consistent with prior
cholecystectomy.
Visualization of the pancreatic tail is slightly limited due to
overlying
bowel gas however the visualized pancreas appears unremarkable
and unchanged.
No pancreatic ductal dilatation is noted. No ascites is seen.
The spleen is
enlarged, measuring 13.8 cm.
IMPRESSION:
1. Patient is status post cholecystectomy. No intra- or
extra-hepatic
biliary ductal dilatation is noted. No choledocholithiasis seen.
2. Incidentally noted splenomegaly.
.
===========
Cardiology
===========
TTE [**3-9**]
Conclusions
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is severely dilated.
Overall left ventricular systolic function is severely depressed
(LVEF= 20 %). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. Right ventricular chamber size is
normal. with borderline normal free wall function. with focal
hypokinesis of the apical free wall. The aortic root is mildly
dilated at the sinus level. There are focal calcifications in
the aortic arch. The number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are severely
thickened/deformed. There is moderate to severe aortic valve
stenosis (area 0.8-1.0cm2). No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. The main pulmonary
artery is dilated. The branch pulmonary arteries are dilated.
Compared with the findings of the prior study (images reviewed)
of [**2140-10-12**], no major change is evident.
.
Myocardial perfusion study [**3-11**]
IMPRESSION: 1) Severe left ventricular enlargment 2) Probably
some viability within an inferior wall defect.
TTE [**2141-3-14**] The left ventricular cavity is dilated. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is severely depressed (LVEF= 20 %). The right
ventricular cavity is mildly dilated with normal free wall
contractility. The aortic valve leaflets are mildly thickened.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**1-13**]+) mitral regurgitation is seen. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Focused views. Severe left
ventricular sysolic dysfunction. Mild to moderate mitral
regurgitation.
Compared with the prior study (images reviewed) of [**2141-3-9**],
this is a limited/emergent/focused study and direct comparison
cannot be made.
Cardiac Cath [**2141-3-20**]
COMMENTS:
1. Coronary angiography of this right dominant system
demonstrated no
angiographically apparent flow-limiting coronary artery disease.
2. Non-selective arteriography of the LIMA-LAD showed no
apparent
flow-limiting disease.
3. Limited resting hemodynamics revealed a central aortic
pressure of
134/92 mmHg.
FINAL DIAGNOSIS:
1. No angiographically apparent flow-limiting coronary artery
disease.
2. Patent LIMA-LAD.
[**2141-3-26**] LEFT UPPER EXTREMITY VENOUS ULTRASOUND: [**Doctor Last Name **]-scale and
color and pulsed wave Doppler examination was performed over the
right subclavian vein as well as the left internal jugular,
subclavian, axillary, brachial, basilic, and cephalic veins.
Note is made of nearly occlusive thrombosis of the left
cephalic, basilic, brachial, and axillary veins. Flow is
demonstrated in the left and right subclavian veins. More
proximally, note is made of likely pacemaker wire entering the
left subclavian vein. The internal jugular vein demonstrates
normal compressibility and flow.
IMPRESSION: Left upper extremity DVT extending from the
superficial cephalic and basilic veins into the brachial and
axillary deep veins.
CXRs:
[**2141-3-28**] PORTABLE SEMI-UPRIGHT RADIOGRAPH OF THE CHEST: The
distal tip of right PICC projects in the mid SVC. There has been
interval removal of the endotracheal tube and NG tube. The
remainder of the study including the position of the AICD leads
and the cardiopulmonary status appear unchanged.
IMPRESSION: Standard position of the right PICC with no
complication.
Pertinent Micro data
[**2141-3-22**] 2:00 pm URINE Source: Catheter.
**FINAL REPORT [**2141-3-24**]**
URINE CULTURE (Final [**2141-3-24**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 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-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
GRAM STAIN (Final [**2141-3-21**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2141-3-24**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. MODERATE 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.
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
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
C diff negative
Blood cx ngtd
Brief Hospital Course:
# VT: Initially on home meds of mexilitine and sotalol. On the
floor, had an episode VT on telemetry and lost pulses. He
[**Month/Day/Year 1834**] CPR, receiving a total of 4 shocks, 4mg of
epinephrine, amiodarone 150mg x 2, Lidocaine 100mg x 1,
magnesium 2mg, bicarb 1 amp, and calcium. Pacer interrogation
showed his VT was below the rate of detection. He was manually
paced out of VT several times but with return to VT each time.
Finally, lidocaine and amiodarone gtts were started and the
patient was successfully converted back to a paced rhythm. His
mexilitine and sotalol were held. He was intubated during the
code, but rapidly extubated afterward. From [**3-15**] to [**3-21**], he had
repeated episodes of VT, receiving multiple ICD shocks each
time, with conversion to a paced rhythm. The first of these
episodes was associated with hypotension, but subsequent
episodes showed good BP. He was given ativan for sedation due to
the multiple shocks, and was reintubated [**3-19**] for airway
protection from sedation. Over the course of these several
episodes, he received multiple amiodarone and lidocaine boluses,
and was variably on and off drips of these medications. On [**3-21**],
he had an EP study and had 1 circuit ablated and an epicardial
circuit interrupted. He was transitioned to a final regimen of
oral mexilitene alone. After the study, he was kept sedated and
initially required phenylephrine and vasopressin. He had
multiple VT episodes on [**3-22**], but successfully paced out without
shocks. He was weaned off pressors and extubated, and
subsequently started on metoprolol, which was uptitrated to 25mg
TID. His only further VT was on [**3-28**], and he was successsfully
paced out. EP recommends that he continue on telemetry
monitoring for 48 hours after discharge.
# Chest pain: Has a history of CAD, although cardiac cath done
during admission was clean and biomarkers on admission for chest
pain in the ER were negative. After CPR, patient had significant
reproducible chest wall tenderness that was due to the direct
trauma of chest compressions. This pain was not felt to be
ischemia. He was treated initially with IV morphine and
hydromorphone, but received better pain control after
transitioning to oral MS contin. He is also on [**Month/Year (2) 1988**] tylenol
and a lidocaine patch.
# Anxiety: Patient has known anxiety, and this was significantly
worsened in the setting of recurrent VT and receiving many ICD
shocks. Psychiatry was consulted and advised seroquel PRN in
addition to his standing doses. He was also continued on
citalopram and low dose clonazepam. Despite this, he continued
to have significant anxiety; he would have episodes of
lightheadedness and palpitations, despite normal vital signs and
no telemetry changes. Also, he at times thought his ICD had
fired, but review of telemetry showed this was not the case. He
also becomes diaphoretic, but per patient and wife, this is
long-standing and his baseline.
# Abdominal pain: Presented with nausea, vomiting, abdominal
pain and elevated lipase, otherwise normal LFTs. No cholethiasis
on abdominal u/s. He was ruled out for acute cardiac event. He
was treated with bowel rest and his diet was slowly advanced as
tolerated.
# DVT: LUE had swelling and ultrasound was positive. He was
started on a heparin drip and bridged to warfarin before
discharge. Continued on PPI and sucralfate given history of GI
bleeds and ASA was lowered from 325mg to 81mg daily. He will
need a follow up ultrasound in [**3-15**] mos.
# Pump: LVEF 20% on TTE [**10-19**]. Also has known AS, although
during admission patient was refusing AVR and valvuloplasty. He
became hypervolemic around [**3-18**], requiring a lasix gtt. His
volume status improved and he was transitioned to his home dose
of lasix 40mg PO daily. His digoxin was stopped due to
arrhythmogenic concerns. Beta blocker continued as above.
Spironolactone was increased from 12.5 to 25mg daily.
# CKD: Baseline Cr around 1.6. Prior to discharge, his
creatinine trended up to 2.0 in the setting of increased ACE-I
and restarting furosemide. Per discussion with his outpatient
cardiologist, this is acceptable for now and can be followed
after discharge, with med changes made as needed.
# MRSA Pneumonia: Pt developed MRSA pneumonia with sputum
growing MRSA. He was treated with Vancomycin 8 day course which
he completed on [**2141-3-29**]
# UTI: Pt had E coli UTI. He was initially on pip-tazo for
empiric pneumonia coverage, but changed to ceftriaxone once
sensitivities returned. He completed a 7 day course of
antibiotics.
# CODE: Code status had been changed to 1 externmal shock if
neccessary but no compressions. This was reversed on [**2141-3-28**]
when patient expressed desire to be full code.
Medications on Admission:
Sotalol 80 mg [**Hospital1 **]
Levothyroxine 112 mcg daily
Citalopram 60 mg daily
Quetiapine 50 mg QAM
Quetiapine 25 mg daily at noon
Quetiapine 75 mg QHS
Sucralfate 1 gram QID
Mexiletine 150 mg Q8H
Pantoprazole 40 mg Q12
Atorvastatin 20 mg daily
Fluticasone-Salmeterol 250-50 mc 2 puffs [**Hospital1 **]
Donepezil 5 mg QHS
Metoprolol Succinate 50 mg QHS
Furosemide 40 mg daily
Spironolactone 12.5 mg daily
Nitroglycerin 0.3 mg PRN (as needed) as needed for chest pain.
Clonazepam 0.5 mg TID (3 times a day) as needed for anxiety.
Trazodone 50 mg qhs:prn insomnia
Metoclopramide 25 mg q8 prn
Digoxin 0.0625 mcg daily
Albuterol 90 mcg prn
Aspirin 81 mg daily
K-Dur 20 mEq daily
.
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
9. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
at noon.
10. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
11. Quetiapine 25 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
12. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: Hold for loose stools.
15. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
17. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day) as needed for anxiety.
18. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
19. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
20. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
21. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO four
times a day.
22. 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.
23. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold SBP< 90.
24. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
25. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
26. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
27. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO
once a day.
28. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
29. Morphine 15 mg Tablet Sustained Release Sig: [**1-13**] Tablet
Sustained Releases PO every eight (8) hours as needed for chest
pain.
30. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO once a day.
31. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: check INR on [**2141-4-1**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary: Pancreatitis, Ventricular Tachycardia, Hypotension,
Pneumonia
Secondary: Aortic stenosis, Coronary artery disease
Discharge Condition:
stable, tolerating oral intake
Discharge Instructions:
You presented to the hospital with chest pain and abdominal
pain. There was some initial concern that you were having a
heart attack, but this was ruled out by basic lab work. Your
chest pain resolved in the emergency room and you were chest
pain free on the cardiology floor. It was recommended that you
consider valvuloplasy and angioplasty for your tight aortic
valve in your heart and your blocked blood vessels in your
heart, but you refused this intervention. Your abdominal pain
was felt to be due to inflammation in the pancreas. An
ultrasound of your abdomen did not reveal any stones as the
cause of this inflammation. Your pancreas improved with gently
hydration. While you were in the hospital, you also developed
worsening of your abnormal heart rhythm, requiring many shocks
by your ICD. You were kept sedated and with a breathing tube
since the shocks were so uncomfortable. You [**Location (un) 1834**] a
procedure to help improve your heart rhythm, and this helped
your heart rhythm considerably. You also developed pneumonia
while you were in the hospital, and we are treating you with
antibiotics. We have made several medication changes as listed
below.
.
We made the following changes to your medications:
- sotalol - we discontinued this medication
- trazodone - we discontinued this medication
- spironolactone - we increased this medication from 12.5mg once
a day to 25mg daily.
- reglan - we have decreased this medication from 25mg three
times a day as you need it to 10mg three times a day as you need
it.
- magnesium repletion as given at home.
-your Toprol was changed to short acting metoprolol
-your fluticasone was changed to Advair.
-we started tylenol around the clock, a lidoderm patch and long
acting morphine to treat your chest pain caused by rib
fractures.
-Warfarin to treat the clot in your left arm
.
Please seek immediate medical attention if you experience
worsening shortness of breath, abdominal pain, dizziness, bloody
bowel movements, black tarry bowel movements or any other change
from your baseline health status.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
of 6 pounds in 3 days
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Gastroenterology:
Please follow up with Dr. [**Last Name (STitle) 3708**] on [**4-7**] at 12:30pm. [**Hospital Ward Name 452**] 1,
[**Location (un) **], [**Hospital Ward Name 516**] entrance, [**Hospital1 18**]. If you need to
change this appointment please call [**Telephone/Fax (1) 463**].
.
Cardiology:
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] Phone: ([**Telephone/Fax (1) 2037**]. Date/Time: [**Telephone/Fax (1) 766**] [**4-3**] at 1:00 pm. [**Hospital Ward Name 23**] Building, [**Location (un) 436**] [**Hospital Ward Name 516**], [**Hospital1 18**]
.
Primary care:
Pleaes call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] an appointment
after you leave the rehabilitation facility to discuss this
hospital stay
Completed by:[**2141-3-30**]
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,227
| 165,845
|
20943
|
Discharge summary
|
report
|
Admission Date: [**2194-6-23**] Discharge Date: [**2194-7-3**]
Date of Birth: [**2142-9-23**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 51-year-old white
female patient who is status post coronary artery bypass
grafting x3 at [**Hospital3 **] Medical Center in [**2193-3-12**]. Her surgery was complicated by a sternal wound
infection requiring multiple courses of antibiotics and three
surgical sternal debridements. Patient was subsequently
referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], who is a plastic surgeon at
[**Hospital1 69**] for flap evaluation.
Patient did present for cardiac surgery evaluation as well
due to sternal involvement.
PAST MEDICAL HISTORY: Coronary artery bypass graft as
previously stated.
Insulin dependent-diabetes mellitus.
Hypertension.
Crohn's disease.
Osteoarthritis.
Hypothyroidism.
Depression.
PAST SURGICAL HISTORY: Right ear surgery at age 14.
PREOPERATIVE EVALUATION: Cardiology workup. Her
echocardiogram revealed a normal left ventricular ejection
fraction, no mitral regurgitation, and normal pulmonary
artery pressures.
PREOP MEDICATIONS:
1. Humulin NPH insulin.
2. Glipizide 5 mg p.o. t.i.d.
3. Asacol 400 mg three tablets t.i.d.
4. Celexa 20 mg p.o. t.i.d.
5. Synthroid 88 mcg p.o. q.d.
6. Aspirin 81 mg p.o. q.d.
7. Advil 600-800 mg t.i.d. prn.
8. Lipitor 20 mg p.o. q.d.
9. Lisinopril/hydrochlorothiazide 20 mg/25 mg.
10. Temazepam 15 mg prn.
11. Seroquel 50 mg q.h.s.
ALLERGIES: The patient states an allergy to Bactrim, which
causes a rash.
The patient also underwent a preoperative stress test, which
showed no inducible ischemia and good exercise tolerance.
HOSPITAL COURSE: The patient was taken to the operating room
on [**2194-6-23**], where she underwent a sternal debridement
with pectoral advancement flap with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] and
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Postoperatively, the patient was
transported in good condition to the Cardiac Surgery Recovery
Unit. She was weaned from mechanical ventilation, extubated
the day of surgery.
On postoperative day one, she remained hemodynamically
stable. She had two [**Location (un) 1661**]-[**Location (un) 1662**] drains in place. She was
begun on her preoperative oral medications and transferred
out of the Intensive Care Unit to the telemetry floor. Over
the next few days the patient began to progress slowly with
ambulation. Her cultures from the sternal wound and tissue
reviewed coag-negative Staph and the patient has been
continued on IV Vancomycin for this.
Over the next few days, the patient remained hemodynamically
stable. Continued on her IV Vancomycin. Her drains remained
in for a number of days due to continued drainage.
The patient continued to progress very slowly from Physical
Therapy standpoint, very difficult to get her ambulating and
physically active. On postoperative day four, her TSH was
checked and found to be elevated and her Synthroid was
increased to 100 mcg at that time. However, she remained
very slow to continue ambulation.
On postoperative day four, Hematology consult was obtained
due to persistent leukopenia with a white cell count in the
2.6 to 4.9 range. It was their recommendation to check
peripheral smears, and folate, and B12 levels and continue to
follow her TSH and these are all issues that need to be
continued to be addressed as the patient was discharged from
rehabilitation facility.
On postoperative day five, the [**Location (un) 1661**]-[**Location (un) 1662**] drains were
discontinued. Patient continued to progress very slowly from
an ambulation standpoint. Therefore it was determined that
it would be in the patient's best interest to be discharged
to a rehabilitation facility to help with mobility issues.
Patient has had fluctuating blood glucose levels high in the
170s, but low in the 40s-50s. Her Glipizide was discontinued
as was her NPH insulin, and she was placed on ultimately a
sliding scale coverage of regular insulin for that reason.
Ultimately, the patient will need to be resumed on her
preoperative dose of NPH insulin as well as her oral
hypoglycemic [**Doctor Last Name 360**] Glipizide when she is able to tolerate
p.o. intake more adequately.
The patient remains hemodynamically stable and will be
discharged to a rehabilitation facility today, postoperative
day 10.
CONDITION TODAY: Temperature is 96.5, pulse 72 in normal
sinus rhythm, blood pressure 130/50, respiratory rate 18, and
on room air oxygen saturation was 99 percent. Her intakes
and output for today have not been reported.
PHYSICAL EXAMINATION: Neurologically: The patient is
intact. Pulmonary: Her lungs are clear to auscultation
bilaterally. She has a regular, rate, and rhythm. Her
incision is clean and healing well with no erythema or
drainage. She has no peripheral edema.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. b.i.d.
2. Aspirin 325 mg p.o. q.d.
3. Tylenol 650 mg p.o. q.4h. prn pain.
4. Percocet 1-2 tablets p.o. q.4h prn pain.
5. Milk of magnesia 30 mL p.o. q.d. prn constipation.
6. Mesalamine DR 1200 mg p.o. t.i.d.
7. Celexa 20 mg p.o. t.i.d.
8. Lipitor 20 mg p.o. q.d.
9. Temazepam 15 mg p.o. q.h.s. prn.
10. Seroquel 50 mg p.o. q.h.s.
11. Synthroid 100 mcg p.o. q.d.
12. Lisinopril 20 mg p.o. q.d.
13. Hydrochlorothiazide 25 mg p.o. q.d.
14. Vancomycin 750 mg IV q.12h. for 10 more days after
discharge to be discontinued about the [**2105-7-12**]. Folic acid 1 mg p.o. q.d.
16. Ascorbic acid 500 mg p.o. b.i.d.
17. Ferrous sulfate 325 mg p.o. q.d.
18. Multivitamin one capsule p.o. q.d.
19. Ibuprofen 400-600 mg q.8h. prn pain.
20. Sliding scale regular insulin coverage before meals
and at bedtime for blood glucose of 120-150, she is to
receive 3 units subcutaneously. For a glucose of 151-200,
she is to receive 5 units. Blood glucose of 201-250 7
units. Glucose greater than 250 10 units. The patient
should continue to be re-evaluated on a daily basis for
resumption of her preoperative NPH insulin, which is 8
units at bedtime as well as her Glipizide, which was 5 mg
p.o. t.i.d.
DISCHARGE INSTRUCTIONS: Patient also needs to be followed up
as an outpatient for her leukopenia through her primary care
physician, [**Name10 (NameIs) **] she should also be monitored for her thyroid
replacement and have another TSH level checked in
approximately four more weeks since her Synthroid was
recently increased to 100 mcg. The patient needs to followup
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in approximately four weeks after
discharge from the hospital. She needs to call for an
appointment at [**Telephone/Fax (1) 170**]. Patient is to followup with her
primary care physician, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 14328**], and
she should call for an appointment to be seen upon discharge
from rehabilitation. The patient also needs to be seen by
Plastic Surgery service, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 1416**],
and she should follow up in approximately one week from now
and call to make an appointment.
DISCHARGE DIAGNOSIS: Postoperative sternal wound infection
status post sternal wound debridement and pectoral flaps.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) 5664**]
MEDQUIST36
D: [**2194-7-3**] 07:55:24
T: [**2194-7-3**] 08:46:13
Job#: [**Job Number 55686**]
|
[
"414.00",
"288.0",
"285.1",
"250.00",
"V45.81",
"998.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.22",
"83.82",
"38.93",
"77.81",
"86.74"
] |
icd9pcs
|
[
[
[]
]
] |
4996, 6289
|
7393, 7759
|
1732, 4709
|
6314, 7371
|
939, 1714
|
4732, 4973
|
164, 722
|
745, 915
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,392
| 156,925
|
15374
|
Discharge summary
|
report
|
Admission Date: [**2134-4-21**] Discharge Date: [**2134-4-28**]
Date of Birth: [**2084-1-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine-Iodine Containing
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain, palpitations
Major Surgical or Invasive Procedure:
[**2134-4-21**] Replacement of ascending aorta and hemi arch with a 26-
mm Dacron tube graft using deep hypothermic circulatory
arrest.
Reconstruction of pericardium using CorMatrix Xenograft
scaffolding.
History of Present Illness:
This is a 50 year old male who presented to [**Hospital3 **]
in [**2134-1-5**] with chest pain and palpitations. He was noted
to be in an SVT which resolved with medical therapy. During
evaluation for his SVT, he underwent
echocardiogram which had an incidental finding of ascending
aortic aneurysm of 5.1 cm. Since that time, his aortic aneurysm
has been confirmed by chest CT scan which reports a maximum
diameter of 5.2 cm. Currently on beta blockade, and has had no
further episodes of SVT. Currently doing well with no symptoms
Past Medical History:
Ascending Aortic Aneurysm
History of Supraventricular Tachycardia
Hyperlipidemia
Hemochromatosis, s/p phlebotomy last done 1 week ago
Depression
Colon Adenoma
History of Nephrolithiasis
Alcoholism
Lithotripsy for kidney stones
Social History:
Lives with: Spouse
Occupation: Currently unemployed
Tobacco: denies
ETOH: none in > 10 years - hx of ETOH abuse
Family History:
noncontributory
Physical Exam:
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur - none
Abdomen: Soft[x]non-distended [x] non-tender[x] bowel sounds+
[x]
Extremities: Warm [], well-perfused [x] Edema - none
Varicosities: None [x]
Neuro: alert and oriented x3 nonfocal
Pulses:
Femoral Right: +2 Left: +1
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: no bruit Left no bruit
Pertinent Results:
[**2134-4-27**] 06:10AM BLOOD WBC-7.8 RBC-3.13* Hgb-9.8* Hct-28.8*
MCV-92 MCH-31.3 MCHC-34.0 RDW-13.0 Plt Ct-297
[**2134-4-21**] 01:00PM BLOOD WBC-14.6*# RBC-3.20*# Hgb-11.0*#
Hct-29.5*# MCV-92 MCH-34.3* MCHC-37.1* RDW-13.2 Plt Ct-148*
[**2134-4-25**] 02:05PM BLOOD Neuts-79.3* Lymphs-11.5* Monos-6.1
Eos-2.7 Baso-0.4
[**2134-4-27**] 06:10AM BLOOD Plt Ct-297
[**2134-4-21**] 01:00PM BLOOD PT-14.5* PTT-32.3 INR(PT)-1.3*
[**2134-4-21**] 01:00PM BLOOD Plt Ct-148*
[**2134-4-21**] 01:00PM BLOOD Fibrino-147*
[**2134-4-26**] 08:44AM BLOOD Glucose-99 UreaN-20 Creat-0.8 Na-141
K-4.2 Cl-103 HCO3-29 AnGap-13
[**2134-4-21**] 03:09PM BLOOD UreaN-14 Creat-1.0 Cl-109* HCO3-26
[**2134-4-26**] 08:44AM BLOOD ALT-28 AST-40 LD(LDH)-261* AlkPhos-56
Amylase-29 TotBili-0.6
[**2134-4-23**] 06:30AM BLOOD ALT-35 AST-60* LD(LDH)-322* AlkPhos-49
Amylase-15 TotBili-0.5
[**2134-4-26**] 08:44AM BLOOD Lipase-30
[**2134-4-26**] 08:44AM BLOOD Albumin-3.3* Mg-2.1
Final Report
INDICATION: 50-year-old male with bicuspid aortic valve,
post-ascending aorta
and hemiarch replacement on [**4-21**].
COMPARISON: [**2134-4-24**].
CHEST, PA AND LATERAL: Sequelae of ascending aortic replacement
are seen,
with well-aligned median sternotomy wires and mediastinal clips.
The cardiac
silhouette is again mildly enlarged. The opacity in the left
lung base has
decreased in size, and could represent either atelectasis or
consolidation.
Small bilateral pleural effusions persist, left greater than
right. There is
no pneumothorax. The osseous structures and soft tissues are
unremarkable.
IMPRESSION:
Improving left basilar process. Mild vascular congestion.
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. The patient appears to be in sinus rhythm.
patient. See Conclusions for post-bypass data
Conclusions
PRE-BYPASS:
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is markedly dilated.
The aortic valve is bicuspid. There is a fusion of right and
left coronary cusp with a raphe and no signficiant
calcificiation seen. Mild (1+) aortic regurgitation is seen. The
aortic regurgitation jet is eccentric, directed toward the
anterior mitral leaflet.
The mitral valve appears structurally normal with trivial mitral
regurgitation.
There is no pericardial effusion.
Dr. [**Last Name (STitle) 914**] was notified in person of the results on [**Known lastname 4541**]
before surgical incision.
POST-BYPASS:
Preserved biventricular systolic function. LVEF 55%.
The aortic insufficiency is similar to prebypass.
The thoracic ascending aortic graft is intact.
Trivial MR [**First Name (Titles) **] [**Last Name (Titles) **].
The descending thoracic aortic graft is intact.
Brief Hospital Course:
Admitted [**4-21**] and underwent replacement of ascending aorta and
hemiarch replacement. See operative report for further details.
He received cefazolin for perioperative antibiotics. He was
transferred to the intensive care unit for post operative
management. In the first twenty four hours he was weaned from
sedation, awoke, neurologically intact, and was extubated
without complications. On post operative day one his chest
tubes were removed and he was transferred to the post operative
floor. Physical therapy worked with him on strength and
mobility. He developed fevers with chills, cultures were
obtained but no evidence of infection. Noted for distended
abdomen and xray revealed dilated loops but no obstruction. His
liver function test were normal and he received bowel
medications with good results.
On [**2134-4-24**] pm he developed significant erythema on chest and was
started on cefazolin. He was continued to be monitored,
infectious disease was consulted due to continued chills
although improvement in white blood cell count and erythema. On
post operative day six he had no chills afebrile for forty eight
hours, white count normal, and erythema continued to improve.
PICC line was placed for Cefazolin IV x 7 days. Cleared for
discharge home with services on post operative day seven with
follow up in clinic [**2134-5-4**] prior to completion of intravenous
antibiotics. Once IV antibiotics completed he will in addition
receive one week of oral keflex [**Date range (1) 44643**]. IV abx ends on [**5-5**].
Medications on Admission:
Metoprolol SR 150 mg po daily
Simvastatin 20 mg po daily
Sertraline 200 mg po daily
Discharge Medications:
1. Cefazolin 10 gram Recon Soln Sig: Two (2) gm Injection Q8H
(every 8 hours) as needed for sternal erythema for 7 days:
completes [**5-5**].
Disp:*qs gm * Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
5. Zoloft 100 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
6. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. 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*
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*1*
10. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 1 weeks: for seven days start [**5-6**]-complete [**5-13**].
Disp:*28 Capsule(s)* Refills:*0*
11. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*70 ML(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3894**] Health VNA
Discharge Diagnosis:
Ascending aortic aneurysm and Proximal aortic arch aneurysm s/p
ascending aorta and hemiarch replacement
Sternal erythema
Bicuspid aortic valve with mild aortic insufficiency
Supraventricular Tachycardia
Hyperlipidemia
Hemochromatosis, s/p phlebotomy last done 1 week ago
Depression
Colon Adenoma
History of Nephrolithiasis
Alcoholism
Lithotripsy for kidney stones
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
[**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2134-5-4**] 1:00
Please call to schedule appointments
Primary Care Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-6**] weeks [**Telephone/Fax (1) 31019**]
Cardiologist Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **] in [**2-6**] weeks
Antibiotics - cefazolin IV for sternal wound - follow up in
clinic with Dr [**Last Name (STitle) 914**] [**5-4**] prior to completion
Completed by:[**2134-4-28**]
|
[
"998.59",
"272.4",
"427.1",
"401.9",
"746.4",
"560.1",
"441.2",
"311",
"275.0",
"511.9",
"E878.2",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.45",
"39.61",
"37.49"
] |
icd9pcs
|
[
[
[]
]
] |
8438, 8500
|
5332, 6880
|
316, 535
|
8909, 9005
|
2112, 5309
|
9545, 10108
|
1496, 1513
|
7015, 8415
|
8521, 8888
|
6906, 6992
|
9029, 9522
|
1528, 2093
|
251, 278
|
563, 1099
|
1121, 1350
|
1366, 1480
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,778
| 147,225
|
14303
|
Discharge summary
|
report
|
Admission Date: [**2199-10-9**] Discharge Date: [**2199-10-15**]
Service: MEDICINE
Allergies:
Morphine / Sulfa (Sulfonamides)
Attending:[**Last Name (NamePattern1) 293**]
Chief Complaint:
Seizure activity and hypertensive urgency
Major Surgical or Invasive Procedure:
Intubation in ICU
Intrajugular vein IV access
History of Present Illness:
83 y.o with [**Hospital 7235**] medical problems who initially presented to
OSH with N/V and confusion and was given neurontin and ativan
for restless legs. Patient also noted to have a WBC of 21.7,
temperature of 100F and a positive UA treated with Levofloxacin.
Soon after she had tonic-clonic seizure,given ativan and
transferred to [**Hospital1 18**].
[**Hospital1 18**]-ED Hx: patient agitated and restless on arrival ([**10-9**])
and noted to be hypertensive to SBP > 200. Also, hypoxic and CXR
consistent with CHF. Patient then sedated with ativan and
electively intubated for head CT and LP. Her DNR/DNI code status
was reversed after discussion with family for purposes of Head
CT and LP. Patient also received one dose of Lasix 80 mg, Vanco,
Levo and 2gm ceftriaxone. While in EW, she ruled in for MI, R
inguinal hematoma following femoral line attempt with subsequent
HCT drop from 34 to 28 in ED. Patient sent to MICU at 0200
[**10-10**].
In MICU CT Abd/pelvis [**10-9**] showed 11x2 cm hematoma, vascular
consulted: no surgical intervention, pt recieved total of
3units of PRBCstransfused and Hct stabilized. Patient's head CT
[**10-9**] showed left occipital density possible c/w infarction but
no focal neuro findings; MRI [**10-10**] r/o??????d CVA, CT findings
thought [**1-14**] hypertensive changes. LP showed no blood and neg CSF
culture. HTN controlled w/ Lopressor, nifedipine, clonidine,
and isosorbide dinitrate ?????? weaned from nitro drip [**10-13**]
NSTEMI was felt to be likely [**1-14**] demand ischemia,EKG showed no
further ischemic changes.
The pt also treated with 3d course of ceftriaxone for presumed
UTI (culture negative.
Pt also had fluctuating sensorium in ICU which appeared resolved
at time of transfer to the floor.
No sz activity observed at [**Hospital1 18**] and no anti-epileptics given
here.
Past Medical History:
Recent adm ([**Hospital1 **] [**Location (un) 620**] [**6-16**]) for pna, CHF excerb, CRF (baseline
Cr 1.4)
CHF ([**3-17**] echo BIDN: mild LVH, nl LVEF, 1+ MR)
Anemia (Hct range 3/04 ?????? [**8-17**]: 24.0-35.6)
CAS s/p MI in 64 with normal dobutamine echo ([**6-16**])
Hypercholesterolemia
HTN
DM-2
Achalasia
Hiatal Hernia
Hypothyroidism
S/p Right mastectomy for breast CA
Colon CA in [**2171**]
Depression with psychosis
Social History:
lives in [**Location 620**] with husband and is an ex nurse. Occaisional
ETOH, stopped smoking 40 years ago.
Family History:
Non-contributory
Physical Exam:
Vitals BP 134/50 HR 79 RR 20 Tc 98.7 Tmax 98.7
SAO2 97%RA FSBG: 130??????s-160??????s
GEN: A&Ox3, NAD, pleasant and cooperative with exam
HEENT: PERRL, EOMI, OP clear, MM slightly dry, no LAD
LUNGS: CTAB
HEART: RRR, no M/G/R
ABDOMEN: soft, NTND, NABS
EXT: no CCE
NEURO: 5/5 strength bilat. Upper/lower extremities, good grip,
CN II-XII grossly intact
PSYCH: goal-oriented speech and thought processes, denies A/V
hallucinations, prior delirium resolved
Pertinent Results:
Heme:
[**2199-10-9**] 09:00PM BLOOD WBC-12.4* RBC-2.59*# Hgb-7.6*# Hct-23.3*
MCV-90 MCH-29.4 MCHC-32.7 RDW-17.3* Plt Ct-217
[**2199-10-9**] 09:00PM BLOOD Neuts-85* Bands-0 Lymphs-12* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2199-10-9**] 09:00PM BLOOD PT-14.0* PTT-29.5 INR(PT)-1.2
[**2199-10-14**] 05:41AM BLOOD WBC-10.7 RBC-4.15* Hgb-12.5 Hct-36.5
MCV-88 MCH-30.1 MCHC-34.2 RDW-16.4* Plt Ct-160
Iron studies:
[**2199-10-11**] 03:44AM BLOOD calTIBC-179* Ferritn-353* TRF-138*
Chemistry:
[**2199-10-9**] 09:00PM BLOOD Glucose-155* UreaN-24* Creat-1.5* Na-133
K-4.0 Cl-103 HCO3-22 AnGap-12
[**2199-10-14**] 05:41AM BLOOD Glucose-140* UreaN-21* Creat-1.0 Na-137
K-4.1 Cl-105 HCO3-23 AnGap-13
Cardiac Enzymes:
[**2199-10-9**] 03:14PM BLOOD LD(LDH)-268* CK(CPK)-242*
[**2199-10-9**] 09:00PM BLOOD CK(CPK)-247*
[**2199-10-10**] 04:30AM BLOOD CK(CPK)-194*
[**2199-10-9**] 03:14PM BLOOD CK-MB-8 cTropnT-0.13*
[**2199-10-9**] 09:00PM BLOOD cTropnT-0.09*
[**2199-10-10**] 04:30AM BLOOD CK-MB-5 cTropnT-0.06*
Endocrine:
[**2199-10-12**] 04:09AM BLOOD TSH-2.8
Brief Hospital Course:
Pt. was brought to [**Hospital1 18**]-ED on [**10-9**] for seizure activity and
SBP 200 at OSH. At [**Hospital1 42457**], pt was intubated and taken to CT
scanner; a R. femoral line attempt was complicated by an
inguinal hematoma with subsequent Hct drop. Pt was transfered
to MICU for dropping Hct and continued hypertensive urgency. In
MICU, blood pressure was controlled w/ nitro drip, lopressor,
nifedipine, clonidine, and isosorbide dinitrate. Pt was ruled in
for NSTEMI by enzymes. Anemia was corrected with 3U PRBC and
Hct stabilized. Mental status also fluctuated during MICU
course. Pt was treated with Vanco, Levo, and Ceftriaxone for
clinical signs of sepsis and UTI (positive UA/negative
cultures) prior to adm. Pt was transfered to medical floor
(FAR7)once stabile on [**10-13**] for monitoring. On FAR7, pt.
remained hemodynamically stable and afebrile, mental status
improved to baseline, there was no seizure activity, and pt was
discharged to home with services in good condition.
Problem list:
1. Hypertensive emergency - treated with mutliple agents in
MICU, BP improved and remained stable during course on FAR7 and
was discharaged on PO medications only.
2. Seziure activity - EEG showed underlying structural
abnormalities, no antiepileptics were given at [**Hospital1 18**] as per
neurology recommendations. Outpatient MRI also recommended.
3. NSTEMI - probably secondary to demand ischemia during MICU
course. Pt has remained hemodynamically stable during course on
FAR7 with one episode of angina (with no changes in EKG) that
pt. describes as typical of her 20yr pre-adm history.
4. CHF - patient stabilized with lopressor, diuresis (Lasix),
and other antihypertensives in MICU. No signs/sx of CHF during
course on FAR7
5. Anemia - pt experienced acute drop in Hct during MICU course,
most likely secondary to R. inguinal hematoma. Hct stabilized
after 3U PRBC given in MICU and has remained stable during FAR7
course.
6. L. occipital lobe cerebral ischemia - findings on CT during
MICU course ruled out for CVA by MRI scan. CT findings most
likely secondary to hypertensive episode.
7. AMS - pt. experienced fluctuating sensorium in MICU but was
A&Ox3 on transfer to FAR7 and remained so throughout rest of
hospital course.
8. UTI - treated with 3d course of ceftriaxone completed in
MICU. Pt was asymptomatic on adm to FAR7 and remained so
throughout rest of hospital course.
Medications on Admission:
On transfer to FAR7:
Insulin SC Sliding Scale
Acetaminophen 325-650 mg PO Q4-6H:PRN headache
Isosorbide Dinitrate 50 mg PO TID
Allopurinol 100 mg PO DAILY
Lansoprazole 30 mg PO DAILY
Clonidine HCl 0.1 mg PO BID
Levothyroxine Sodium 125 mcg PO
Docusate Sodium 100 mg PO BID
Metoprolol 150 mg PO TID
Fentanyl Patch 75 mcg/hr TP Q72H as per home regimen
Midazolam HCl 1 mg IV Q6H:PRN agitation not controlled with
Zyprexa
Fluoxetine HCl 10 mg PO DAILY
Miconazole Powder 2% 1 Appl TP TID:PRN
Nitroglycerin 0.2-1.8 mcg/kg/min IV DRIP
Heparin 5000 UNIT SC BID
Nifedipine 60 mg PO Q8H
Hydralazine HCl 20 mg PO Q6H
Olanzapine 2.5 mg PO TID:PRN
Hydralazine HCl 20 mg IV ONCE
Ropinirole HCl 0.25 mg PO HS restless legs
Simvastatin 10 mg PO DAILY
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*qs Tablet(s)* Refills:*2*
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*qs Tablet(s)* Refills:*2*
3. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*qs Tablet(s)* Refills:*2*
4. Fluoxetine HCl 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*qs Capsule(s)* Refills:*2*
5. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*qs * Refills:*2*
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
Disp:*qs * Refills:*0*
7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*qs Capsule, Delayed Release(E.C.)(s)* Refills:*2*
8. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*2*
9. Ropinirole Hydrochloride 0.25 mg Tablet Sig: One (1) Tablet
PO HS (at bedtime) as needed for restless legs.
Disp:*30 Tablet(s)* Refills:*2*
10. Nifedipine 20 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
Disp:*4 Capsule(s)* Refills:*2*
11. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for headache.
Disp:*qs Tablet(s)* Refills:*0*
13. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
14. Valsartan 80 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
15. Clonidine HCl 0.1 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Hypertensive urgency complicated by NSTEMI and anemia
Seizure
hypertension
non-ST elevation MI
COngestive heart failure
diabetes mellitus
Discharge Condition:
Good
Discharge Instructions:
Please take all medications as instructed, please return to ED
for unusual chest pain, shortness of breath, seizure, elevated
blood pressure or worrisome deterioration of condition.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 20**] [**Last Name (NamePattern1) 569**] [**Telephone/Fax (1) 3259**] Call to schedule
appointment
|
[
"518.81",
"250.00",
"424.0",
"244.9",
"599.0",
"E878.8",
"410.71",
"998.12",
"401.0",
"285.1",
"780.39",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.04",
"03.31",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9393, 9442
|
4419, 5425
|
289, 337
|
9625, 9631
|
3333, 4035
|
9861, 10028
|
2804, 2822
|
7624, 9370
|
9463, 9604
|
6863, 7601
|
9655, 9838
|
2837, 3314
|
4052, 4396
|
208, 251
|
365, 2211
|
5439, 6837
|
2233, 2661
|
2677, 2788
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,599
| 161,114
|
22317
|
Discharge summary
|
report
|
Admission Date: [**2177-9-5**] Discharge Date: [**2177-9-10**]
Date of Birth: [**2177-9-5**] Sex: F
Service: Neonatology
HISTORY: This female infant is a 3.28 kg product of a 38
week gestation who was transferred from [**Hospital **] Hospital for
treatment of severe anemia and fetal maternal hemorrhage.
Mother is a 27 y.o. G1P0 to now 1 mother. Serologies: O
negative, RI, RPR NR, HepBsAg negtive, GBS negative.
Pregnancy was complicated by diet-controlled gestational
diabetes, 2 vessel umbilical cord, and polyhydramnios.
Mother was followed on a weekly basis. Just two days after her
last assessment mother noticed decreased fetal movement. She
was admitted to [**Hospital **] hospital where biophysical profile
was 0 out 8. Stat cesarean section was performed with no
evidence of abruption.
Infant emerged with poor respiratory effort, hypotonic and
pale. She was given positive pressure ventilation with good
response. Apgars were 6 and 6. In the special care nursery,
she was given volume resuscitation (normal saline bolus x 3)
and 15 cc/kg of O negative blood via UVC. CBC and blood
culture sent. She was started on ampicillin and gentamycin.
Venous blood gas 7.12, TCO2 22, hematocrit was 9. The infant
was transported to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] on a
Dopamine drip at 10 ug per kg per minute.
ADMISSION PHYSICAL EXAMINATION: Birth weight was 3.28 grams
(75th percentile), length was 48 cm (50th percentile), head
circumference 36 cm (greater than 90th percentile). The
infant was pale, poorly perfused. Anterior fontanel flat.
Clear breath sounds with occasional grunts. Normal S1 and S2.
No murmurs. Pulses full. Abdomen soft. No
hepatosplenomegaly. Normal female external genitalia. Anus
patent. Moves all extremities. Slightly decreased in tone.
Good cry.
HISTORY OF HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY: The infant initially required nasal cannula
oxygen to maintain saturations greater than 95 percent. She
has been stable in room air since day of life No. 2, and has
had no further issues.
CARDIOVASCULAR: The infant had volume resuscitation at the
time of delivery requiring normal saline boluses x 3 and was
transported to the [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] on
Dopamine. Dopamine was discontinued upon admission to the
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. She has been
cardiovascularly stable throughout her admission with no
murmur on exam.
FLUID AND ELECTROLYTES: Her birth weight was 3.280 kg. Her
discharge weight is 3.125 kg. She was initially started on 60
cc/ kg per day of D10W. Enteral feedings were initiated on
day of life No. 2 and the infant is currently po ad lib
feeding Similac 20 calorie or BM taking in good amounts.
GASTROINTESTINAL: Her peak bilirubin was on day of life 4,
of 10.6/0.3. Her most recent bilirubin on [**9-11**] was
10.3/0.3.
HEMATOLOGY: A Kleihauer-Betke test at [**Hospital **] Hospital
confirmed the fetal-maternal hemorrhage. The value was 3.78%
(approximately 50cc of fetal blood loss per 1 percent).
Hematocrit on admission was 9. The infant received a total
of 55 cc per kg of packed red blood cells. Her most recent
hematocrit was on [**9-11**] is 53.7 with a reticulocyte count
of 5.5. The patient's blood type is O positive, Coomb's
negative.
The infant also had thrombocytopenia presumably due to the
extent of whole blood that was lost with the fetal-meternal
hemorrhage. Her lowest count was 53 on [**9-10**]. Today, on [**9-11**],
her platelet count was 116.
There is no clinical evidence to suggest that the infant
experienced multi-system involvment as a result of the
fetal-maternal hemorrhage. Renal function tests and liver
function testes were all within acceptable ranges. And,
fortunately, the infant is demonstrating normal neurological
examinations as well as having a reassuring head ultrasound.
INFECTIOUS DISEASE: CBC and blood culture was obtained on
admission. CBC was benign. Blood culture remained negative
at 48 hours and ampicillin and gentamycin were discontinued.
RENAL: A renal ultrasound was performed due to the 2-vessel
cord and the study was normal.
NEUROLOGICAL: The infant's neurological exam has been
appropriate for gestational age. Head ultrasound was
performed on [**9-8**] demonstrated a germinal matrix cyst.
No intracranial bleeding, or parenchymal abnormalities were
noted.
AUDIOLOGY: Automated auditory brain stem response was
performed and the infant passed.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43143**], telephone No. [**Telephone/Fax (1) 58128**]. Fax No. [**Telephone/Fax (1) 46702**].
FEEDS AT DISCHARGE: Ad lib feeds of Sim20 or
breastfeeding/breastmilk.
MEDICATIONS:
None.
CAR SEAT POSITION SCREENING: Not indicated as gestational age
was greater than 37 weeks.
STATE NEWBORN SCREEN: Sent per protocol; however, this was
after multiple blood transfusion. The infant will need a
repeat state screen sent.
IMMUNIZATIONS: The infant received hepatitis B vaccine on
[**2177-9-9**].
DISCHARGE DIAGNOSES:
1. Fetal maternal hemorrhage.
2. Transient hypotension.
3. Transient oxygen requirement.
4. Anemia, resolved.
5. Thrombocytopenia, resolving.
6. Rule out sepsis, on antibiotics for 48 hours.
7. 2-vessel umbilical cord, with normal renal ultrasound.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) 56045**]
MEDQUIST36
D: [**2177-9-9**] 23:23:46
T: [**2177-9-10**] 03:17:18
Job#: [**Job Number **]
|
[
"772.0",
"V05.3",
"762.6",
"776.5",
"796.3",
"287.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.55",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
4776, 4974
|
5393, 5896
|
1949, 4718
|
1469, 1920
|
4989, 5372
|
4743, 4752
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,844
| 141,196
|
34681
|
Discharge summary
|
report
|
Admission Date: [**2188-12-10**] Discharge Date: [**2188-12-18**]
Date of Birth: [**2109-3-11**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Oxycontin / Penicillins / Prednisone / Codeine /
Advair Diskus
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Left leg pain and swelling
Major Surgical or Invasive Procedure:
[**2188-12-10**]: Four compartment fasciotomies of left leg (Dr.
[**Last Name (STitle) 1005**]
[**2188-12-12**]: closure of left lower extremity fasciotomies. (Dr.
[**Last Name (STitle) **]
[**2188-12-15**]: AVNRT ablation by EP cardiology
History of Present Illness:
Mrs. [**Known lastname **] is a 79 year old female with history of NSCLC with
liver metastases s/p right middle lobe lobectomy and
chemotherapy with taxol, carboplatin, and avastin. She was
recently admitted from [**Date range (1) 79530**] for managment of recent
bilateral pulmonary embolism after presenting with SOB in her
[**Date range (1) 5564**], Dr.[**Name (NI) 3279**], office on [**2188-10-21**]. She was
discharged on enoxaparin 90 mg [**Hospital1 **] and was injecting this into
her bilateral thighs. Around [**2188-12-7**] she started noticing calf
and ankle swelling and tightness. She underwent a u/s at
[**Hospital1 **] which, per report, was negative for DVT. She presented
to [**Hospital1 18**] on [**2188-12-10**] where she was evaluated by the orthopedic
trauma service for concern for hematoma-related left calf
compartment syndrome. She underwent urgent left calf fasciotomy
on [**2188-12-10**]. She recovered well from that procedure without much
pain or discomfort.
.
On the morning of [**2188-12-15**], Mres. [**Known lastname **] was thought to be in
atrial fibrillation with RVR with rate in the 170s on the floor.
She got IV metoprolol x2, and was found to be hypotensive with
systolic BPs in 80s. She was evaluated by the MICU team who
noted a regular narrow complex tachycardia. Vagal maneuvers were
unsuccessful. BP was 90/40 on transfer to the MICU. She denied
chest pain, palpitations, shortness of breath, or dizziness at
that time. She did endorse constipation and a cough productive
of sputum.
.
In the MICU, the patient was noted to be in AVNRT which would
only break for about 5 seconds with adenosine. After getting 11
doses of adenosine over the course of the morning on [**2188-12-14**]
without good effect, EP consult was obtained. On [**2188-12-15**] the
AVNRT was ablated; there were multiple ectopic atrial beats
noted.
.
She was transferred to the medicine floor on [**2188-12-16**]. On the
floor she reports feeling well. She denies pain except for pain
in her leg at the site of her recent surgery. No headache, SOB,
CP, palpitations, N/V/D/C. Last BM was yesterday. Has been OOB
with PT in MICU, with minimal weight bearing on LLE. Denies
fevers, chills, urinary or bowel habit changes. She states that
her last chemotherapy was received in [**2188-9-6**]. Prior to
her episode of pulmonary embolus in [**10-15**], she felt in her usual
state of health.
.
ROS was otherwise essentially negative. The pt denied recent
unintended weight loss, fevers, night sweats, chills, headaches,
dizziness or vertigo, changes in hearing or vision, neck
stiffness, dysphagia, odynophagia, heartburn, nausea, vomiting,
diarrhea, constipation, melena, hematochezia, cough, hemoptysis,
wheezing, shortness of breath, chest pain, palpitations,
orthpnea, joint pain.
Past Medical History:
1. Non small cell lung cancer (adenocarcinoma)
*[**2186**]: T1 N0 2.6-cm moderately differentiated
adenocarcinoma s/p right middle lobectomy at [**Hospital1 2177**] [**2186-7-11**] by
Dr. [**First Name (STitle) **].
*[**2187**]: increasing right lower lung nodule. [**2187-7-31**] biopsy
consistent with non-small cell carcinoma, favor
adenocarcinoma.
*[**2188**]: MRI of her brain done at [**Hospital6 **] on
[**2188-6-26**]: no evidence of tumor. CT-guided biopsy of liver
[**7-15**]: showed poorly differentiated metastatic NSCLC.
2. Allergic rhinitis.
3. Hypertension.
4. Hyperlipidemia.
5. Gastroesophaeal reflux disease.
6. Esophageal stricture, status post-dilation.
7. Status post-total hip replacements and one knee replacement.
8. Osteoarthritis.
9. Chronic obstructive pulmonary disease: emphysema plus
restriction secondary to volume loss from lobectomy.
Social History:
She is married and lives with her husband, [**Name (NI) **]. They winter in
[**State 108**] and they live in [**Location (un) 1110**], MA the rest of the time. She
does not work anymore, but used to work as an assistant to a
thoracic surgeon at the [**Location 1268**] VA. She does not drink any
alcohol. She smoked one pack a day for 30-years, but quit in
[**2162**].
Family History:
There is no family history of any lung disease. Her brother had
some type of cancer, which was either a thyroid cancer or throat
cancer, the patient is not sure.
Physical Exam:
ON ADMISSION (per orthopedic surgery notes):
AVSS
NAD
NCAT
RRR, S1S2
CTAB
Soft, NTND
RLE - NVI. SILT. compartments soft. Mild pedal edema
LLE - NVI. SILT. compartments mildly tense. Calf is markedly
swollen with ecchymossis over the medial malleolus.
AT DISCHARGE:
Vitals: T: 97.3 BP: 141/71 P: 91 R: 18 SaO2: 96%RA.
General: Awake, alert, NAD, pleasant, slightly HOH.
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, OP clear.
Neck: supple, no significant JVD or carotid bruits appreciated.
Pulmonary: Lungs CTA bilaterally, no wheezes, rhonchi or rales.
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated.
Abdomen: NABS, soft, NT, ND, no rebound or guarding. There are
stable, firm ecchymoses over the abdomen in areas where she has
received injections.
Extremities: Able to move all 4 extremities. +2 non-pitting
edema bil [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]>R, 2+ radial, DP pulses b/l difficult to
appreciate secondary to edema, but [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**] are warm and
well perfused.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: no rashes or lesions noted. Ecchymoses as noted above
over abdomen.
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. Normal bulk, strength and tone throughout. No
abnormal movements noted. No deficits to light touch throughout.
No dysarthria, intention or action tremor.
Pertinent Results:
ADMISSION LABS:
[**2188-12-10**] 04:50PM BLOOD WBC-8.6# RBC-2.66* Hgb-8.2* Hct-24.4*
MCV-92 MCH-30.7 MCHC-33.4 RDW-17.5* Plt Ct-281#
[**2188-12-10**] 04:50PM BLOOD PT-14.0* PTT-37.4* INR(PT)-1.2*
[**2188-12-10**] 04:50PM BLOOD Glucose-114* UreaN-17 Creat-1.1 Na-135
K-4.1 Cl-100 HCO3-24 AnGap-15
[**2188-12-12**] 05:46AM BLOOD CK(CPK)-585*
[**2188-12-12**] 05:46AM BLOOD CK-MB-3 cTropnT-<0.01
[**2188-12-12**] 04:22PM BLOOD CK-MB-4 cTropnT-0.04*
[**2188-12-13**] 05:06AM BLOOD CK-MB-3 cTropnT-0.03*
[**2188-12-12**] 05:46AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.7
[**2188-12-12**] 05:46AM BLOOD TSH-1.1
[**2188-12-10**] 04:58PM BLOOD Glucose-112* Lactate-1.7 Na-137 K-3.9
Cl-97* calHCO3-26
IMAGING:
LLE U/S [**2188-12-10**]: IMPRESSION:
1. No deep venous thrombosis.
2. Large avascular hypoechoic collection on the left medial calf
at site of palpable mass. Correlate clinically as this may
represent a seroma, less likely infected collection.
CT Chestm11/5/09: Impression:
1) Decreased pre-tracheal lymph nodes, with stable right hilar
and subcarinal lymphadenopathy.
2) Stable large subpulmonic effusion associated with thickening
of the
overlying pleura and enhancement suggesting metastatic disease.
3) Status post right lobectomy with atelectasis at the suture
line unchanged.
4) Stable multiple solid and ground-glass nodules: the largest,
in the
anterior segment of the left upper lobe, is lobulated and has
punctate
fat-attenuation. This was not PET-avid and may represent an
unrelated
non-aggressive abnormality, such as a hamartoma.
5) Mild coronary artery and aortic valvular calcification.
6) Enlargement of the left adrenal gland is stable, probably
metastasis.
7) No pulmonary embolism, aortic dissection or aneurysm.
DISCHARGE LABS:
[**2188-12-18**] 06:50AM BLOOD WBC-5.5 RBC-3.42* Hgb-9.6* Hct-30.4*
MCV-89 MCH-28.1 MCHC-31.6 RDW-16.1* Plt Ct-365
[**2188-12-18**] 06:50AM BLOOD Glucose-102 UreaN-13 Creat-0.7 Na-139
K-4.3 Cl-100 HCO3-34* AnGap-9
[**2188-12-18**] 06:50AM BLOOD Calcium-8.4 Phos-2.5* Mg-1.7
Brief Hospital Course:
Mrs. [**Known lastname **] is a 79 year old female with history of NSCLC
metastatic to the liver, recent bilateral PE diagnosis s/p
fasciotomy on [**2188-12-10**] for left calf hematoma-related compartment
syndrome. She was initially transferred to MICU for tachycardia
and hypotension and is s/p AVNRT ablation on [**2188-12-15**]. She was
transferred to the medicine floor on [**2188-12-16**] for further
management. Her complete hospital course is outlined as a
timeline and by problem below:
===============================
EMERGENCY DEPARTMENT/ORTHOPEDICS COURSE:
Mrs. [**Known lastname **] was seen in the ED by orthopedic surgery and her
LLE compartments were measured. The pressures (in mm Hg) were
45, 78, 35, and 38 for the posterior superficial, posterior
deep, anterior, and lateral comparments, respectively. She was
taken urgently to the OR for 4 compartment decompressive
fasciotomies. She tolerated the procedure well and recovered in
the PACU without acute events. Her HCT post-op was 24 and she
was given 2 units of PRBCs for acute blood loss anemia.
On the morning of [**2188-12-12**], the patient went into a
supra-ventricular tachycardia rhythm that was persistent for
over an hour with HR up to 180. The patient was asymptomatic
and denied any CP/SOB/Dizziness/HA/Blurry vision. She was given
10mg IV lopressor but her heart rate only came down to the 160s
and SBPs were in the 80s to 90s. Carotid massage and valsalva
maneuvers were also unsuccessful. The MICU team was consulted
at this point because it was likely that she would require
either adenosine or electro-cardioversion. The patient was
transferred to the MICU and given adenosine, after which her
heart rate came down to the 80s. She remained stable in normal
sinus rhythm afterwards and was considered stable enough to
proceed to the operating room for closure of fasciotomies of the
left leg.
================================
MICU COURSE:
SVT: Pt was re-started on her home dose of diltiazem ass her
episode on SVT to the 190s occured in the setting of her beeing
off this medication. Her dose was titrated up to 90mg qid. Pt
again developed SVT into the 190s on more than her home dose of
diltiazem. This then recurred a doszen times, each episode was
symptomatic with SOB and systolic in 80s; they all terminated
with 6mg IV adenosine. The frequency of these episodes decreased
with esmolol drip. EP was consulted and ablation was sucessful.
COMPARTMENT SYNDROME: Post-op keflex discontinued on [**2188-12-16**].
[**Date Range 1957**] signed off. Patient has follow-up with orthopedics within
two weeks of discharge on [**2188-12-25**].
PE: Oncology comfortable with pt being on coumadin over lovenox
for PE even in setting of malignancy given her significant
complication on lovenox. INR bumped to 6 after one dose of 5mg
coumadin in the setting of concurrent Abx. Pt called out of MICU
on 2mg daily, maintenance dose to be determined.
==================================
MEDICINE WARDS COURSE POST MICU (by problem):
#1. AV nodal non-reentry tachycardia: EKG on admission to MICU
appeared to be narrow complex tachycardia. Patient convereted to
NSR with 6mg IV adenosine x1. Hypotension resolved at that time,
but patient quickly reverted to AVNRT refractory to multiple
doses of adenosine. Underlying causes were thought to be due to
recent surgery, 2 missed doses of diltiazem on the day prior,
new pulmonary embolism, hyperthyroidism, or myocardial
infarction.
-Status post ablation on [**2188-12-15**], HR and BP have been stable
since.
-Patient was monitored on telemetry: no events x >72 hours
post-ablation.
.
#2. Bilateral pulmonary emboli:: Likely secondary to known
malignancy.
-Mrs. [**Known lastname **] was on warfarin 2 mg daily, INR on admission to
medicine was therapeutic at 2.2; remained therapeutic at 2.7 at
time of discharge (goal [**3-11**]).
-Continue with current dose of warfarin, monitor daily INR
initially as outpatient, then at least 2-3 times weekly to
titrate dose appropriately.
.
#3. Left lower extremity compartment syndrome: Due to hematoma
that patient developed while on lovenox for bilateral pulmonary
emboli.
-Status post fasciotomy and subsequent wound closure by
orthopedics.
-Patient completed post-operative course of antibiotics with
Keflex on [**2188-12-16**].
-Per MICU sign out, [**Date Range 5564**] Dr. [**Last Name (STitle) 3274**] is okay with
treating patient with coumadin vs. Lovenox.
.
#4. Normocytic anemia: Baseline HCT approximately 30; 28.9 on
admission to floor.
-Monitored HCT daily, stable at 30.4 at time of discharge.
.
#5. Metastatic NSCLC:: Patient not on any current treatment;
per pt, completed last chemotherapy course in [**9-14**]. Dr.
[**Last Name (STitle) 3274**] has asked that the patient has follow-up with him
within two weeks of discharge from the rehabilitation facility.
Patient has been informed of same.
.
#6. Hypertension/Hyperlipidemia: Continued patient's home
medications.
.
#7. COPD: Mrs. [**Known lastname **] has emphysema superimposed on a baseline
of restriction related to volume loss from her lobectomy.
Continued patient's home medications for this.
.
Mrs.[**Doctor First Name 79531**] code status was confirmed as FULL CODE during
this admission. Her husband, [**Name (NI) **] is her HCP. She was deemed
medically stable and fit for discharge to a rehabilitation
facility on [**2188-12-18**]. She will have close follow-up scheduled
with her primary care provider, [**Name10 (NameIs) 5564**], and orthopedic
surgery as an outpatient.
Medications on Admission:
Lovenox 90mg IM q12hr
Aspirin 162mg daily
Lipitor 20mg qHS
Spiriva INH 18mcg 1 puff daily
Combivent 2 puffs QID
Diltiazem 60mg PO TID
Protonix 40mg daily
KCl 20 Meq [**Hospital1 **]
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) as
needed for risk of bleeding.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Hold for INR> 3.0.
7. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): Hold for SBP<110, HR<55.
8. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain: Hold for sedation, RR<15. Do not
drive or operate machinery while on this medication. This
medication may cause drowsiness.
9. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) puff Inhalation once a day.
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day: Hold
for K>4.8.
11. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 3548**] [**Doctor Last Name 3549**] Nursing & Rehabilitation Center - [**Location (un) 1110**]
Discharge Diagnosis:
Left lower extremity compartment syndrome.
AV nodal non-reentrant tachycardia.
Secondary:
Bilateral pulmonary emboli.
Non small cell lung cancer with liver metastases
Discharge Condition:
Stable, NSR at 96 bpm, oxygenating 96% on room air.
Discharge Instructions:
Mrs. [**Known lastname **], you were admitted to the hospital because of left
lower leg swelling. You had a surgery to relieve this swelling.
You were also noted to have an irregular heartbeat, and
underwent a procedure called an ablation to fix this arrythmia.
You were deemed medically stable and fit for discharge to a
rehabilitation facility on [**2188-12-18**].
The following changes have been made to your medications:
NEW MEDICATIONS:
Warfarin 2 mg daily
STOP TAKING THESE MEDICATIONS:
Lovenox injections every 12 hours.
Please call your doctor or go to the nearest emergency room if
you have increasing shortness of breath, chest pain, you lose
consciousness, have a fever >100.4, you have diarrhea or
vomiting for more than 24 hours, you have bleeding, or other
concerning symptoms.
Follow-up appointments have been scheduled for you as outlined
below. It was a pleasure caring for you during this hospital
stay.
Followup Instructions:
The following appointments have been scheduled for you:
Provider: [**Name10 (NameIs) **] XRAY ([**Hospital Ward Name 23**] Clinical Center, [**Location (un) 551**])
Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2188-12-25**] 7:40 AM
Provider: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP (Orthopedics)
Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2188-12-25**] 8:00 AM
Please also call Dr. [**First Name (STitle) 2174**] at [**Telephone/Fax (1) 42422**] and Dr. [**Last Name (STitle) 3274**]
at ([**Telephone/Fax (1) 3280**] to make follow-up appointments within two
weeks of discharge from the rehabilitation facility.
Completed by:[**2188-12-18**]
|
[
"272.4",
"530.89",
"416.8",
"496",
"427.89",
"729.92",
"729.72",
"427.0",
"V12.51",
"162.8",
"V58.61",
"285.1",
"458.29",
"197.2",
"197.7",
"V43.64",
"401.9",
"V43.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.14",
"37.34",
"83.65",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
15527, 15669
|
8479, 14017
|
363, 605
|
15881, 15935
|
6434, 6434
|
16910, 17606
|
4776, 4939
|
14249, 15504
|
15690, 15860
|
14043, 14226
|
15959, 16887
|
8181, 8456
|
4954, 5206
|
5220, 6415
|
297, 325
|
633, 3437
|
6450, 8165
|
3459, 4373
|
4389, 4760
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,183
| 192,480
|
40948
|
Discharge summary
|
report
|
Admission Date: [**2185-6-10**] Discharge Date: [**2185-6-24**]
Date of Birth: [**2112-5-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Coronary artery bypass x2 (Left internal mammary artery to left
anterior descending artery and greater saphenous vein to right
coronary artery)on [**2185-6-15**].
History of Present Illness:
73 year old male presents with shortness of breath to outside
hospital. He reports progressive dyspnea throughout previous
day and awoke on morning of admission with severe dyspnea,
diaphoresis but denied chest discomfort. He was treated with
CPAP and nitrates and 80 mg IV Lasix for HF with moderate
improvement. Initial RA sats 88%. Anterior-lat changes on EKG,
trop 0.10->0.13, ruled in for NSTEMI. Underwent cardiac
catheterization [**2185-6-10**] that revealed significant coronary
artery disease. cardiac surgery consulted for revascularization.
Past Medical History:
Type II DM - on oral agents
HTN
Hyperlipidemia
Multiple Melanomas
Left knoww fx, B/L heel fractures
B/L ankle sprains
Right hand tendonitis - wears brace at night
Hx 55 lung nodules
Diverticulitis with frequent diarrhea
Diabetic nephropathy
Left eye cataract
Urinary hestitancy/frequency
Severe OA in multiple joints
Chronic LE edema
CCY Spet [**2184**]
Mulitple malignant melanoma removals
Left knee ORIF with "rods and screws in place"
Social History:
Lives with: Alone
Occupation: Retired systems analyst
Tobacco: Quit [**2165**] - previously smoked 2 ppd x 10-15 years
ETOH: Quit [**2165**]
Ambulates short distances without assistance at home - "to
mailbox or up and down driveway" - restriced due to OA
Family History:
Mother - valvular disease - s/p [**Name (NI) 1291**],
Father with CAD s/p CABG x 3 - both deceased
Physical Exam:
Pulse:73 Resp:18 O2 sat:2 L 99%
B/P Right: 139/79 Left:
Height: 5'4" Weight: pre-op day 102.3 kg
General: AAO x 3 in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] Glasses
Neck: Supple [x] Full ROM [x] -thick neck
Chest: Lungs clear bilaterally [] - Scattered wheezes LUL
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x] Obese
Extremities: Warm [], well-perfused [] Edema 1+ B/L LE edema
Varicosities: None [x] - LE cool
Neuro: Grossly intact
Pulses:
Femoral Right:cath site Left:1+
DP Right:dopplerable Left:dopplerable
PT [**Name (NI) 167**]:dopplerable Left:dopplerable
Radial Right:1+ Left:1+
Carotid Bruit Right:none Left:none
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.7 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% >= 55%
Left Ventricle - Stroke Volume: 54 ml/beat
Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.06 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 14 < 15
Aorta - Sinus Level: 2.9 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.3 cm <= 3.0 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.4 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 24
Aortic Valve - LVOT diam: 1.7 cm
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A ratio: 1.13
Findings
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast in
the body of the RA. Normal interatrial septum. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Mild (non-obstructive)
focal hypertrophy of the basal septum. Top normal/borderline
dilated LV cavity size. Mild-moderate regional LV systolic
dysfunction. Mildly depressed LVEF. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Normal descending aorta diameter. Simple atheroma in descending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Pre-CABG
The left atrium is dilated. 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 body of the right
atrium. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses are normal. There is mild
(non-obstructive) focal hypertrophy of the basal septum. The
left ventricular cavity size is top normal/borderline dilated.
There is mild to moderate regional left ventricular systolic
dysfunction with hypokinesis of the septum, anteroseptal, and
anterior walls. Overall left ventricular systolic function is
mildly depressed (LVEF= 40%). 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 but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is no
pericardial effusion.
Post-CABG
The patient is AV-paced and on a phenylephrine infusion. Right
ventricular systolic function is unchanged. Left ventricular
systolic function is slightly improved with better movement of
the anterior wall. LVEF 50%. Mitral regurgitation and tricuspid
regurgitation remains trace. The thoracic aorta is intact post
decannulation.
Dr. [**Last Name (STitle) 914**] was notified in person of the results at the time of
the study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2185-6-15**] 16:25
Radiology Report CHEST (PA & LAT) Study Date of [**2185-6-19**] 6:24 PM
Final Report: PA and lateral chest compared to [**6-17**]. Small
bilateral pleural effusions are little changed since [**6-17**].
There is no pneumothorax, pulmonary edema, or appreciable
atelectasis. Cardiomediastinal silhouette has a normal
postoperative appearance.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Admission labs:
[**2185-6-10**] 07:45PM PT-12.4 PTT-24.0 INR(PT)-1.0
[**2185-6-10**] 07:45PM PLT COUNT-257
[**2185-6-10**] 07:45PM WBC-12.3* RBC-4.36* HGB-13.2* HCT-38.7*
MCV-89 MCH-30.3 MCHC-34.1 RDW-13.4
[**2185-6-10**] 07:45PM %HbA1c-6.1* eAG-128*
[**2185-6-10**] 07:45PM ALBUMIN-4.1 CALCIUM-9.3 PHOSPHATE-3.4
MAGNESIUM-1.9
[**2185-6-10**] 07:45PM cTropnT-0.12*
[**2185-6-10**] 07:45PM LIPASE-54
[**2185-6-10**] 07:45PM ALT(SGPT)-22 AST(SGOT)-24 LD(LDH)-218 ALK
PHOS-54 AMYLASE-65 TOT BILI-0.4
[**2185-6-10**] 07:45PM GLUCOSE-216* UREA N-28* CREAT-1.6* SODIUM-138
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-29 ANION GAP-14
Discharge labs:
[**2185-6-23**] 09:15AM BLOOD WBC-10.4 RBC-3.25* Hgb-9.7* Hct-29.6*
MCV-91 MCH-29.9 MCHC-32.9 RDW-13.5 Plt Ct-456*
[**2185-6-23**] 09:15AM BLOOD Plt Ct-456*
[**2185-6-15**] 03:20PM BLOOD PT-14.3* PTT-31.9 INR(PT)-1.2*
[**2185-6-23**] 09:15AM BLOOD Glucose-281* UreaN-33* Creat-1.6* Na-134
K-4.7 Cl-98 HCO3-25 AnGap-16
Brief Hospital Course:
Transferred in from outside hospital for surgical evaluation and
underwent preoperative work up. He was started on heparin for
chest discomfort that had resolved prior to notifying staff and
then was treated for shortness of breath with intravenous lasix
with improvement. Denied any further chest discomfort or
dyspnea. He was started on ciprofloxacin for proteus urinary
tract infection. On [**6-15**] he was brought to the operating room
for Coronary artery bypass x2 (Left internal mammary artery to
left anterior descending artery and greater saphenous vein to
right coronary artery) with Dr.[**Last Name (STitle) 914**]. Cross Clamp time: 43
minutes. Cardiopulmonary Bypass Time=63 minutes. Please see
operative report for further surgical details. He tolerated the
procedure well and was transferred to the CVICU intubated and
sedated. He awoke neurologically intact and was weaned and
extubated without difficulty. He weaned off pressors and was
started on Beta-blocker/Statin/ASA and diuretics. All lines and
drains were discontinued per cardiac surgery protocol. He was
transferred to the step down unit on POD3 for further
monitoring. He developed some sternal drainage and was started
on cefazolin. The remainder of his hospital course was
uneventful. He worked with nursing and physical therapy to
increase his mobility and strength. On POD# 9 he was cleared for
discharge to home. All follow up appointments were advised.
Medications on Admission:
Fish oil 1 gm po daily
Tums 1 tab po prn
MVI 1 po daily
Vit C 500 daily
Vit E 400 daily
Tylenol 325 TID PRN
ASA 81 daily
Lisinopril 40 daily
Zestril 40 daily
Zantac 75 mg [**Hospital1 **]
Lopressor 50 mg [**Hospital1 **]
Metformin 1000 mg [**Hospital1 **]
HCTZ 25 mg daily
Norvasc 2.5 mg daily
Glyburide 10 mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
3. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. glyburide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
10. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): please continue to monitor creatinine.
11. Outpatient Lab Work
please check BUN/creatinine on Monday [**6-27**]
12. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
13. insulin
insulin fixed dose and sliding scale ( see attached)
14. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a
day.
15. potassium chloride 20 mEq Packet Sig: One (1) packet PO once
a day for 1 weeks: hold for K+ > 4.5.
16. furosemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day
for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
17. potassium chloride 10 mEq Capsule, Extended Release Sig: Two
(2) Capsule, Extended Release PO once a day for 10 days.
Disp:*20 Capsule, Extended Release(s)* Refills:*0*
18. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
19. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
20. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever/pain.
Discharge Disposition:
Home with Service
Facility:
tba
Discharge Diagnosis:
Coronary artery disease s/p cabg x2
Acute systolic heart failure
non-ST elevation MI
Type II DM - on oral agents
right pulmonary nodules ( f/u scheduled in 3 months)
HTN
Hyperlipidemia
Multiple Melanomas
Left knoww fx, B/L heel fractures
B/L ankle sprains
Right hand tendonitis - wears brace at night
Hx 55 lung nodules
Diverticulitis with frequent diarrhea
Diabetic nephropathy
Left eye cataract
Urinary hestitancy/frequency
Severe OA in multiple joints
Chronic LE edema
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tramadol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage.
Edema: 2+ 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
Surgeon: Dr [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2185-7-12**] 2:30
WOUND CARE NURSE at cardiac surgery [**Hospital **] medical office
building Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2185-6-29**] 11:45
Cardiologist: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11300**] [**7-1**] @ 12:00 pm
CAT SCAN Phone:[**Telephone/Fax (1) 327**] :[**2185-9-15**] 1:15 [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 23**] 4
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2185-9-15**] 3:30 pm
Please call to schedule appointments with your
Primary Care Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 32467**] in [**5-10**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2185-6-24**]
|
[
"599.0",
"414.01",
"414.2",
"V15.82",
"715.90",
"041.6",
"583.81",
"518.5",
"V10.82",
"428.21",
"272.4",
"428.0",
"V15.51",
"250.40",
"401.9",
"410.71",
"518.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
12118, 12152
|
8331, 9773
|
293, 458
|
12668, 12893
|
2681, 5078
|
13697, 14732
|
1795, 1896
|
10140, 12095
|
12173, 12647
|
9799, 10117
|
12917, 13674
|
7989, 8308
|
5121, 7335
|
1911, 2662
|
234, 255
|
486, 1042
|
7351, 7973
|
1064, 1504
|
1520, 1779
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,566
| 100,184
|
8947
|
Discharge summary
|
report
|
Admission Date: [**2191-11-28**] Discharge Date: [**2191-12-21**]
Date of Birth: [**2114-4-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Morphine / Heparin Agents
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Mrs. [**Known lastname **] is s/p CABG [**2187**], and now has increasing
SOB/DOE. She underwent cardiac catheterization [**11-24**] which
showed patent LIMA-LAD, totally occluded SVG-OM and ectatic
SVG-PDA, and an aortic valve area of 0.59cm2. She was admitted
to [**Hospital 24356**] hospital for diuresis due to an elevated wedge
pressure and then was transferred to [**Hospital1 18**] for surgery
Major Surgical or Invasive Procedure:
s/p redo sternotomy/CABGx1 SVG-PDA/AVR 21mm pericardial [**12-7**]
History of Present Illness:
Mrs. [**Known lastname **] is s/p CABG [**2187**], and now has increasing
SOB/DOE. She underwent cardiac catheterization [**11-24**] which
showed patent LIMA-LAD, totally occluded SVG-OM and ectatic
SVG-PDA, and an aortic valve area of 0.59cm2. She was admitted
to [**Hospital 24356**] hospital for diuresis due to an elevated wedge
pressure and then was transferred to [**Hospital1 18**] for surgery.
Past Medical History:
CAD
s/p CABG [**2187**]
aortic stenosis
h/o breast CA s/p lumpectomy and radiation therapy to R breast
carotid stenosis-bilateral 50-70% lesions
DM-type 2
elevated cholesterol
venous stasis
Physical Exam:
discharge physical exam:
T:98.1 P63 atrial fibrillation BP:123/62 RR:18 RA:SpO2 95% on RA
weight:[**12-21**] 91.4kg
Neurological exam:She is awake, alert, oriented x3, non-focal.
Cardiovascular exam: regular rate and rhythm without rub or
murmur
Respiratory:breath sounds are clear without wheezes or rales
GI:positive bowel sounds, soft, obese, non-tender,
non-distended, no nausea
Extremities:warm and well perfused, bilateral lower extremeties
with mild erythema, chronic venous stasis changes with plaques.
No warmth or tenderness.
Sternal incision is clean and dry, there is an area at the at
the proximal portion of the incision with 2 areas of scabbed
skin tears. There is no erythema or drainage.
The veing harvest site at the knee is clean, dry and intact
Pertinent Results:
[**2191-12-21**] 05:58AM BLOOD WBC-8.4 RBC-4.27 Hgb-12.9 Hct-37.9 MCV-89
MCH-30.3 MCHC-34.1 RDW-15.7* Plt Ct-277
[**2191-12-21**] 05:58AM BLOOD Plt Ct-277
[**2191-12-21**] 05:58AM BLOOD PT-20.3* PTT-32.6 INR(PT)-2.6
[**2191-12-21**] 05:58AM BLOOD Glucose-66* UreaN-16 Creat-1.0 Na-138
K-4.2 Cl-95* HCO3-34* AnGap-13
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted to [**Hospital1 18**] on [**11-28**] for
pre-operative evaluation. She was started on IV heparin for her
coronary disease. She was taken to the operating room on [**12-2**]
and was induced with general anesthesia. It was then noted that
she had purulent drainage from her lower extremeties in the area
of the venous stasis. The surgery was canceled and she was
transferred to the ICU to allow to awaken and she was started on
antibiotics. A vascular surgery and infectious disease consult
was obtained and patient underwent ultrasound studies of her LE
which did not show any significant reflux and no arterial
occlusion. With the antibiotics, the erythema and drainage
improved and with continued Lasix the edema improved and patient
was taken to the operating room on [**12-7**] for a redo sternotomy,
CABGx1-SVG-PDA, and AVR with a 21 mm pericardial valve. The
patient was transferred to the ICU in stable condition. She was
weaned and extubated from mechanical ventilation on [**12-7**]
without difficulty. She had episodes of nausea and was started
on Reglan and an antiemetic with some relief. Her chest tubes
and pacing wires were removed without incident. She was started
on lo dose Lopressor which she tolerated well, and had
escalating doses of Lasix to achieve adequate diuresis. She was
transferred from the ICU to the regular floor on POD#5. In the
early morning of POD 6, she developed atrial fibrillation which
was rate controlled. She had some thrombocytopenia
postoperatively and a heparin antibody test was found to be
positive. A hematology consult was obtained and it was
recommended that she be started on argatroban for
anticoagulation. This was started as well as Coumadin and the
argatroban was turned off when her INR became therapeutic. She
underwent an ultrasound of her R arm due to swelling which did
not show any venous clot or obstruction. During her
postoperative course, she continued to be nauseaus, a KUB showed
a lot of stool and she had an aggressive bowel regime. During
this time, her PO intake was poor. A GI consult was obtained
and it was recommended to continue the current therapy and by
POD#13 the nausea was improving. On POD#12 it was noted that
she was having some periods of bradycardia with the atrial
fibrillation and it was decided to discontinue the Lopressor,
after which there were no further pauses.
Medications on Admission:
aspirin 325mg qd
lisinopril 5mg qd
insulin 70/30 18 units qam, 15units qpm
lopressor 50mg qam 25mg qpm
nitropaste
lasix 80mg iv qd
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. Rosuvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
11. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q4-6H (every 4 to 6 hours) as needed for pain.
12. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for nausea.
16. Insulin 70/30 70-30 unit/mL Suspension Sig: Five (5) units
Subcutaneous twice a day.
17. Insulin Regular Human 300 unit/3 mL Syringe Sig: as directed
Subcutaneous four times a day: BS 121-140 2units SC
BS 141-160 3units SC
BS 161-180 4units SC
BS 181-200 5units SC
BS 201-220 6units SC
BS 221-240 7units SV
.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] at [**Location (un) 701**]
Discharge Diagnosis:
AS/CAD
h/o CHF
DM
PVD
s/p breast lumpectomy d/t CA
s/p radiation to R breast
carotid stenosis 50-70% bilaterally
s/p CABG [**2187**]
s/p redo sternotomy/AVR/redo CABG
bilateral LE venous stasis
bilateral LE cellulitis
post op atrial fibrillation
post op urinary retention
post op gastroparesis/ileus/constipation
+heparin antibodies
Discharge Condition:
good
Discharge Instructions:
you may take a shower and wash your incisions with mild soap and
water
do not swim or take a bath for 1 month
do not drive for 1 month
do not lift anything heavier than 10 pounds for 1 month
do not apply lotions, creams, ointments or powders to your
incisions
Followup Instructions:
follow up with Dr. [**Last Name (STitle) **] in 2 weeks
follow up with [**Doctor Last Name **] in 2 weeks
follow up with Dr. [**Last Name (STitle) **] in [**3-31**] weeks
Completed by:[**2191-12-21**]
|
[
"560.1",
"V58.61",
"E878.4",
"250.00",
"788.20",
"518.0",
"536.3",
"428.20",
"997.3",
"414.02",
"V70.7",
"997.1",
"V64.1",
"412",
"682.6",
"454.1",
"427.31",
"997.5",
"287.4",
"424.1",
"272.0",
"E934.2",
"997.4",
"440.20",
"V10.3",
"428.0",
"414.01",
"564.00",
"433.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.22",
"96.04",
"36.11",
"35.21",
"99.04",
"96.71",
"39.61",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
6895, 6969
|
2554, 4970
|
697, 766
|
7346, 7352
|
2214, 2531
|
7660, 7863
|
5151, 6872
|
6990, 7325
|
4996, 5128
|
7376, 7637
|
1427, 1427
|
1561, 2195
|
255, 659
|
794, 1199
|
1221, 1412
|
1452, 1543
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,281
| 113,147
|
51890
|
Discharge summary
|
report
|
Admission Date: [**2131-7-27**] Discharge Date: [**2131-8-16**]
Date of Birth: [**2083-10-5**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Iodine; Iodine Containing / Peanut
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
N/V/D
Major Surgical or Invasive Procedure:
Therapeutic Paracentesis
Orthotopic Liver [**First Name3 (LF) **] [**2131-8-5**]
History of Present Illness:
47 year old female with HepC/Cirrhosis on liver [**Month/Day/Year **] list,
referred for abnormal labs, WBC of 77K on [**7-25**]. She complains of
RUQ pain (chronic) as well as 2 days of nausea, vomiting, and
diarrhea. No Melena or BRBPR. Recently admitted with SBP in
[**6-/2131**], and more recent admission for therapeutic paracentesis.
Felt very fatigued and dehydrated. Admits to poor po intake b/c
of N/V, and decreased urine output. Also admits to feeling of
heart racing. Denies CP, SOB. Has minimal cough. No dysuria.
.
In the ED, vs=T97.2, BP 120/64, HR 112, RR 18, 99%ra. Labs
notable for normal WBC, and diagnostic paracentesis was negative
for SBP. Sodium noted to be 123 (discharged with Na 128), and Cr
1.2 (baseline 0.6). LFTs, Tbili, INR all at baseline values. CXR
negative for pneumonia.
Past Medical History:
- HCV cirrhosis
- Hepatoma, s/p RFA of 1 lesion in [**2130-9-27**]
- h/o HSV infection - cold sores in the past
- HPV - h/o cervical dysplasia
- ? Hepatorenal syndrome type 2
- Ventral hernia s/p repair
- Osteopenia
Social History:
Lives with Husband and 3 children. Has 4 children. Husband and
all 4 children have tested negative for HCV. Quit smoking 27
years ago. Did clerical work in the past. Occasional ETOH in the
past. Denies street drugs.
Family History:
Mother has HTN. Father had HTN and passed away with brain tumor.
Physical Exam:
vs: T97.8, BP 102/60, HR 79, RR 18, 100%ra
gen: jaundiced but appears well otherwise
heent: icteric sclerae. EOMI. dry mm
lungs: bibasilar crackles, but otherwise CTA b/l
heart: RRR, nl S1S2, no M/R/G
abd: Tympanic. Distended. Non-tender.
ext: 1+ b/l edema, L slightly greater than R
neuro: AAOx3. No asterixis.
Pertinent Results:
On Admission: [**2131-7-26**]
WBC-10.3# RBC-3.65* Hgb-12.3 Hct-36.7 MCV-101* MCH-33.6*
MCHC-33.4 RDW-17.4* Plt Ct-93*
PT-23.7* PTT-44.5* INR(PT)-2.3* Fibrino-111*
Glucose-114* UreaN-37* Creat-1.2* Na-123* K-3.5 Cl-86* HCO3-25
AnGap-16
ALT-66* AST-149* AlkPhos-211* TotBili-30.2* Lipase 60
TotProt-7.2 Albumin-3.8 Globuln-3.4
Calcium-9.3 Phos-4.2 Mg-2.9*
On Discharge: [**2131-8-16**]
WBC-9.5# RBC-3.77* Hgb-11.4* Hct-33.1* MCV-88 MCH-30.3 MCHC-34.5
RDW-16.5* Plt Ct-155
PT-14.7* INR(PT)-1.3*
87 UreaN-32* Creat-2.0* Na-137 K-4.8 Cl-98 HCO3-30 AnGap-14
ALT-22 AST-18 AlkPhos-72 TotBili-2.5* Lipase-20
Calcium-8.7 Phos-3.5 Mg-1.8
Brief Hospital Course:
47 y.o. female with ESLD on [**Month/Day/Year **] list, referred for
leukocytosis but this was lab error, admitted with N/V/D and
hyponatremia.
She was treated with fluid resuscitation and had a diagnostic
paracentesis that was negative for SBP, ultrasound neg for
portal vein thrombosis.
During the admission she developed increased coagulopathy and
was starting to have increased confusion, Head CT was negative
for mass effect or hemorrhage. Blood cultures were nagative.
She continued to be managed medically and on [**2131-8-5**] she was
offered a liver. She underwent Orthotopic deceased donor liver
[**Date Range **] (piggyback), portal vein to portal vein anastomosis,
common bile duct to common bile duct (no T tube), celiac patch
(donor) to junction of common hepatic and splenic artery
(recipient) with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. She had 9 liters of ascites
deeply stained due to her
hyperbilirubinemia. She had severe portal hypertension with
marked collaterals and a small cirrhotic shrunken liver. She
had somewhat abnormal anatomy in that her gastroduodenal artery
came off somewhat anterior just proximal to the
bifurcation of the right and left hepatic arteries.
She received 1000 cc normal saline, 2500 cc of Plasma-Lyte, 10
units of fresh frozen
plasma, 9 units of packed red cells, 4 units of platelets and
made 540 cc of urine. Estimated blood loss was 5000 cc. She was
transferred in stable condition to the SICU.
POst op ultrasound revealed Patent hepatic vasculature with
absent diastolic flow in hepatic arteries. There was no biliary
dilatation or hepatic collections identified.
She was extubated on POD 2.
Liver ultrasound on POD 5 showed patent vasculature with good
diastolic upstrokes.
She followed the post op pathway and made excellent progress
daily.
The Lateral drain was left in place at discharge as volumes were
still elevated, however the medial drain was d/c'd prior to
discharge.
Her main complaint was pain at the hernia site in her left
abdomen. This responded well to an abdominal binder.
She did have complaints of nausea which were reported better
once the hernia was under better control.
Of special note, the donor liver was from a woman that expired
following exposure to someone who had eaten nuts and suffered an
anaphylactic reaction and died. Patient was thoroughly
instructed as well as the family on avoidance of nuts and nut
products. She was sent home with epi pens. In addition, RAST
testing was initiated and shouls be followed in the post op
period for development of a transmitted peanut allergy.
At the time of discharge she was ambulating, tolerating diet and
had regained bowel function. She was well versed in her meds.
She was not sent home on insulin as readings were acceptable in
the post op period with minimal need for insulin coverage.
Medications on Admission:
Folic Acid 1 mg PO DAILY
Cyanocobalamin 100 mcg PO DAILY
Ciprofloxacin 250 mg PO Q24H
Ascorbic Acid 500 mg PO DAILY
Oxycodone 5 mg, 1 Tablet PO Q6H PRN
Omeprazole 40 mg PO DAILY
Acetaminophen 325 mg 1 tab PO Q6H prn
Furosemide 20 mg po daily
Spironolactone 25 mg PO BID
Lactulose prn
Nadolol 40mg po daily
Mag oxide 400mg po daily
Caltrate +D 600 po BID
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day.
2. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
4. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Trimethoprim-Sulfamethoxazole 80-400 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. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO twice a day.
12. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
HCV Cirrhosis now s/p orthotopic liver [**Hospital **]
Nausea
Dehydration
Hernia
Discharge Condition:
Stable
Discharge Instructions:
Please call the [**Hospital **] clinic at [**Telephone/Fax (1) 673**] for fever >
101, chills, nausea, vomiting, inability to take or keep down
medications, increased abdominal pain, yellowing of eyes
Monitor the incision for redness, drainage or bleeding
Empty and record drain output twice a day and more often as
needed. Call the office if the drain output increases, changes
in color or develops a foul odor.
You may wear the binder to help control the hernia
Take your medications exactly as prescribed.
Lab tests every Monday and Thursday, results faxed to
[**Telephone/Fax (1) 697**]
AVOID ALL PEANUTS, NUT PRODUCTS, and oils as reviewed with you
by [**Doctor First Name 1370**], your dietitian
No driving if taking narcotic pain medication
No lifting of anything heavier than a gallon of milk
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) 156**] [**First Name3 (LF) **] SOCIAL WORK Date/Time:[**2131-8-22**] 10:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2131-8-22**]
11:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2131-8-29**]
11:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2131-8-17**]
|
[
"276.1",
"070.54",
"789.59",
"572.4",
"571.5",
"276.51",
"733.90",
"572.3",
"V10.07",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"00.93",
"54.91",
"50.59"
] |
icd9pcs
|
[
[
[]
]
] |
7085, 7143
|
2788, 5642
|
313, 396
|
7268, 7277
|
2135, 2135
|
8126, 8725
|
1721, 1788
|
6046, 7062
|
7164, 7247
|
5668, 6023
|
7301, 8103
|
1803, 2116
|
2503, 2765
|
268, 275
|
424, 1232
|
2149, 2489
|
1254, 1471
|
1487, 1705
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,739
| 169,126
|
50365
|
Discharge summary
|
report
|
Admission Date: [**2126-2-15**] Discharge Date: [**2126-3-5**]
Date of Birth: [**2058-7-11**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 67 year-old
male with a history of Hodgkin's disease, iron deficiency
anemia who has had on and off diarrhea since [**Month (only) **].
Ongoing workup led to an esophagogastroduodenoscopy to rule
out celiac disease on [**2-13**]. The patient was discharged from
that procedure and doing fine. Last night the patient
started to AHV abdominal pain with distention. He felt warm,
but no temperature was taken. He ahs had no vomiting or
nausea. No recent diarrhea. He did have a bowel movement
this morning. He did not have flatus. No bright red blood
per rectum. His pain is reported to be in the left lower
quadrant, nonradiating, sharp and has not improved.
Emergency Department CT scan showed free air in the abdomen.
PAST MEDICAL HISTORY:
1. Hodgkin's in the left groin.
2. Iron deficiency anemia.
3. Asthma.
4. Status post chemotherapy in [**2118**] and x-ray therapy in
[**2118**], [**2122**] and [**2124**].
PAST SURGICAL HISTORY:
1. Left axillary node biopsy.
2. Right groin lymph node excision.
3. Prostate biopsy.
MEDICATIONS:
1. Flovent.
2. Albuterol.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient has a 40 pack year history of
tobacco and only takes social alcohol.
PHYSICAL EXAMINATION: The patient has a temperature of 99.7.
Heart rate 125. Blood pressure 98/48. Respiratory rate 24.
Satting 98% on room air. He is in no acute distress. Sinus
tachycardia. Clear to auscultation bilaterally. Belly is
soft, distended, tender, has epigastric and left lower
quadrant tenderness with guarding, no rebound. The patient
was guaiac negative. Has normal tone and an enlarged
prostate.
LABORATORY: White blood cell count of 9.5, hematocrit 30.6.
Electrolytes are normal although creatinine is 1.0 up from .6
baseline. Coags are normal. Liver function tests are
normal. Abdominal CT shows free air in the abdomen, although
no other pathology.
HOSPITAL COURSE: The patient was admitted on [**2126-2-15**] and
received intravenous resuscitation, made NPO and prepared for
exploratory laparotomy. Prior to surgery the patient did
spike a temperature of 101.4. He was taken to the Operating
Room on [**2126-2-15**] where exploratory laparotomy was performed
with a preop diagnosis of perforated viscus, postoperative
diagnosis of large and small bowel lymphoma with descending
colon perforation. The patient had a total abdominal
colectomy and ileostomy and small bowel resection performed
by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7280**] and Dr. [**First Name4 (NamePattern1) 6644**] [**Last Name (NamePattern1) **].
The patient received 2 units of packed red blood cells
intraoperatively. Postoperatively, the patient remained
hypotensive and oliguric. He was placed on vasopressors and
fluid resuscitation was continued. The patient was
transferred to the Intensive Care Unit for further care. The
patient had a Swan Ganz catheter in place to guide fluid
resuscitation. He was left intubated at that time. The
patient had a JP drain left in place in the abdomen. He was
also left on perioperative antibiotics postoperatively
including Ampicillin, Levofloxacin and Flagyl. The patient
was quickly weaned off his pressors with appropriate fluid
resuscitation.
Early in the patient's stay oncology was consulted who
indicated that they believed that his lymphoma to be a large
B cell lymphoma, which would have been different from his
previous history of Hodgkin's lymphoma. A PET scan on [**2-13**]
showed new increased uptake on the right SM region. Abnormal
uptake in the T6 and T10 vertebral bodies. Oncology
continued to follow and guide the oncologic care throughout
the patient's stay. Over the course of the next few days it
became evident that the patient had high capillary leak and
received albumin to try to stimulate an increase in
intravascular volume. He was also ruled out for a myocardial
infarction. He was transfused multiple units of packed red
blood cells and fresh frozen platelets. He was also noted to
have thrombocytopenia for which a heparin induced
thrombocytopenia antibody check was sent. The patient had a
hyperbilirubinemia thought to be partially due to hemolysis
from transfusion as well as effects of the patient's care on
his liver. A right upper quadrant ultrasound was performed
ruling out gallbladder pathology. Common bile duct stone was
ruled out with the ultrasound. The patient was initiated on
total parenteral nutrition while awaiting return of bowel
function. Culture returned back from the patient's surgery
showing gram negative rods, yeast, corynebacterium and
Enterococcus from the patient's intraabdominal culture.
Antibiotics were not changed at that time. By the end of the
first week an effort was made to try to start diuresing the
patient as well as to wean the patient's ventilatory
settings.
The patient spiked a temperature for which his Swan was
discontinued and tip was sent for culture. The PA line was
changed as central venous line. The patient required free
water intravenous secondary to hypernatremia. He was placed
on Lopressor secondary to tachycardia and hypertension. On
the last day of the month the patient's experienced a drop in
blood pressure and tachycardia as well as a fever. It was
initially thought that he may have been overdiuresed,
although because of the increase in fever blood cultures were
sent and his central line was changed over a wire and then
eventually removed and tip sent for culture. Blood cultures
came back with MRSA as well as the cath tip. Within 24 hours
the patient's hemodynamic stability returned. After that
episode a vent wean was proceeded and the patient was
extubated on the [**1-24**]. The patient also received
at that time Diamox for metabolic alkalosis probably
secondary to diuresis from Lasix. Toward the beginning of
[**Month (only) 956**] the patient's JP drain began to thicken and become
cloudy. It was felt that this was not a purulent drainage as
a result of resection, but rather necrotic tumor. Per
oncology's recommendation the patient underwent an MRI to
look for central nervous system involvement of his lymphoma.
This was initiated because of the patient's failure to
improve significantly with regard to his mental status. MRI
was essentially negative and LP was performed. Lumbar
puncture showed a low white blood cell count and low protein
indicating low likelihood of central nervous system
involvement by his lymphoma. Pathology is still pending.
Vancomycin was added due to the blood culture positive for
MRSA. Speech and swallow was consulted to attempt allowing
the patient to swallow although he did not do well with this
test.
Physical therapy was consulted to help the patient get out of
bed, although he did not have any adequate physical
capabilities for independence. On the 6th the patient was
started on tube feeds secondary to lack luster and eating.
This was short lived, however, on the [**2-1**] the
patient again became hypotensive with difficulty in
maintaining his pressures. Vasopressors were started as well
as Fluconazole empirically as tube feeds were stopped. The
patient was made DNR. Oncology indicated at that time that
the likelihood that the patient would survive another four
months would be unlikely and that with his current question
of sepsis any further treatment chemotherapeutically was
unwise. They also indicated that if the patient were to
improve the patient would not likely live four months even
with chemotherapy as chemotherapy would only be palliative.
With extensive discussions between Dr. [**Last Name (STitle) **], Dr.
[**Last Name (STitle) **], Dr. [**First Name (STitle) **] and the family it was finally decided on
O2/10/04 to make the patient CMO. This was done late in the
evening on the [**2-2**] and the patient died at
approximately 5:20 on the morning of [**2126-3-5**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 28129**], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern4) 12487**]
MEDQUIST36
D: [**2126-3-5**] 05:30
T: [**2126-3-6**] 06:55
JOB#: [**Job Number 104981**]
|
[
"V66.7",
"569.83",
"038.9",
"202.80",
"V10.72",
"276.6",
"287.4",
"518.5",
"567.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"45.62",
"45.8",
"99.04",
"03.31",
"96.6",
"46.23"
] |
icd9pcs
|
[
[
[]
]
] |
2093, 8418
|
1122, 1292
|
1414, 2075
|
155, 900
|
922, 1099
|
1309, 1391
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,713
| 135,319
|
4058+55539
|
Discharge summary
|
report+addendum
|
Admission Date: [**2140-9-6**] Discharge Date: [**2140-9-13**]
Service: [**Hospital1 139**]
HISTORY OF PRESENT ILLNESS: This is an 80 year old female
with diabetes mellitus Type 2 who was initially admitted to
the Medicine Intensive Care Unit with hyperosmolar
nonketotic, versus diabetic ketoacidosis. The patient was
delivered to the Emergency Department by ambulance after the
family called emergency medical services because the patient
was falling repeatedly. On arrival the emergency medical
technicians found her in bed with bilious vomit. The
patient's family states that she had taken no p.o. for the
past 24 hours. In the Emergency Department the patient was
incoherent and tachypneic. Initial finger stick blood
glucose was greater than 500 and serum blood glucose was 837.
The patient was given regular insulin 10 units intravenously
followed by an insulin drip, given calcium with 5 liters of
normal saline and was also treated with Ceftriaxone and
Flagyl. The patient was then transferred to Medicine
Intensive Care Unit for management of her diabetic acidosis.
PAST MEDICAL HISTORY: 1. Herpes zoster, the patient had an
outbreak four weeks prior to admission and then reportedly
another outbreak in the week prior to admission. 2.
Osteoporosis with a history of rib fracture. 3. Diabetes
mellitus Type 2. 4. Hypertension. 5. Pernicious anemia.
6. Status post cholecystectomy. 7. History of back pain,
having undergone epidural steroids times two.
MEDICATIONS ON ADMISSION: 1. Atenolol 50 b.i.d.; 2.
Fosamax 70 q. week; 3. Lantis and Humalog; 4. Diovan 80
b.i.d.; 5. Hydrochlorothiazide 25 q.d.; 6. Vitamin B 12
injections, 1 mg per month; 7. Aspirin 81 q.d.; 8. Vitamin
C, E and a multivitamin; 9. Lisinopril.
ALLERGIES: The patient has an allergy to Univasc, she gets a
rash and/or edema.
SOCIAL HISTORY: The patient is unmarried. She works as an
auditor. She drinks occasional alcohol and she does not
smoke tobacco.
FAMILY HISTORY: There is a history of cerebrovascular
accident.
PHYSICAL EXAMINATION: Physical examination on admission
revealed vital signs with temperature of 99.4, blood pressure
120/43, heartrate 110, respiratory rate 24, oxygen saturation
100% on 4 liters of nasal cannula. General: Confused,
agitated and uncooperative. Head, eyes, ears, nose and
throat: Pupils surgical bilaterally, extraocular movements
intact. Mucous membranes very dry. Neck: Supple, no
lymphadenopathy, no jugulovenous distension. Cardiovascular:
Tachycardiac, normal S1 and S2, no murmurs, rubs or gallops.
Lungs: Clear. Abdomen: Decreased bowel sounds, soft,
nontender, nondistended without hepatosplenomegaly.
Extremities, warm, well perfused, no edema, clubbing or
cyanosis. Positive tenting of the medial thigh.
Neurological, oriented to [**Known firstname 2127**] [**Known lastname 17866**] (only). Cranial
nerves II through XII grossly intact, moves all four
extremities.
LABORATORY DATA: Laboratory data on admission revealed white
count 38 including 87 polys, 7% lymphs, 6% monos, hematocrit
35, platelets 449. Sodium 134, potassium 6.7, chloride 93,
bicarbonate 5, BUN 57, creatinine 2.1, glucose 837 with anion
gap of 26. Arterial blood gases showed pH of 6.98, carbon
dioxide 24, and oxygen of 147 on 4 liters. Urinalysis:
Negative leukocyte esterase, negative nitrates, 1000 glucose,
50 ketones, [**11-21**] red blood cells, 6 to 10 white blood cells.
Computerized tomography scan of the head: Negative for acute
intracranial process. Chest x-ray: Showed no consolidation,
effusion or congestive heart failure. Electrocardiogram:
Sinus tachycardia at 120, normal axis, prolonged QT, left
ventricular hypertrophy by voltage, [**Street Address(2) 4793**] depression V3
through V5.
HOSPITAL COURSE: 1. Diabetic ketoacidosis - The patient
came in in florid diabetic ketoacidosis with a pH of 6.98 and
a bicarbonate of 5. She was aggressively treated with 4
liters of normal saline and insulin. Her potassium was also
elevated at 6.7. She was continued on an insulin drip with
1/2 normal saline and kept NPO. Her glucose responded
relatively quickly dropping below 200 into the 100s. Her
anion gap also corrected relatively rapidly and the patient
did well from this standpoint. Attempts were then made to
normalize the patient's sugars which varied widely from low
sugars on Glargine 12 and insulin sliding scale to high
sugars on Glargine 8 and a regular insulin sliding scale.
The acidosis associated with her diabetic ketoacidosis once
corrected remained corrected and the patient did not again
have an anion gap. Fluid repletion continued through her
stay and by approximately the fourth day the patient was
beginning to take p.o. well. The day before admission the
patient was eating a full diabetic diet.
2. Cardiac - During the course of the stay the patient ruled
in for a non-ST elevation myocardial infarction with
troponins in the range of .4 to .5 and creatinine kinases in
the range of 300. The patient was effectively asymptomatic,
however, her mental status was confused during this time.
The patient was treated with conservative medical management,
receiving Aspirin and beta blocker. The patient had an
echocardiogram during the admission which showed preservation
of left ventricular function with an ejection fraction
greater than 55%. Plan was to start the patient on a statin
drug, either at the end of this admission or as an outpatient
for its cardioprotective effects. The patient had a total
cholesterol during admission of 106, however, this can be
artificially low around the time of a myocardial infarction.
3. Abdominal pain - On day #2 of admission, the patient
complained of some abdominal pain and had an increased
amylase and lipase. The patient underwent abdominal
computerized tomography scan which showed no evidence of
colitis, bilateral pleural effusions or uterine fibroids.
The patient's increased amylase and lipase resolved fairly
rapidly. The patient did not continue to have any abdominal
pain.
4. Change in mental status - Initially the patient was quite
confused and disoriented, oriented only to her name. Her
mental status slowly improved over the course of the
admission. She had a head computerized tomography scan that
was negative for acute process. Her B12 and Folate levels
were both normal. RPR was negative. Because of the
patient's persistent change in mental status, the patient
underwent a lumbar puncture during the admission. The
results were consistent with an aseptic meningitis with
cerebrospinal fluid showing 59 white blood cells, 9 red blood
cells, protein 53 and glucose of 121. Cryptococcal antigen
was negative, RPR was negative, herpes PCR was negative,
fungal culture negative, blood culture negative, and urine
cultures were negative. A neurology consult was obtained and
this will be discussed below. The patient's mental status
continued to improve. She was able to passive swallow on
evaluation, and her mental status changes were felt simply
related to severe extent of her illness. She did have an
myocardial infarction of the head and cervical spine which
was also negative for an intracranial process.
5. Bilateral proximal arm weakness - The patient began to
complain of this as her mental status improved and she
literally could not move her upper arms very much, several
days after admission. On further investigation it was
determined that this was a longstanding problem for the
patient and as she recovered from the illness she actually
regained strength and decreased pain in her upper arms.
Neurology was consulted for this problem as she did receive a
head computerized tomography scan and computerized tomography
scan of the spine. Computerized tomography scan of the head
showed reversible posterior encephalopathy possibly secondary
to hypertension but no masses, no midline shift. Magnetic
resonance imaging scan of the spine showed cervical
spondylosis C5-C6 and C6-C7 with some narrowing of the spinal
canal but no epidural abscess or other intraspinal process.
At the time of this dictation, it was suggested that the
patient follow up with Neurosurgery for the pain and the
findings either as she remains in-house or as an outpatient.
6. Hypertension - The patient came in an extensive
hypertensive regimen including Lisinopril,
Hydrochlorothiazide, Diovan and Atenolol. The patient was
treated in the hospital with Metoprolol 275 t.i.d. She was
started on Losartan 100 initially. An ACE inhibitor was not
used because of the patient's allergy to Univasc. Her
regimen will likely change before discharge, but she did
continue to be hypertensive to the 180s/approximately 80 to
90.
7. Glaucoma - After several days off of treatment, the
patient was continued on a home glaucoma regimen.
8. Anemia - The patient's hematocrit did drop below 28 and
the patient received 1 unit of packed red blood cells to good
affect increasing her hematocrit to 34. The patient will
have her hematocrit monitored for the remainder of her stay
and should continue receiving her B12 shots.
This dictation will be addended with the patient's discharge
information at time of discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1604**], M.D. [**MD Number(1) 1605**]
Dictated By:[**Last Name (NamePattern1) 6006**]
MEDQUIST36
D: [**2140-9-12**] 14:37
T: [**2140-9-12**] 14:45
JOB#: [**Job Number 17867**]
Name: [**Known lastname 2862**], [**Known firstname 1194**] R Unit No: [**Numeric Identifier 2863**]
Admission Date: [**2140-9-6**] Discharge Date: [**2140-9-13**]
Date of Birth: [**2057-3-5**] Sex: F
Service:
ADDENDUM:
The patient continued to do well on the last day of her stay.
Her glucose was reasonably well controlled on Glargine 10
units q.h.s. and a regular insulin sliding scale. The patient
continued to have increased blood pressure, especially at
night. The patient was orthostatic on the date of discharge.
This was felt due to autonomic dysfunction. The patient's
metoprolol was increased to 100 mg t.i.d. and Amlodipine was
increased to 5 mg q.d. and Hydralazine 10 mg q.i.d. was added
on the date of discharge. The patient would likely benefit
from transition from metoprolol to Carvedilol for its alpha
effects during her rehabilitation stay.
DISCHARGE DISPOSITION: Extended care facility.
DISCHARGE INSTRUCTIONS:
1. Contact primary doctor with any chest pain, shortness of
breath, palpations, dizziness, abdominal pain, or change in
mental status.
2. The patient should have glucose monitored closely to
establish an effective insulin regimen.
3. Have blood pressure monitored closely to establish an
effective hypertensive regimen. Give probable autonomic
dysfunction, the patient is to be transitioned from
metoprolol to a beta blocker with mixed activities such as
Carvedilol.
4. The patient should see primary care doctor, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 2864**], [**Telephone/Fax (1) 2865**] within two weeks.
5. The patient is to see cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on
[**2140-9-28**] at 12:00 p.m., [**Telephone/Fax (1) 2866**].
6. The patient is to see a neurologist, Dr. [**Last Name (STitle) 2867**]
[**Name (STitle) **], on [**2140-9-20**].
CONDITION ON DISCHARGE: Good.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg once a day.
2. Protonix 40 mg once a day.
3. Dorzolamide 2% drops, one drop t.i.d.
4. Betaxolol 0.25% drops one b.i.d.
5. Metoprolol 100 mg b.i.d.
6. Amlodipine 5 mg q.d.
7. Hydralazine 10 mg q.i.d.
8. Losartan 100 mg q.d.
9. Colace 100 mg b.i.d.
10. Insulin Glargine 10 units subcutaneously q.h.s.
11. Regular insulin sliding scale.
12. Fosamax 70 mg q. week.
13. Cyanocobalamin 1 mg injection q. month.
14. Multivitamin q.d.
DISCHARGE DIAGNOSIS:
1. Diabetes mellitus, type 2, uncontrolled.
2. Viral meningitis.
3. Delirium, transient.
4. Pain in limb.
5. Myocardial infarction, non-Q wave myocardial infarction.
6. Cervical spondylosis.
7. Hypertension, benign.
8. Autonomic dysfunction secondary to diabetes.
[**First Name11 (Name Pattern1) 2868**] [**Last Name (NamePattern4) 2869**], M.D. [**MD Number(1) 2870**]
Dictated By:[**Last Name (NamePattern1) 2223**]
MEDQUIST36
D: [**2140-9-15**] 03:50
T: [**2140-9-15**] 18:06
JOB#: [**Job Number 2871**]
|
[
"401.9",
"250.62",
"250.22",
"337.1",
"047.9",
"721.0",
"410.71",
"293.0",
"280.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
10413, 10438
|
1999, 2048
|
11451, 11906
|
11927, 12481
|
1521, 1849
|
3795, 10389
|
10462, 11396
|
2071, 3777
|
133, 1096
|
1119, 1494
|
1866, 1982
|
11421, 11428
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,366
| 183,271
|
34714
|
Discharge summary
|
report
|
Admission Date: [**2138-10-28**] Discharge Date: [**2138-11-12**]
Date of Birth: [**2058-12-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
PICC line placement. Red blood cell transfusion.
History of Present Illness:
Patient is a 79 year old male with history of interstitial lung
disease on oral prednisone taper (5-10 mg) at home, 3-4L nasal
cannula oxygen at night at home, diastolic congestive heart
failure, type two diabetes mellitus, coronary artery disease
with recent NSTEMI, unresectable cholangiocarcinoma status-post
ex-laparotomy with Roux-en-Y hepaticojejunostomy ([**2138-9-16**]) with
positive margins, common bile duct excision, cholecystectomy,
lymph node biopsy and percutaneous drain placement ([**2138-9-16**]) who
was admitted to an outside hospital on [**10-26**] with fever, hypoxia,
confusion thought to be PNA/CHF treated with levofloxacin and
diuresis. He was found to have NSTEMI which was medically
managed. He was transferred to [**Hospital1 18**] for evaluation of possible
abscess in setting of recent surgery, but CT abdomen was
negative for abscess.
.
Patient was transferred from surgery to medicine on [**11-1**] after
he was found to have hypoxia, with oxygen saturation of 70-80s
on NC at transfer. He was given nebs but no diuresis since [**10-31**]
due to increased Cr. He has been followed by pulmonary consult
while in house - unable to get workup for PCP, [**Name10 (NameIs) **] for high res
CT. Has been on 5L NC and stable. On morning of transfer, around
4:15am, desat to 40-50s and found to be in respiratory distress
with accessory muscle use and cyanotic. On 6L NC and high flow
mask with O2 sat of 94% but with paO2 of 55 on ABG. 7.48/34/55.
Lactate up to 3.2. CXR showing increased effusion with increased
haziness on right side. Given 20mg IV lasix, 60mg PO prednisone,
nitro SL. EKG unchanged. SBP 120s.
.
Patient's code status still full code - from a cancer
perspective, the patient has been told that his expected life
expectancy in the 5 year range.
Past Medical History:
-Cholangiocarcinoma - unresectable; s/p Roux-en-Y
hepaticojejunostomy done by Dr. [**First Name (STitle) **] on [**2138-9-16**] after had
positive proximal and distal margins. Percutaneous drain in
place.
-Biliary Stricture s/p [**Date Range **] and stenting
-Interstitial lung disease, on home O2 and taper of prednisone
daily
-DM2
-HTN
-Dyslipidemia
-Arthritis
-GERD - GI bleed in [**2137**]
-Osteoperosis
-Cataracts (Bilateral)
-Diastolic CHF
-CAD - s/p recent NSTEMI
Social History:
Patient is a former smoker. He quit 20 years ago and had smoked
for 50 pack years prior. He drinks 1-3 beers a day. He was
formerly a floor supervisor in a paint shop, where he worked
with chemicals and electronics.
Family History:
Father with DM, mother died at 97
Physical Exam:
At time of admission to medical intensive care unit:
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-16**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Pertinent Results:
High resolution chest CT [**2138-11-3**]:
IMPRESSION:
1. Recent changes over four days documented by conventional
chest radiographs
indicate that at least some of the reticular and ground-glass
abnormalities in
the lungs, which have worsened since [**10-29**] are pulmonary
edema. The
progression of the same abnormalities between [**10-9**] and
[**10-29**] could
be due to some component of interstitial lung disease, which was
clearly
present on the earliest examination.
2. Persistent pulmonary arterial hypertension and global
cardiomegaly. Severe
coronary atherosclerotic calcification. Aortic valvular
calcification of
uncertain significance.
3. Large thyroid cysts or nodules. Ultrasound examination
recommended if not
already obtained.
[**2138-10-31**]
Transthoracic Echocardiogram:
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 size is normal.
Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). There is
no ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic arch is mildly dilated.
The aortic valve leaflets (3) are mildly thickened. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**2-12**]+) mitral regurgitation is seen. The left ventricular inflow
pattern suggests impaired relaxation. The tricuspid valve
leaflets are mildly thickened. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2138-8-25**], no
definite change.
Brief Hospital Course:
Mr. [**Known lastname **] is a 79 year old male with past medical history of
type two diabetes mellitus, interstitial lung disease, diastolic
congestive heart failure, coronary artery disease status post
NSTEMI with recent diagonsis of unresectable cholangiocarcinoma
status post common bile duct excision, cholecystectomy, lymph
node biopsy, percutaneous drain placement and Roux-en-Y
hepaticojejunostomy, with no further surgical management,
transferred to MICU for hypoxia.
.
Hypoxia - Differential at time of arrival to medical intensive
care unit included exacerbation of his interstitial lung
disease, congestive heart failure, hospital-acquired pneumonia,
and PCP. [**Name10 (NameIs) **] respiratory status was too tenuous to undergo
bronchoscopy for further diagonostic purposes. Given that he had
been on long-standing steroids, and after a high-resolution CT
was obtained as noted above, therapy for hospital acquired
pneumonia with vancomycin and zosyn was initiated. Patient was
begun on steroids and bactrim for treatment of possible PCP as
well. Gentle diuresis was attempted, although it did not appear
as though he was volume overloaded on exam. This was limited by
borderline blood pressures with systolics in the 90's. He was
ruled out for a myocardial infarction, and his symptoms were not
felt to be consistent with acute coronary syndrome.
No improvement was noted with the above therapies, and the
intensive care team was unable to wean Mr. [**Known lastname **] from 100%
oxygen high-flow mask. Given that it appeared most likely that
he had a flare and exacerbation of his pulmonary fibrosis, he
was started on high dose pulse steroids. Culture data was
unrevealing for an infection. He was transfused red blood cells
with subsequent diuresis without improvement in his dyspnea.
During his time in the intensive care unit from [**2138-11-3**]
onward, the patient became progressively more short of breath.
He required both high flow mask of 100% oxygen as well as 10 L
nasal cannula, and was only able to maintain oxygen saturations
in the 80's as of [**2138-11-11**]. The patient, along with his family,
pastor, and friends, made the decision to not pursue intubation
or resuscitation, as the patient understood that it was unlikely
that he would be able to be weaned off of the ventilator should
he be intubated. His focus shifted towards lessening the feeling
of his dyspnea as his respiratory status worsened.
On the morning of [**2138-11-12**], patient expressed that he wished to
stop receiving oxygen therapy and focus solely on comfort
measures. With his family at the bedside, his morphine drip was
increased to provide him comfort. He passed away at 3:55 PM. His
family declined an autopsy.
During his stay, his transplant surgery team and oncology team
were notified of his admission and assisted in his management.
His outpatient pulmonologist was also notified and provided
additional history regarding the patient's interstitial lung
disease.
Medications on Admission:
At time of transfer:
Nitroglycerin SL 0.4 mg SL Q5MN PRN PAIN
Acetaminophen 650 mg PO Q4H:PRN
Pantoprazole 40 mg PO Q24H
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Aspirin EC 325 mg PO DAILY
Clopidogrel 75 mg PO DAILY
PredniSONE 5 mg PO DAILY
Furosemide 20 mg IV ONCE Duration:
PredniSONE 60 mg PO ONCE
Heparin 5000 UNIT SC TID
Senna 1 TAB PO BID
Insulin SC (per Insulin Flowsheet)
Sliding Scale & Fixed Dose
Simvastatin 80 mg PO DAILY
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN
Metoprolol Tartrate 12.5 mg PO BID
Ursodiol 300 mg PO TID
Multivitamins 1 TAB PO DAILY
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory failure
Discharge Condition:
Expired.
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
[
"716.90",
"428.33",
"276.3",
"414.01",
"285.22",
"458.9",
"793.99",
"288.60",
"410.71",
"250.00",
"530.81",
"156.9",
"401.9",
"V45.89",
"V43.3",
"428.0",
"416.8",
"V46.2",
"276.1",
"482.9",
"584.9",
"515",
"272.4",
"733.00",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07",
"38.93",
"87.41"
] |
icd9pcs
|
[
[
[]
]
] |
9200, 9209
|
5561, 8549
|
326, 377
|
9273, 9284
|
3775, 5538
|
9336, 9472
|
2940, 2976
|
9170, 9177
|
9230, 9252
|
8575, 9147
|
9308, 9313
|
2991, 3756
|
279, 288
|
405, 2196
|
2218, 2691
|
2707, 2924
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,439
| 100,961
|
9886
|
Discharge summary
|
report
|
Admission Date: [**2134-8-14**] Discharge Date: [**2134-8-17**]
Date of Birth: [**2064-9-18**] Sex: M
Service: MEDICINE
Allergies:
Tetracyclines
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 33170**] is a 69 y/o man with PMH of metastatic insulinoma,
hypertension, and paroxysmal atrial fibrillation not
anticoagulated who presents with hypoglycemia. Patient's partner
notes that patient slept in this morning to 8 or 9 am (usual
wake up time is 6 am). At that time, his partner wanted to take
his blood sugar as this was unusual for him but patient would
not cooperate. His partner then called EMS who reportedly found
FSBS 20. An amp of D50 was given at that time with increased
alertness and FSBS to 136 and then to 113.
.
He arrived at [**Hospital3 **] Hospital at about 11 am, and FSBS at 1151
am was 27 and repeated to be 59. He got 1 amp D50 at 1200 pm. He
was then started on a D51/2NS infusion at 150 cc / hour.
.
On arrival to our ED, initial vitals T 98, HR 85, BP 110/76, RR
14, O2 98% on RA. Initial FSBS 106, with repeat 111 at 1650 and
99 at 1830 prior to transfer to floor. He was maintained on
D51/2NS at 150 cc/hour while in the ED. He vomited X 1 en route
to [**Hospital1 18**] after drinking OJ in the ambulance.
.
On arrival to the ICU, the patient denies any headache,
dizziness, chest pain, or difficulty breathing. He endorses
abdominal distension which is chronic but maybe slightly
increased in past few weeks. He reports decreased PO intake due
to decreased appetite for the past few days as well as feeling
overall "weak" and "tired." He denies any nausea/vomiting or
diarrhea at home. He denies any blood in his stools.
.
Typically checks fingersticks twice per day-morning and before
bed. No recent low fingersticks in past few days. Tried decrease
in dexamethasone to 1 mg alternating with 1.5 mg every other day
but did not tolerate this due to morning fingersticks in the
40s.
.
ROS: Denies headache, nasal congestion, sore throat, enlarged
lymph nodes, chest pain, difficulty breathing, and cough. Denies
fever, chills, or recent weight loss. Denies dysuria though
reports nighttime incontinence which has been ongoing for some
time. Denies blood in his stools. Endorses lower extremity
swelling which has been worse with dexamethasone treatment.
Endorses right hand tingling in all fingers for past few weeks
without right hand weakness or clumsiness.
Past Medical History:
* Hypertension
* Paroxysmal atrial fibrillation (s/p DCCV, now on dofetilide,
previously on coumadin)
* Transitional cell bladder cancer s/p cystectomy & prostatecomy
with ileal neobladder
* Metastatic insulinoma with metastases to liver resulting in
gastric/esophageal varices & portal hypertension
- s/p treatment with Adriamycin/5FU/streptozocin in [**4-6**] and
chemoembolization in [**5-7**] & [**5-8**]
- treated with temsirolimus [**10-8**] which was stopped due to side
effects
- initiated treatment with sirolimus in [**12-8**] which was stopped
on [**2134-8-10**]
- now followed at the [**Company 2860**], last CT there last week, Dr. [**Last Name (STitle) 33171**]
is oncologist, plan for initiation of avastin on [**8-19**]
* Gonadal insufficiency on topical androgen replacement
* h/o anal fissure s/p surgical repair
* GERD on PPI, recent GI bleed in [**3-9**] [**1-2**] to Dieulafoy lesion
* h/o pancytopenia
* s/p appendectomy
Social History:
Patient lives with his partner, [**Name (NI) **] [**Last Name (NamePattern1) 19952**], in [**Name (NI) 3615**].
Currently not working but previously worked in property
management. Denies tobacco, alcohol, and illicit drug use. No
pets.
Family History:
Father deceased age 56 with MI. Mother deceased age [**Age over 90 **] with
complications from hip repair. Has 5 siblings.
Physical Exam:
vs: T 99.2, BP 105/51, P 86, RR 19, 100% ra
gen: alert, oriented, no acute distress
heent: PERRL, EOMI, sclerae anicteric, MM slightly dry, no
lymphadenopathy in the neck, JVP at 7 cm
lungs: clear bilaterally without rhonchi or wheezing
CV: RRR, heart sounds distant, no appreciable murmur
abd: distended but tympanitic, normoactive bowel sounds,
slightly tender diffusely to palpation, + fluid wave on exam,
ext: 1+ pitting edema in bilateral lower extremities to knees,
warm throughout, DP pulses 2+ bilaterally
skin: scattered acneiform lesions on back, no rash
neuro: cranial nerves II-XII intact, speech clear, strength 5/5
in bilateral biceps/triceps, hand grip, wrist extension, hip
flexion, ankle dorsiflexion/plantarflexion; DTRs 2+ at biceps
and patellar tendons, sensation intact upper & lower extremities
to light touch
psych: appropriately answering questions
Pertinent Results:
ADMISSION LABS (from [**Hospital3 **] Hospital):
WBC 6.3 (83%N, 12%L, 5% monos), Hgb 13.1, Hct 39, Plt 165
Troponin I < 0.10
Alk phos 124
Total bili 0.9
Direct bili 0.2
Indirect bili 0.7
Total protein 6.6
Albumin 3.6
AST 29
ALT 32
Na 140, K 4, Cl 115, CO2 17, BUN 24, Cr 1.3
Ca 8.8
Glucose 167
INR 1.1
.
Labs from [**Company 2860**] ([**2137-8-10**]):
WBC 4.7 <-- 3.2
Hct 34.5 <-- 35
Plt 109 <-- 106
Na 140 <-- 139
k 5 <-- 4
Cl 118 <-- 116
CO2 14 <-- 12
BUN 31 <-- 33
Cr 1.6 <-- 1.4
glucose 96 <-- 101
calcium 9.3 <-- 9.1
albumin 3.7
alk phos 114 <-- 118
.
EKG: sinus rhythm at 90, normal axis, biphasic p wave in V1, TWI
in V1 and III, no ST-T elevations or depressions
[**2134-8-14**] 08:46PM GLUCOSE-114* UREA N-26* CREAT-1.4* SODIUM-142
POTASSIUM-3.7 CHLORIDE-117* TOTAL CO2-15* ANION GAP-14
[**2134-8-14**] 08:46PM ALT(SGPT)-32 AST(SGOT)-29 LD(LDH)-213 ALK
PHOS-120* AMYLASE-85 TOT BILI-0.6
[**2134-8-14**] 08:46PM LIPASE-29
[**2134-8-14**] 08:46PM ALBUMIN-3.6 CALCIUM-8.7 PHOSPHATE-2.6*
MAGNESIUM-1.8
[**2134-8-14**] 08:46PM WBC-3.1* RBC-3.77* HGB-11.8* HCT-34.1* MCV-90
MCH-31.3 MCHC-34.6 RDW-13.9
[**2134-8-14**] 08:46PM PLT COUNT-92*
[**2134-8-14**] 08:46PM NEUTS-76.5* LYMPHS-15.9* MONOS-5.8 EOS-1.5
BASOS-0.4
[**2134-8-14**] 08:46PM PT-13.1 PTT-25.0 INR(PT)-1.1
.
.
PERTINENT LABS/STUDIES:
.
Hct: 34.1 ([**8-14**]) -> 29.6 -> 30.1 -> 31.4 ([**8-17**])
WBC: 3.1 ([**8-14**]) -> 2.8 -> 2.5 -> 2.5 ([**8-17**])
Plt: 92 -> 82 -> 83 -> 92
HCO3: 15 ([**8-14**]) -> 11 -> 12 -> 12 ([**8-17**])
Cl: 117 -> 117 -> 118 -> 119
Glucose: 114 ([**8-14**]) -> 151 -> 123 -> 84 ([**8-17**])
ABG: 7.41 / 20 / 96 / 13
.
U/A: Small leukocytes, many bacteria
URINE CULTURE (Final [**2134-8-17**]):
KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
CXR ([**8-14**]): Comparison is made to the prior study from [**2132-5-10**]. There are low lung volumes with mild bibasilar atelectasis.
The remainder of the lungs are clear. Cardiomediastinal
silhouette is unremarkable.
.
.
DISCHARGE LABS:
[**2134-8-17**] 04:55AM BLOOD WBC-2.5* RBC-3.48* Hgb-10.7* Hct-31.4*
MCV-90 MCH-30.8 MCHC-34.2 RDW-13.9 Plt Ct-92*
[**2134-8-15**] 10:37PM BLOOD Neuts-78.7* Lymphs-15.5* Monos-5.4
Eos-0.4 Baso-0.2
[**2134-8-17**] 04:55AM BLOOD Plt Ct-92*
[**2134-8-17**] 04:55AM BLOOD Glucose-84 UreaN-27* Creat-1.3* Na-140
K-3.7 Cl-119* HCO3-12* AnGap-13
[**2134-8-17**] 04:55AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.0
Brief Hospital Course:
Patient is a 69 yo male with known metastatic insulinoma who was
admitted with hypoglycemia in the setting of progressive
metastatic disease.
.
#. Hypoglycemia: Patient had a recent CT on [**2134-8-12**], which
showed progressive disease per primary oncologist. Patient was
planning on starting Avastin therapy on [**2134-8-19**]. Patient had
decreased appetite for a few days prior to admission, and his
recent hypoglycemic episode was most likely secondary to
decreased PO intake. The patient was started on D10 IV fluids,
and was eventually transitioned to D5 IV Fluids. The patient's
dexamethasone was also increased to 4 mg [**Hospital1 **]. On hospital day
#3, the patient's IV Fluids were stopped, and his finger stick
glucoses remained within normal limits. The patient has a
follow-up appointment with his oncologist on Thursday, [**8-19**].
.
#. Possible UTI: The patient had a U/A on admission which showed
WBCs and bacteria. Patient has an ileal conduit, and thus he
may have chronic bacteriuria. Patient does not endorse any
symptoms, and urine cultures grew Klebsiella Oxytoca. The
patient was not started on antibiotics during this admission.
.
# Metabolic Acidosis: The patient had persistently low HCO3 on
this admission, which was thought to be secondary to his ileal
neobladder. An ABG was performed on the patient, which showed a
normal pH, but a decreased CO2 to 20, significant for a chronic
process. The patient has an ileal conduit, and a metabolic
acidosis is normally found in this setting when there is
increased transit time in the ileoconduit (i.e. possible stomal
stenosis). It was recommended that the patient visit his
urologist at his convenience to have a loopogram performed to
assess the patency of his ileoconduit. The patient was
discharged on bicarbonate replacement.
.
# Atrial fibrillation: The patient has a history of Atrial
fibrillation and was continued on his home dose of dofetilide.
He was in normal sinus rhythm throughout this admission. He is
not anticoagulated secondary to a recent GI bleed, but he
remained on ASA 81 mg daily during this admission.
.
#. Hypertension: The patient has a h/o hypertension and is
currently on dofetilide. He was continued on this medication
throughout his hospital stay and did not have any acute events.
.
#. GERD with recent UGI bleed: Patient has a history of a
recent GI bleed. He was stable throughout this hospital stay
and was maintained on his home dose of PPI.
.
# Code: Full
Medications on Admission:
Dofetilide 375 mcg twice a day
dexamethasone 1.5 mg daily
omeprazole 20 mg [**Hospital1 **]
nadolol 20 mg daily (pt unsure if he still takes this med)
AndroGel 1% pump (occasional use only)
vitamin C 1000 mg daily
aspirin 81 mg a day
simethicone 125 mg 2-4 times/day
Sirolimus 2 mg daily - stopped on [**8-10**]
spironolactone/hydrochlorothiazide 12.5 daily - stopped [**7-30**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Insulinoma
Hypoglycemia
Secondary:
Metabolic non-gap acidosis
Atrial Fibrillation
Discharge Condition:
Good. Patient's vital signs are stable, and his fingerstick
glucose levels have all been within normal limits.
Discharge Instructions:
You were admitted to the hospital because you experienced an
episode of hypoglycemia. While you were here, your dose of
Dexamethasone was increased and you were placed on IV fluids
with glucose. Your blood sugars remained stable on this
regimen, so we took you off of the IV fluids. Your sugars
remained stable overnight and appeared to have responded to the
increased dose of Dexamethasone.
While you were here, we made the following changes to your
medications:
1. We started you on Sodium bicarbonate to increase this level
in your blood.
2. We increased your dose of Dexamethasone to 4 mg [**Hospital1 **].
Please take all medications as prescribed.
Pleae keep all previously scheduled appointments.
Please return to the ED or your healthcare provider immediately
if you experience confusion, low blood sugars, weakness,
lethargy, chest pain, shortness of breath, fevers, chills, or
any other concerning symptoms.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 33171**]. Date: [**2134-8-19**].
Provider: [**Last Name (NamePattern4) **]/EYE LIST OR EYE SURGERY Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2134-9-16**] 7:30
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2134-9-17**] 4:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2135-1-26**] 1:00
Completed by:[**2134-8-17**]
|
[
"456.8",
"456.21",
"401.9",
"157.4",
"572.3",
"251.1",
"276.2",
"041.85",
"530.81",
"197.7",
"427.31",
"V10.51",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10770, 10776
|
7848, 10340
|
285, 293
|
10912, 11026
|
4811, 7410
|
11999, 12546
|
3778, 3902
|
10797, 10891
|
10366, 10747
|
11050, 11976
|
7427, 7825
|
3917, 4792
|
233, 247
|
321, 2541
|
2563, 3508
|
3524, 3762
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,410
| 116,458
|
28351
|
Discharge summary
|
report
|
Admission Date: [**2142-4-13**] Discharge Date: [**2142-4-18**]
Date of Birth: [**2086-10-31**] Sex: M
Service: NEUROSURGERY
Allergies:
Nsaids / bee stings / Zyvox
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Brain mass
Major Surgical or Invasive Procedure:
Right craniotomy for open biopsy of Right parietal brain lesion
History of Present Illness:
This is a 55 yo male patient with metastatic lung CA and right
parietal mass. He was recently seen by Dr. [**Last Name (STitle) **] and me and
his
case was discussed with the brain tumor clinic and a biopsy
prior
to radiation was recommended. He therefor represents for
evaluation.
He denies headaches, nausea, emesis, seizure activity.
He reports to have a productive cough all winter that is
improving. He was recently admitted for tachycardia related to
dehydration.
Past Medical History:
- Paranoid schizophrenia
- NIDDM
- Depression
- Hepatitis C
- Cirrhosis.
- Lung Cancer s/p surgery and chemo-radiation 1 year ago
recently found with mets to parietal lobe
Social History:
He lives in a group home/extended care facility. He used to
work as a
manual laborer. He has 40-pack-year smoking history and prior
heavy drinking.
Family History:
Coronary artery disease and MIs.
Physical Exam:
On Admission:
Gen: WD/WN, comfortable, NAD. Wearing a mask due to cough
HEENT: Pupils: 1-0.5 EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 1 to 0.5
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-2**] throughout. No pronator drift
Coordination: normal on finger-nose-finger
On Discharge:
Gen: WD/WN, comfortable, NAD. Wearing a mask due to cough
HEENT: Pupils: 1-0.5 EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 1 to 0.5
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-2**] throughout. No pronator drift
Coordination: normal on finger-nose-finger
On Discharge:
Motor: mild leftsided 4+/5 weakness. Right side is full
strength.
Pertinent Results:
CT HEAD W/O CONTRAST [**2142-4-13**]
Expected post biopsy changes of pneumocephalus, small amount of
blood, and fluid. No large hemorrhage. No evidence of infarction
MR brain [**2142-4-13**]
Redemonstration of the right parietal lesion measuring 1.8 x 2.3
x 2.4 cm. for surgical planning. Other details as above
CT head noncontrast [**2142-4-13**]: Expected post biopsy changes of
pneumocephalus, small amount of blood, and fluid. No hemorrhage.
No evidence of infarction.
Chest Xray [**4-16**] : no change from [**2142-4-10**]. No focal
consolidation or pleural effusion is seen. The cardiomediastinal
silhouette is within normal limits.
Brief Hospital Course:
This is a 55 year old man with history of metastaic lung CA
presents for open biopsy of R parietal brain lesion. Post
operative head CT was stable. He remained in the ICU overnight
for close monitoring. On [**4-14**], patient remained stable.
Overnight his blood glucose was elevated to 455 and an insulin
gtt was started. On the morning of [**4-14**], his gtt was weaned off
and patient was transferred to the SDU. He had BS over 400
twice and [**Last Name (un) **] was consulted on [**4-15**]. Steroids were lowered.
On [**4-16**] his dexamethasone continued to be weaned and [**Last Name (un) **]
contined to see him titrating his sliding scale. On [**4-17**] he was
deemed fit from a neurosurgical perspective for discharge to
rehab, however after discussion with [**Last Name (un) **] he continued to
require more time to devise an appropriate blood glucose
management regimen so his discharge was placed on hold. He was
transferred to floor status on [**4-17**].
He was seen and evaluated by physical therapy and occupational
therapy who felt that he would benefit from rehab.
At the time of discharge he was tolerating a diabetic diet,
ambulating with a walker, afebrile with stable vital signs.
Medications on Admission:
fluticasone-salmeterol, tiotropium bromide, dexamethasone,
citalopram, clonazepam, olanzapine, trihexyphenidyl, tamsulosin,
aspirin 325, docusate sodium, haloperidol, omeprazole,
metformin, albuterol, gabapentin
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. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
7. olanzapine 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
8. trihexyphenidyl 2 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
10. haloperidol 5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. gabapentin 400 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhaler Inhalation Q6H (every 6 hours)
as needed for wheezing.
13. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
16. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
17. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for Pain.
Disp:*50 Tablet(s)* Refills:*0*
18. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
19. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
21. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-29**]
Tablets PO every 6-8 hours as needed for pain.
22. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for itching .
23. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO twice a day as needed for constipation.
24. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
25. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: per insulin flowsheet per insulin flowsheet Subcutaneous
per insulin flowsheet: Please follow insulin Flowsheet.
26. dextrose 50% in water (D50W) Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 13990**] Health Care Center - [**Location (un) 5110**]
Discharge Diagnosis:
Right parietal brain lesion
Hyperglycemia
Tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge 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.
?????? Dressing may be removed on Day 2 after surgery.
?????? If you have dissolvable sutures you may wash your hair and get
your incision wet day 3 after surgery. You may shower before
this time using a shower cap to cover your head.
?????? If your wound was closed with staples or non-dissolvable
sutures then 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.
?????? If you were on a medication such as Aspirin, prior to your
injury, you may safely resume taking this on [**2142-4-20**].
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**8-7**] days(from your date of
surgery) for a wound check. This appointment can be made with
the Nurse Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**].
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**4-23**] at
930am. 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**]. Please call if you need to change your
appointment, or require additional directions.
Completed by:[**2142-4-18**]
|
[
"V15.82",
"571.5",
"V10.11",
"070.54",
"272.4",
"198.3",
"295.30",
"401.9",
"250.00",
"V45.76",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.14"
] |
icd9pcs
|
[
[
[]
]
] |
8199, 8293
|
4053, 5261
|
304, 370
|
8391, 8391
|
3385, 4030
|
10402, 11102
|
1250, 1285
|
5524, 8176
|
8314, 8370
|
5287, 5501
|
8542, 10379
|
1300, 1300
|
3298, 3366
|
254, 266
|
398, 871
|
2690, 3284
|
1314, 1446
|
8406, 8518
|
893, 1066
|
1082, 1234
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,195
| 140,803
|
46638
|
Discharge summary
|
report
|
Admission Date: [**2106-11-16**] Discharge Date: [**2106-11-23**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4309**]
Chief Complaint:
Mechanical fall
Major Surgical or Invasive Procedure:
Left hip hemiarthroplasty
History of Present Illness:
87 yo F w/ PMHx sig for colon cancer s/p mechanical fall with L
femoral neck fracture. Patient endorses pain at left hip, per
ortho admission note.
Past Medical History:
Colon cancer s/p resection, chemotherapy, and XRT in [**2096**]
osteoporosis
macular degeneration
s/p ccy
Social History:
Works 2 days a week in a cafeteria at a local school, was a
former telephone operator. Lives in [**Location 2312**], [**State 350**]
with her [**Age over 90 **] yo brother w/ [**Name2 (NI) 11964**] and whom she cares for.
Family History:
NC
Physical Exam:
NAD A&Ox3
reduced ROM L hip/knee [**3-8**] pain
SILT distally
Motor [**6-8**]
Wiggles toes
2+ dp pulse
(per ortho)
Pertinent Results:
[**2106-11-16**] 01:55PM WBC-10.1 RBC-3.85* HGB-11.9* HCT-35.8* MCV-93
MCH-30.8 MCHC-33.2 RDW-14.3
[**2106-11-16**] 01:55PM NEUTS-87.4* LYMPHS-9.0* MONOS-3.0 EOS-0.4
BASOS-0.2
[**2106-11-16**] 01:55PM GLUCOSE-104 UREA N-30* CREAT-0.9 SODIUM-141
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14
[**2106-11-16**] 04:15PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-0.2 PH-8.0
LEUK-NEG
[**2106-11-16**] 04:15PM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-0
[**2106-11-16**] 04:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
MRI:
1. Extensive diffusion abnormalities at the junction of the
anterior and middle cerebral artery territories as well as at
the junction of middle and posterior cerebral artery
territories, with corresponding areas of T2 and FLAIR
hyperintensities, most consistent with a watershed distribution
of infarct.
2. Mild pruning of some of the branches of the left middle
cerebral artery, compared with the contralateral side, without
evidence of a definite occlusion of a vessel.
3. Stenosis at the origin of the vertebral arteries, left
greater than right, but otherwise unremarkable MRA of the neck.
4. Persistent areas of T2 and FLAIR hyperintensity in the
subcortical and periventricular white matter in addition to
those associated with the infarct described above, nonspecific
in nature, but most consistent with the sequela of chronic
microangiopathy given the patient's age.
Echo:
The interatrial septum is aneurysmal with early appearance of
agitated saline seen in the left atrium and left ventricle,
consistent with a small ASD or stretched PFO. Mildly hypokinetic
left ventricle. Mildly dilated right ventricle with moderate to
severe tricuspid regurgitation and mild to moderate pulmonary
hypertension. Mild mitral regurgitation
EEG:
This is an abnormal portable EEG due to slowing and
disorganization of the background rhythm with intermittent
triphasic waves. These findings are suggestive of a moderate to
severe encephalopathy. Medications, toxic/metabolic
disturbances, and infection are common causes. There were no
focal, lateralized, or epileptiform features noted during this
recording
CXR:
New opacity in the right lower lobe is worrisome for aspiration
given the clinical history. Mild cardiomegaly is unchanged. NG
tube tip is out of view below the diaphragm. There is no
pneumothorax or enlarging pleural effusion. Apical pleural
thickening is unchanged. No evidence of enlarging pleural
effusions.
Brief Hospital Course:
87F with fall & traumatic hip fracture s/p repair.
Patient underwent left hip hemiarthroplasty [**11-17**] w/ estimated
300cc blood loss. S/p arthroplasty patient was noted have
altered mental status; a head CT was negative for acute process.
She was then noted to have R hemiparesis and aphasia, and a
witnessed left sided tonic clonic seizure that resolved with
ativan x1. A follow up head CT showed no interval changes. Ms.
[**Known lastname 44077**] was also tachycardic to 120s during the seizure,
received 5 mg of metoprolol IV. CEs were positive w/ trop 1.05
and MB 7.7. Cardiology and Neurology were consulted and patient
admitted to MICU for further management.
.
Neurology evaluated the patient who suspected a CNS ischemic
insult. The etiology was thought to be either secondary to
embolic event vs hypoperfusion/hypotension intraoperatively
(though per anesthesia note, patient experienced only brief
episode of hypotension sbp 89). An MRI showed evidence of
diffusion abnormalities consistent with watershed infarct. An
EEG completed further into hospitalization was significant for
toxic/metabolic encephalopathy, though infectious and toxic work
up was negative. An echo was done and showed evidence of
PFO/ASD. Her course was complicated by non-ST elevation MI.
Per cardiology the patient was medically managed with asa and
bb, while maintaining adequate blood pressure ranges for
cerebral perfusion. Anticoagulation was held in this setting
given MRI results as above. Throughout MICU course, patient was
nonresponsive and somnolent.
.
Patient was subsequently transferred to the floors for further
medical management. Upon transfer, patient was nonresponsive
and unable to follow commands. Patient had episode of
aspiration with CXR concerning for aspiration pneumonitis vs
pneumonia. A long discussion was had with family and health
care proxy regarding goals of care. Per [**Hospital 228**] health care
proxy, the decision was made to decline any invasive measures
including NGT, IVFs, and antibiotics. Patient was made comfort
measures status, and social work and palliative care were
consulted for hospice planning and family coping. Patient was
discharged to Community Hospice House in [**Location (un) **].
.
Patient is DNR/DNI with goal of comfort.
.
Contact is her HCP, [**Name (NI) 1494**]: [**Telephone/Fax (1) 99027**]
Medications on Admission:
aspirin 81 mg daily
alendronate 70 mg weekly
calcium/vit D
glucosamine/chondroitin
MVI
Ocuvite
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for comfort.
4. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q2H
(every 2 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
IHS - [**Location (un) 5450**], NH
Discharge Diagnosis:
Primary: Left displaced femoral neck fracture, CVA, NSTEMI,
Seizure disorder
Discharge Condition:
Poor
Discharge Instructions:
Ms. [**Known lastname 44077**] was seen in the hospital for your hip fracture.
She underwent a left hemiarthroplasty ([**2106-11-17**]) and after this
operation she sustained a seizure, stroke, and heart attack.
She was medically managed, but unfortunately did not improve
with therapy. The decision was made per her written and
previously expressed wishes as well as per the health care proxy
to transition the patient for hospice care.
The following medications have been added for comfort care:
Tylenol, Lorazepam, and Morphine
Followup Instructions:
None
Completed by:[**2106-11-26**]
|
[
"410.71",
"820.8",
"997.1",
"285.1",
"780.39",
"V10.05",
"E885.9",
"434.11",
"997.02",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.52"
] |
icd9pcs
|
[
[
[]
]
] |
6474, 6535
|
3581, 5949
|
280, 308
|
6656, 6663
|
1025, 3558
|
7244, 7281
|
871, 875
|
6095, 6451
|
6556, 6635
|
5975, 6072
|
6687, 7221
|
890, 1006
|
225, 242
|
336, 486
|
508, 616
|
632, 855
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,936
| 110,539
|
8915+8916
|
Discharge summary
|
report+report
|
Admission Date: [**2135-6-20**] Discharge Date: [**2135-6-25**]
Date of Birth: [**2064-5-10**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
HPI: Pt is a 71M admitted overnight to the medicine service for
B/L LE pain with new DVT in the L calf. This morning R
foot/toes
noted to be cool, and a vascular surgery consult was obtained.
Patient reports several days of B/L LE pain which started in the
L leg and has moved to the R leg. Pain is now worse in the R
leg.
However, at the time of interview, patient says pain is minimal.
Patient denied weakness, numbness. No ulcers. He denies trauma.
Of note, patient was started on heparin gtt for the DVT. In the
ED he was also noted to be hyperkalemic with a K of 5.7. EKG
without peaked T waves. Patient is a poor historian; most of
the
history obtained from the medical record.
Major Surgical or Invasive Procedure:
Diagnostic abdominal aortogram, pelvic
arteriogram, and right lower extremity runoff; percutaneous
balloon angioplasty of the superficial femoral artery,
popliteal, and posterior tibialis; stenting of the posterior
tibialis, below-the-knee and above-the-knee popliteal, and
superficial femoral artery as well as the tibioperoneal
trunk; primary stenting of the right external iliac artery
History of Present Illness:
HPI: Pt is a 71M admitted overnight to the medicine service for
B/L LE pain with new DVT in the L calf. This morning R
foot/toes
noted to be cool, and a vascular surgery consult was obtained.
Patient reports several days of B/L LE pain which started in the
L leg and has moved to the R leg. Pain is now worse in the R
leg.
However, at the time of interview, patient says pain is minimal.
Patient denied weakness, numbness. No ulcers. He denies trauma.
Of note, patient was started on heparin gtt for the DVT. In the
ED he was also noted to be hyperkalemic with a K of 5.7. EKG
without peaked T waves. Patient is a poor historian; most of
the
history obtained from the medical record.
Past Medical History:
Past Medical History:
EtOH cirrhosis with diuretic resistant ascites(US guided para on
[**2135-5-19**] removing 8.5L and on [**2135-5-6**] removing 4 L): followed by
Dr [**Last Name (STitle) **]
DM
CKD
Laryngeal cancer status post XRT
Anemia
Colonic adenoma
GERD
Social History:
lives with daughter, smoked since age 12. Stopped drinking when
got diagnosis of cirrhosis years ago - now drinks only "milk,
water, and tea."
Family History:
Non-contributory
Physical Exam:
T 99.6 P 60 BP 111/95 RR 16 97%2L
The patient is in moderate pain ([**3-8**]) controlled with
medication. He is no acture distress, alert and orientated.
CVS regular rhythm and rate
Resp clear to auscultation bilat
Abdomen distended
lower legs DP/PT dopplerable bilat
right calf less tense.
Pertinent Results:
[**2135-6-24**] 08:45AM BLOOD WBC-6.5 RBC-3.22* Hgb-8.9* Hct-27.5*
MCV-86 MCH-27.5 MCHC-32.2 RDW-16.2* Plt Ct-347
[**2135-6-20**] 03:40PM BLOOD Neuts-72.1* Lymphs-18.6 Monos-5.0 Eos-3.0
Baso-1.3
[**2135-6-24**] 08:45AM BLOOD Plt Ct-347
[**2135-6-24**] 08:45AM BLOOD PT-11.4 PTT-52.5* INR(PT)-1.0
[**2135-6-24**] 08:45AM BLOOD Glucose-160* UreaN-16 Creat-1.6* Na-139
K-4.5 Cl-102 HCO3-30 AnGap-12
[**2135-6-24**] 08:45AM BLOOD CK(CPK)-4001*
Brief Hospital Course:
Pt is a 71M admitted [**2135-6-20**] overnight to the medicine service
for
B/L LE pain with new DVT in the L calf. This morning R
foot/toes
noted to be cool, and a vascular surgery consult was obtained.
Patient reports several days of B/L LE pain which started in the
L leg and has moved to the R leg. Pain is now worse in the R
leg.
However, at the time of interview, patient says pain is minimal.
Patient denied weakness, numbness. No ulcers. He denies trauma.
Of note, patient was started on heparin gtt for the DVT. In the
ED he was also noted to be hyperkalemic with a K of 5.7. EKG
without peaked T waves. Patient is a poor historian; most of
the
history obtained from the medical record.
ON [**6-21**] the patient underwent Right lower extremity angiogram
angioplasty and multiple stents placed. The patient tolerated
the procedure well and was transferred to the VICU for
monitoring.
The patient remained stable throughout.
On [**6-24**] the hepatology team performed a ascitic tap of his
abdomen. The patient tolerated the procedure well and was
discharged [**6-25**].
Medications on Admission:
RISS, NPH-Regular (70-30) - 12 units qam, 20 units qpm,
lactulose 30''', Folic Acid 1, pantoprazole 40
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
6. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Cartridge
Sig: Twelve (12) units Subcutaneous twice a day: 12 units qam
20 units qpm.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic right lower
extremity limb-threatening ischemia
Discharge Condition:
stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? If instructed, take Plavix (Clopidogrel) 75mg once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**1-1**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
?????? It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**1-30**] weeks for
post procedure check and ultrasound
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Followup Instructions:
Patient should contact the office of Dr. [**Last Name (STitle) **] on Monday
for a follow up appointment.
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2135-7-11**] 1:30
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2135-7-25**] 2:00
Admission Date: [**2135-6-26**] Discharge Date: [**2135-7-5**]
Date of Birth: [**2064-5-10**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
RLE ischemia
Major Surgical or Invasive Procedure:
[**2135-6-30**]: Rt Fem-PT with in-situ SVG
History of Present Illness:
This was a 71-year-old male who had recently
been diagnosed with left lower extremity DVT and he was also
found to have right foot ischemia and was taken for angiogram
for angioplasty and stenting of a very long segment
throughout his right leg. The patient was discharged home but
developed a cool foot and was re-admitted for heparinization.
The patient had a duplex showing his posterior tibial artery
was open and therefore the decision was made to take the
patient for bypass.
Past Medical History:
Past Medical History:
EtOH cirrhosis with diuretic resistant ascites(US guided para on
[**2135-5-19**] removing 8.5L and on [**2135-5-6**] removing 4 L): followed by
Dr [**Last Name (STitle) **]
DM
CKD
Laryngeal cancer status post XRT
Anemia
Colonic adenoma
GERD
Agram [**2135-6-21**]: Stent EIA, Aplast/stent SFA,[**Doctor Last Name **],PT
Social History:
lives with daughter, smoked since age 12. Stopped drinking when
got diagnosis of cirrhosis years ago - now drinks only "milk,
water, and tea.
Family History:
Non-contributory
Physical Exam:
VS: 98.4, 63, 100/49, 16 96%RA
Pain [**1-8**]- RLE, surgical
Gen: NAD
Neuro: A&Ox3
CV: RRR
Lungs: CTA
ABD: soft, +BS
RLE incision C/D/I
Pulses: LT DP/PT palp
RT DP dop, PT and graft palp
Pertinent Results:
[**2135-7-5**] 04:53AM BLOOD
Hct-32.2*#
[**2135-7-4**] 04:00AM BLOOD
WBC-7.4 RBC-2.84* Hgb-7.8* Hct-23.4* MCV-83 MCH-27.4 MCHC-33.1
RDW-16.2* Plt Ct-481*
[**2135-7-1**] 05:23AM BLOOD
WBC-7.8 RBC-3.42* Hgb-9.4* Hct-28.4* MCV-83 MCH-27.5 MCHC-33.1
RDW-16.5* Plt Ct-469*
[**2135-7-4**] 04:00AM BLOOD
Plt Ct-481*
[**2135-7-4**] 04:00AM BLOOD
Glucose-95 UreaN-15 Creat-1.5* Na-139 K-4.7 Cl-110* HCO3-23
AnGap-11
[**2135-7-4**] 04:00AM BLOOD
Calcium-8.1* Phos-4.2 Mg-1.9
Brief Hospital Course:
[**2135-6-25**]: Presented to ED day of discharge with new onset RLE
pain, cold sensation. Patient s/p Stent RT EIA,
Angioplasty/stent SFA,[**Doctor Last Name **],PT on [**2135-6-21**]. IVF/mucomyst started
for possible angio in am. Started on Heparin gtt.
[**Date range (2) 30992**]: VSS, no events. Pain controlled with oxycodone.
Heparin gtt adjusted per ptt. RT PT/DP pulses absent. Angio
cancelled. Will obtain NIAS, duplex and plan for surgery.
[**6-27**]: RLE Duplex showing patent iliac, CFA, proximal SFA,
occluded distal SFA, [**Doctor Last Name **] and PT. NIAS: Poor/flat waveforms RT
metatarsal, RT iliac, B/L SFA and Tibial Dz. RT DP/PT pulses
absent.
[**6-28**] Duplex: The right posterior tibial artery appears to be
occluded at the mid calf level. Just beyond this however, it
regains patency but as expected, shows extremely low flows with
monophasic waveforms. This can be visualized to the level of the
ankle.
[**6-29**]: Preop for [**2135-6-30**]. Transfused 1uPRBCs for HCT 24 (post HCT
29.6).
[**6-30**] Underwent uneventful Right femoral to posterior tibial
bypass with in-situ
saphenous vein graft. Extubated and transferred to PACU. Pain
controlled with Dilaudid PCA. Post K- 6.0. Treated with
insulin/D50. ECG WNL. Transferred to VICU.
[**7-1**] POD1: VSS, no events. RT DP/PT and graft palpable. On
bedrest, pulmonary toilet. Continued on ASA/Plavix and Hep gtt.
[**7-2**] POD2: VSS, no events. Diet advanced. Home meds started. Off
heparin gtt.
[**7-3**] POD3: VSS, no events. OOB to chair with nursing. Physical
therapy consulted.
[**7-4**] POD4: VSS, no events. Monitoring K. HCT 23.4, repeat
24.9-transfused 1unit PRBC. Repeat HCT 34. Tolerating regular
diet. Foley and CVL discontinued. Awaiting physical therapy
consult and rehab bed.
[**2135-7-5**] VSS. No overnight events. Discharged to rehab.
Medications on Admission:
RISS, NPH-Regular (70-30) - 12 units qam, 20 units qpm,
lactulose 30''', Folic Acid 1, pantoprazole 40
Discharge Medications:
1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Month/Day/Year **]:*30 Tablet(s)* Refills:*0*
6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
[**Month/Day/Year **]:*40 Tablet(s)* Refills:*0*
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): until ambulatory at rehab.
8. Regular insulin sliding scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular
Glucose Insulin Dose
0-70 mg/dL [**11-30**] amp D50
71-120 mg/dL 0 Units
121-160 mg/dL 2 Units 2 Units 2 Units 2 Units
161-200 mg/dL 4 Units 4 Units 4 Units 3 Units
201-240 mg/dL 6 Units 6 Units 6 Units 4 Units
241-280 mg/dL 8 Units 8 Units 8 Units 5 Units
281-320 mg/dL 10 Units 10 Units 10 Units 6 Units
321-360 mg/dL 12 Units 12 Units 12 Units 7 Units
> 360 mg/dL Notify M.D.
9. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: 8 units with breakfast, 6 units with dinner Subcutaneous
twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 11729**] Home - [**Location (un) 686**]
Discharge Diagnosis:
71 M w/ cool R ft & L DVT s/p angio w/stent [**6-21**] d/c'd returns
w/ cool RLE
PMH: EtOH cirrhosis, DM II - on insulin, GERD, gastritis on EGD
[**4-4**], CKD - baseline Cr 1.8, anemia, h/o laryngeal ca - s/p XRT,
h/o colon adenoma, tobacco abuse, EtOH abuse , IVC filter
Agram [**2135-6-21**]: Stent EIA, Aplast/stent SFA,[**Doctor Last Name **],PT
Discharge Condition:
Good
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**1-1**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Call Dr.[**Name (NI) 7446**] office to schedule post op visit to be
seen in [**9-11**] days.
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2135-7-11**] 1:30
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2135-7-25**] 2:00
Completed by:[**2135-7-5**]
|
[
"585.9",
"250.02",
"440.20",
"428.0",
"571.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
13947, 14030
|
10554, 12387
|
8716, 8762
|
14426, 14433
|
10053, 10531
|
17276, 17736
|
9813, 9831
|
12540, 13924
|
14051, 14405
|
12413, 12517
|
14457, 16843
|
16869, 17253
|
9846, 10034
|
8664, 8678
|
8790, 9274
|
9318, 9638
|
9654, 9797
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,061
| 145,004
|
5732
|
Discharge summary
|
report
|
Admission Date: [**2143-4-14**] Discharge Date: [**2143-4-24**]
Date of Birth: [**2066-3-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Coronary Angiography
CABG
History of Present Illness:
77YOM h/o DM, AS, dCHF, HTN, hyperlipidemia, CKD, stable angina
referred in from [**Hospital **] hospital for CP. He has been having
increasing exertional angina over the last year, however was
hesitant to have a catheter due to concern about receiving
contrast in setting of CKD. In lieu of this pt had a pMIBI
performed in [**Month (only) **] that showed moderate reversable defect in
distal anterior wall, unchanged from [**2138**].
CP has been worse over the last 2 weeks, and today was so bad
such that he was not able to vacuum his floor. He is to say that
he needs to have intervention. He was seen by Dr. [**Last Name (STitle) **] 2 weeks
ago as well as Dr. [**First Name (STitle) 679**] who is his PCP. [**Name10 (NameIs) **] has a summer home in
[**State 531**], where he was today, went to the hospital was found to
have a troponin of 0.062 (normal for their lab <0.034). He was
given aspirin, nitro paste 1 inch, and 80 mg of Lovenox. Guaic
negative there.
On arrival to ED he was chest pain free.
ED Course (labs, imaging, interventions, consults):
- Initial Vitals/Trigger: 97.8 64 180/90 16 99% 3L Nasal Cannula
- EKG: SR @62, NA, NI, twI laterally
- cxr
- labs, with CK-MB, trop=0.08
Vitals on transfer were 98.6 169/75 69 98 82.6 KG
On floor, pt is currently chest pain free.
Past Medical History:
Diabetes mellitus, Type 2
Hypercholesterolemia
Hypertension
Hypothyroidism
CKD (baseline Cr 1.5-1.8)
Gout
s/p appendectomy
Social History:
Lives at home with wife, denies smoking hx, etoh or drugs.
Walks [**4-7**] miles at least once a week without any ischemic
symptoms
Family History:
Father and mother died of heart disease when elderly.
Physical Exam:
VS:98.6 169/75 69 98 82.6 KG
GENERAL: white male 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 6 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No 2/6 systolic ejection. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
NEURO: CN II-XII tested and intact, strength 5/5 throughout,
sensation grossly normal. Gait not tested.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Cardiac Cath [**2143-4-14**]
COMMENTS:
1. Selective coronary angiography of this left-dominant system
demonstrated severe single vessel CAD. The LMCA was short
without
significant disease. The proxima LAD had a long lesion with 95%
stenosis. This lesion involved the origin of the D1 branch. The
mid-LAD
had 70% stenosis, which also involved a small D2 branch. The
dominant
LCX was a large caliber vessel without significant disease. The
nondominant RCA had 60% proximal stenosis.
2. Limited resting hemodynamics revealed mildly elevated
left-sided
filling pressures with an LVEDP 15mmHg. There was no significant
AV
gradient on pullback. There was severe systemic arterial
hypertension
with a measured central aortic pressure of 181/68/96.
3. Left ventriculography was deferred.
FINAL DIAGNOSIS:
1. Single vessel CAD.
2. Recommend CABG for LAD/D1 disease given complex bifurcation
lesion,
DM, and CKD.
3. Will restart heparin gtt without bolus 4-6h post-sheath pull.
No plavix given.
[**2143-4-24**] 05:23AM BLOOD WBC-13.7* RBC-3.16* Hgb-9.7* Hct-29.9*
MCV-95 MCH-30.7 MCHC-32.5 RDW-16.1* Plt Ct-253
[**2143-4-18**] 02:49PM BLOOD PT-11.9 PTT-28.4 INR(PT)-1.1
[**2143-4-23**] 04:50AM BLOOD Glucose-140* UreaN-41* Creat-1.7* Na-139
K-3.9 Cl-105 HCO3-23 AnGap-15
[**Known lastname **],[**Known firstname **] [**Medical Record Number 22871**] M 77 [**2066-3-17**]
Radiology Report CHEST (PA & LAT) Study Date of [**2143-4-22**] 2:02 PM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2143-4-22**] 2:02 PM
CHEST (PA & LAT) Clip # [**0-0-**]
Reason: r/o inf, eff
Final Report
INDICATION: 77-year-old male post-CABG.
COMPARISON: [**2143-4-20**].
CHEST, AP UPRIGHT AND LATERAL: Again seen are changes of median
sternotomy, mediastinal clips, and coronary artery bypass
grafting. Lung volumes remain low, with increasing discoid
atelectasis in the left lower lobe. There is mild central
venous congestion. Small bilateral pleural effusions, right
greater than left. No pneumothorax. Heart size is top normal.
IMPRESSION: Limited study. Low lung volumes and small
effusions.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 10307**] HO
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Brief Hospital Course:
MEDICAL COURSE:
77YOM h/o DM, AS, dCHF, HTN, hyperlipidemia, CKD, stable angina
referred in from [**Hospital **] hospital for worsening NSTEMI, found to
have extensive LAD disease requiring CABG.
# NSTEMI: EKG with antero-lateral TWI (I avl v5-v6) and twd (I
avl v6) and elevation in III. All of these changes were evident
on prior ekgs (last [**2143-3-6**]). Pt was treated with heparin and
went for coronary angiogram on HD2 which revealed extensive LAD
disease extending into DM1, which was too extensive for stent.
Pt was continued on heparin drip and did not have any more chest
pain. A pre-CABG workup was done and he was cleared for CABG.
Surgery occurred on [**2143-4-18**]
# h/o dCHF/AS: mild as on last echo. Currently euvolemic. will
continue with home medications.
- lasix, bb, [**Last Name (un) **]
- I/O monitor
# HTN: continue with home medications
- norvasc
- continue with [**Last Name (un) **]
# discordant blood pressures: R>L, would expect opposite if
aortic dissection, has been documented in past. likely
subclavian or distal lesion
- trend
# CKD: [**1-3**] diabetic nephropathy. baseline cr is 1.8. currently
at 1.7.
# DM: insulin sliding scale + glargine 20mg
# hypothyroidism: ccontinue with synthroid
SURGICAL COURSE:
The patient was brought to the Operating Room on [**2143-4-18**] where
he underwent CABG x 3 (left internal mammary artery graft to
left anterior descending, reverse saphenous vein graft to the
diagonal branch of the right coronary artery)with Dr.[**Last Name (STitle) **].
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD # 1 found the patient extubated, alert and oriented and
breathing comfortably. He was neurologically intact and
hemodynamically stable, weaned from inotropic and vasopressor
support. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. The patient was
transferred to the telemetry floor for further recovery. Chest
tubes and pacing wires were removed (1 atrial lead was cut).
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD #6 the patient was stable but needed assistance with
ambulation, so it was recommended that he go to rehab. The wound
was healing and pain was controlled with oral analgesics. The
patient was discharged to [**Hospital1 599**] of [**Location (un) 55**] on POD#6 in
good condition with appropriate follow up instructions.
Medications on Admission:
Nitroglycerin 0.3 mg
norvasc 10
(OMR says on nifedipine 60ER)
metoprolol succinate 50mg qday
valsartan 320mg PO daily
hydralazine 50mg PO TID
tamsulosin 0.4mg ER qday
dutasteride 0.5mg qday
pramipexole 0.5mg qday
atorvastatin 80mg qday
lasix 20mg qday
synthroid 112mcg
insulin glargine 20U qday
lantus ss
ASA 81
colchicine
allopurinol
Discharge Medications:
1. potassium chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 10 days.
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
12. pramipexole 0.5 mg Tablet Sig: One (1) Tablet PO daily ().
13. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
15. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheeze.
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze.
17. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
18. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days.
19. Lantus 100 unit/mL Solution Sig: One (1) 25 units
Subcutaneous at bedtime.
20. insulin regular human 100 unit/mL Solution Sig: One (1) as
per sliding scale Injection four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Coronary Artery Disease
Diabetic x 25yrs on insulin for past 10yrs
CRI creat 1.6-1.8
Poorly Hypertension
Hypercholesterolemia
BPH
Hypothyroid
Gout
Fx right arm
T&A as child
Appy
Amputation of left thumb due to accident
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tramadol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2143-5-7**] 10:15 in
the [**Hospital Unit Name **] [**Hospital Unit Name **]
Surgeon: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2143-5-22**] 1:45 in the [**Last Name (un) 2577**] Building [**Hospital Unit Name **]
Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 62**], [**2143-7-5**],
9:40
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 682**] in [**3-7**] 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:[**2143-4-24**]
|
[
"410.71",
"585.3",
"414.01",
"403.90",
"428.32",
"600.00",
"250.40",
"V58.67",
"424.1",
"428.0",
"272.0",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.55",
"37.22",
"36.15",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
10159, 10249
|
5356, 7928
|
321, 348
|
10511, 10731
|
3038, 3819
|
11500, 12376
|
1991, 2047
|
8313, 10136
|
10270, 10490
|
7954, 8290
|
3836, 5333
|
10755, 11477
|
2062, 3019
|
271, 283
|
376, 1678
|
1700, 1825
|
1841, 1975
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,580
| 150,902
|
43666
|
Discharge summary
|
report
|
Admission Date: [**2169-6-15**] Discharge Date: [**2169-6-20**]
Date of Birth: [**2122-2-3**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 5911**]
Chief Complaint:
fibroids, abdominal pain
Major Surgical or Invasive Procedure:
Uterine artery embolization
laparoscopy converted to ex-lap, supracervical hysterectomy,
left salpingo-oophorectomy, lysis of adhesions, cystoscopy, air
leak test
History of Present Illness:
This is a 47 yo G0 with known markedly enlarged fibroid uterus
and left ovarian endometriomas who presents to the ED on [**2169-6-15**]
with complaint of abdominal pain. Pt reports that she had new
onset of abdominal pain 2 days prior which she describes as
sharp and accompanied by n/v. The next day, she took two aleeve
and went to work, but felt that her pain persisted despite the
NSAIDs. On the nigh prior to presentation, she reports she
could not sleep at all, and by this morning reports the pain was
so severe that she could not move and could barely walk. Her
partner drove her to the [**Name (NI) **]. She describes the pain as "acute,
sharp", exacerbated with use of her abdominal muscles,
and left sided more than right. Upon arrival to the ED, she was
given 5mg of morphine IV with marked improvement in her pain.
Of note, the patient has been evaluated by Dr. [**Last Name (STitle) 4686**] of IR
and Dr. [**Last Name (STitle) **] of gyn, with plan for UAE this coming Monday with
hope of lsc MMY ~2 months following.
Past Medical History:
ObHx: G0
GynHx:
- LMP [**2169-6-10**], light flow now
- menarche age 13. Regular menses with heavy bleeding,
dysmenorrhea, clots for several years. +Sxs of pelvic pressure,
fullness, bladder pressure and urinary frequency.
- Last Pap [**1-/2169**], negative, no hx abnormal.
- same sex partnership ([**Name (NI) **]) currently
- no current need for contraception
- no hx STI
PMH:
- fibroids/menorrhagia as above
- allergic rhinitis
- arthritis R thumb
- tennis elbow
PSH: dental only, [**2141**]
Social History:
Social: ~7 EtOH drinks/week, denies tobacco or illicits. Works
in a restaurant. Lives with [**Doctor First Name **], her partner of 2 years.
Family History:
NC
Physical Exam:
ON ADMISSION:
99.4, 94, 119/83, 16, 97%
Gen: comfortable, fatigued, pleasant woman, presenting with
partner to [**Name (NI) **]
CV: RRR
lungs: CTAB, no wheeze or crackles
abd: soft, not TTP, significantly distended and firm with
obvious mass filling abd/pelvis with minimal room for mobility,
nl bs, no HSM, no scars
pelvic: deferred
Extr: NT, NE
ON DISCHARGE:
afebrile, VSS
NAD, comfortable
RRR, CTAB
abd soft, NT, ND
midline vertical incision intact with staples, no
erythema/drainage
no edema
Pertinent Results:
[**2169-6-16**] 05:48AM BLOOD WBC-15.8* RBC-3.64* Hgb-10.0* Hct-32.0*
MCV-88 MCH-27.5 MCHC-31.3 RDW-15.1 Plt Ct-201
[**2169-6-16**] 12:46AM BLOOD WBC-19.8*# RBC-3.86* Hgb-10.8* Hct-34.3*
MCV-89 MCH-28.1 MCHC-31.6 RDW-15.0 Plt Ct-240
[**2169-6-15**] 04:20AM BLOOD WBC-9.9 RBC-3.87* Hgb-10.8* Hct-33.4*
MCV-86 MCH-27.9 MCHC-32.4 RDW-14.3 Plt Ct-227
[**2169-6-16**] 05:48AM BLOOD PT-11.5 PTT-24.6* INR(PT)-1.1
[**2169-6-16**] 05:48AM BLOOD Glucose-141* UreaN-7 Creat-0.5 Na-134
K-4.1 Cl-105 HCO3-21* AnGap-12
[**2169-6-16**] 05:48AM BLOOD ALT-10 AST-28 AlkPhos-38 TotBili-0.7
[**2169-6-16**] 05:48AM BLOOD Albumin-3.0* Calcium-8.0* Phos-3.3 Mg-2.6
Brief Hospital Course:
Ms. [**Known lastname 93884**] is a 47 year old with known fibroid uterus who
presents to the ED with acute abdominal pain, nausea, and
vomiting. At that time, she was afebrile with a normal white
blood cell count and a pelvic US showed: an enlarged uterus with
multiple uterine fibroids. At least two large exophytic
pedunculated fibroid masses. The dominant fibroid seen in the
left lower quadrant of the abdomen with carneous degeneration
seen on the prior MRI of [**2169-3-31**], has minimally increased in
size. Additional smaller degenerating fibroids are similar. No
significant change in the overall fibroid size. Trace free fluid
in the left lower quadrant. Left ovarian endomteriomas are
stable since [**2169-4-7**].
Degenerating and possibly torsion of these known fibroids and/or
left ovarian cyst was thought to be the cause of her acute pain.
She had been scheduled for UAE and hysterectomy to follow in
the upcoming months, but decision was made to proceed urgently
with these procedures. She had a UAE then proceeded to the OR
for laparoscopy converted to supracervical hysterectomy and LSO
for fibroid uterus and endometrioma. Intra-operative findings
revealed a markedly enlarged fibroid uterus (weighing ~2129g),
stage 4 endometriosis with extensive adhesions, a large left
ovarian endometrioma, and copious amount of brown tinged
ascites-- the cause of the patient's acute pain was unclear.
Please refer to Dr.[**Name (NI) 93885**] operative note for full details. She
received 1u PRBC intraop for 1000cc EBL; hematocrit was stable
post-op at 34 -> 32.
Post-op, she was admitted to the ICU for close monitoring given
her long operation and large amount of intraoperative fluids.
She remained hemodynamically stable during her ICU stay. Her
pain was managed with a Dilaudid PCA with good effect. She was
transferred back to the ob/gyn service on POD1.
Post-operatively, she did very well. Her post-operative
milestones were met by POD [**2-6**]. Her diet was advanced slowly
given extensive lysis of adhesions. A plan was made to keep the
foley in place for 10-14 days post-operatively to allow for
bladder healing given the extent of lysis of adhesions involving
the bladder. She was discharged to home on POD 5 in good
condition.
Medications on Admission:
claritin, albuterol, flonase
Discharge Medications:
1. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every [**7-14**]
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*2*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
4. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
5. Pepcid 20 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for heartburn.
Disp:*60 Tablet(s)* Refills:*2*
6. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
fibroid uterus
endometrioma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 93884**],
You were admitted with acute abdominal pain thought to be due to
your large fibroids. For this, you underwent supracervical
hysterecotmy and left salpingo-oophorectomy (tube & ovary) for
an endometrioma.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* No strenuous activity until your post-op appointment
* Nothing in the vagina (no tampons, no douching, no sex), no
heavy lifting of objects >10lbs for 6 weeks.
* You may eat a regular diet
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
* If you have steri-strips, leave them on. They will fall off on
their own or be removed during your followup visit.
* If you have staples, they will be removed at your follow-up
visit.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call [**Telephone/Fax (1) 2806**]
Followup Instructions:
STAPLE REMOVAL APPOINTMENT
Department: GYN SPECIALTY
When: FRIDAY [**2169-6-23**] at 9:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 8246**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
BLADDER CATHETER REMOVAL APPOINTMENT
Department: GYN SPECIALTY
When: FRIDAY [**2169-6-30**] at 11:15 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 8246**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 5913**]
|
[
"V64.41",
"617.1",
"617.3",
"E878.8",
"789.59",
"593.89",
"288.60",
"620.2",
"218.9",
"276.2",
"493.00",
"614.6",
"617.0",
"596.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"68.39",
"68.25",
"59.8",
"54.59",
"65.49"
] |
icd9pcs
|
[
[
[]
]
] |
6622, 6628
|
3483, 5748
|
342, 506
|
6700, 6700
|
2814, 3460
|
7977, 8708
|
2276, 2280
|
5827, 6599
|
6649, 6679
|
5774, 5804
|
6851, 7505
|
7520, 7954
|
2295, 2295
|
2659, 2795
|
278, 304
|
534, 1574
|
2310, 2644
|
6715, 6827
|
1596, 2099
|
2115, 2260
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,433
| 128,254
|
46440
|
Discharge summary
|
report
|
Admission Date: [**2204-11-15**] Discharge Date: [**2204-12-5**]
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / A.C.E Inhibitors / Tobramycin
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83 y.o. female with PMH of CAD s/p stents x2 (unknown year)
placed at OSH who presents with sudden onset of chest pain and
pressure at NH. Pt was discharged from [**Hospital1 112**] where she receives
all of her care yesterday for N/V/D. She was discharged on
Levaquin for a UTI and Flagyl for GI coverage although C.diff
negative. Pt received IV hydration at that time for Na of 115 on
admission. This improved to 131 on discharge. Hyponatremia
thought to be secondary to dehydration. Per dishcarge summary,
pt had no cardiac complaints during this admission. However, she
did have an episode of Afib with RVR thought to be secondary to
electrolyte abnormalities. Pt returned to [**Location **] where she developed
sudden onset of CP and SOB. Denies lightheadedness and
dizziness. No N/V.
In [**Name (NI) **] pt received 2mg Morphine with complete resolution of chest
pain. However, ECG concerning for new lateral TWI and ? ST
elevation. Repeat ECG when pain free showed improvement in ST
changes. Q waves in II, III, and AVF. Pt discussed with
Cardiology fellow who recommended [**Hospital Unit Name 196**] admission. Considered
starting Heparin in ED but patient refused.
The patient was originally admitted to [**Hospital Unit Name 196**] and was then
transferred to the medicine team. At this point the ICU team
evaluated and felt the patient appropriate for ICU level care.
Because the patient was refusing a central line, it was decided
that the patient would remain on the medicine service.
Past Medical History:
1. Coronary artery disease, status post right coronary
artery stent times two.
2. History of non-ST segment elevation myocardial infarction
over the past year. Recent Adenosine MIBI stress test in
[**2200-6-25**] with a mild inferior ischemia. ECHO [**2204-10-17**] showed
low normal LV function with EF 50-55%.
3. History of ischemic bowel, status post total colectomy,
resection of one-third of her small intestine in [**2200-3-25**].
4. Chronic obstructive pulmonary disease with an FEV 1 of
1.34.
5. Status post cholecystectomy in [**2200-8-25**] for acute
cholecystitis.
6. History of gallstone pancreatitis.
7. History of spinal stenosis.
8. History of hypertension.
9. History of Vancomycin resistant enterococcal urinary
tract infection.
10. History of thyroidectomy.
Social History:
The patient currently lives at [**Hospital3 24509**] Home in
[**Location (un) 55**], previously she lived in [**Location 1268**]. She has
never been married and has no children. She has no next of [**Doctor First Name **].
The contact is Ms [**First Name8 (NamePattern2) 2127**] [**Name (NI) 8421**] who can be reached at
[**Telephone/Fax (1) 98654**]. Walks with walker.
Family History:
Non-contributory
Physical Exam:
VS 96.1 80/30 63 16 100%2L
GENERAL: Elderly female, ill appearing, NAD, lying in bed
HEENT: PERRL, EOMI, dry mucous membranes.
NECK: No JVD appreciated
CARDIOVASCULAR: RRR, no murmurs.
LUNGS: good air movement, crackles at bases (minimally) R>L
ABDOMEN: ND, ecchymoses, ileostomy bag in place (which large
amount of bile like material).
EXTREMITIES: chronic venous stasis changes bilaterally.
NEURO: able to state name, month, and the fact that she is in
hospital
Pertinent Results:
LABS:
[**2204-11-15**] 03:00AM BLOOD WBC-20.1*# RBC-5.16# Hgb-15.2# Hct-43.8#
MCV-85# MCH-29.5 MCHC-34.7 RDW-15.5
[**2204-11-16**] 07:00AM BLOOD WBC-9.2 RBC-3.32* Hgb-9.6* Hct-28.8*
MCV-87 MCH-29.1 MCHC-33.5 RDW-15.4
[**2204-11-15**] 03:00AM BLOOD Neuts-77* Bands-0 Lymphs-14* Monos-6
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-2*
[**2204-11-15**] 01:00PM BLOOD PT-12.7 PTT-36.1* INR(PT)-1.1
[**2204-11-16**] 07:00AM BLOOD PT-14.5* PTT-84.2* INR(PT)-1.4
[**2204-11-15**] 03:00AM BLOOD Glucose-115* UreaN-36* Creat-2.1* Na-128*
K-9.6* Cl-93* HCO3-24 AnGap-21*
[**2204-11-15**] 01:00PM BLOOD Glucose-123* UreaN-34* Creat-1.7* Na-135
K-4.2 Cl-100 HCO3-25 AnGap-14
[**2204-11-16**] 07:00AM BLOOD Glucose-72 UreaN-21* Creat-1.1 Na-138
K-2.8* Cl-111* HCO3-19* AnGap-11
[**2204-11-15**] 03:00AM BLOOD ALT-25 AST-92* CK(CPK)-156*
[**2204-11-15**] 01:00PM BLOOD ALT-14 AST-19 LD(LDH)-190 CK(CPK)-23*
AlkPhos-104 TotBili-0.3
[**2204-11-16**] 07:00AM BLOOD CK(CPK)-19*
[**2204-11-15**] 03:00AM BLOOD CK-MB-3 cTropnT-0.04*
[**2204-11-15**] 01:00PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2204-11-16**] 07:00AM BLOOD CK-MB-3 cTropnT-<0.01
[**2204-11-15**] 03:00AM BLOOD Calcium-9.8 Phos-4.2 Mg-2.1
[**2204-11-15**] 01:00PM BLOOD Albumin-2.8* Calcium-8.2* Phos-3.2
Mg-1.5*
[**2204-11-16**] 07:00AM BLOOD Calcium-6.4* Phos-2.2* Mg-0.9*
[**2204-11-15**] 01:00PM BLOOD TSH-0.48
[**2204-11-15**] 01:00PM BLOOD Free T4-1.7
[**2204-11-15**] 01:00PM BLOOD Cortsol-15.3
[**2204-11-15**] 03:10AM BLOOD K-9.4*
[**2204-11-15**] 04:21AM BLOOD K-4.5
[**2204-11-15**] 01:59PM BLOOD Lactate-2.7*Imaging:
.
CXR ([**2204-11-15**]) - Unchanged appearance of the chest compared to
[**2200-11-25**]. Marked tortuosity of the aorta, unchanged.
EKG ([**2204-11-15**]) - NSR at 85, new TWI in V4-6. Low voltage,
Resolution of ST elevation in V3-V6.
CXR ([**2204-11-15**]) - Interval development of left lower lobe
opacity.
.
ECHO ([**2204-11-15**]) - The left ventricular cavity size is normal.
Overall left ventricular systolic function is moderately
depressed. Anterior, distal septal and apical akinesis is
present. The aortic valve leaflets (3) are mildly thickened.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Trivial mitral
regurgitation is seen.
.
MICRO:
Stool - negative for C diff x 3; C diff B toxin pending;
Giardia/crypto DFA negative
Blood [**2204-11-15**] - negative
URINE CULTURE (Final [**2204-12-2**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION. SENSITIVE TO AMIKACIN.
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 E. coli and Klebsiella species.
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
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 E. coli and Klebsiella species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R =>32 R
CEFAZOLIN------------- =>64 R =>64 R
CEFEPIME-------------- =>64 R R
CEFTAZIDIME----------- =>64 R =>64 R
CEFTRIAXONE----------- =>64 R R
CEFUROXIME------------ =>64 R =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ =>16 R =>16 R
IMIPENEM-------------- <=1 S <=1 S
LEVOFLOXACIN---------- =>8 R =>8 R
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I 128 R
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- <=4 S 16 S
TOBRAMYCIN------------ 8 I =>16 R
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
Brief Hospital Course:
1. CHEST PAIN - On admission, the patient had chest pain that
resolved with morphine. Troponin was 0.04 (with CRI) with
concerning EKG (lateral ST changes). The patient was started on
lovenox (patient refused q6 PTT checks making heparin
inappropriate). The patient refused cardiac cath or any other
intervention. She was continued on maximal medical management.
An ECHO 1 month ago at [**Hospital1 112**] showed an EF 55%. A ECHO on
admission here showed a new reduced EF of 35%. The patient was
managed medically. She again complained of CP on the day prior
to d/c but continued to refuse all interventions. Her EKG
continued to show lateral/inferior TWI c/w her presentation.
Her troponins were 0.01 on discharge and never elevated beyond
0.04 on admission. She was managed medically with a beta
blocker which can be titrated up as her blood pressure allows -
on discharge she is on metoprolol 25 mg [**Hospital1 **], with BP ranging
from 90-120 systolic. An ACE-I was not started secondary to a
reported "allergy" in the past. She is on ASA 325 mg daily,
Lipitor 10 mg daily. Provided the patient continues to refuse
intervention, nitroglycerin can be attempted for chest pain
relief. An oral nitrate could also be considered.
2. HYPOTENSION - The patient was hypotensive on admission. She
was not responding well to fluid bolues and a MICU consult was
called. They recommended transfer to the ICU, but the patient
was refusing central line placement and other ICU level care so
she was kept on the general medicine floor. Her hypotension was
thought secondary to infection (WBC 20/Lactate 2.7) and she was
started on linezolid/axtreonam (multiple resistence organisms in
the past with pen/ceph/tobra allergies). Blood/Urine/Stool
cultures were sent. She was maintained on NS overnight and her
blood pressure stabalized. Her original CXR did not show any
acute pulmonary process. A repeat CXR showed a possible LLL
opacity. A PA+Lat was performed for better visulalization of
the opacity. The patient refused a PICC making antibiotic
choice difficult. Later, her antibiotic coverage was changed to
Levofloxacin. She had two other episodes of hypotension on this
admission with SBP to the 80's. These other episodes were
thought to be due to hight ostomy output and responded well to 1
liter normal saline fluid boluses. Left upper extremity PICC
placed on [**11-21**] for hydration and electrolyte repletion. She
completed her course of levaquin in house. Her urine
subsequently grew out Klebsiella and E. Coli, resistant to
multiple drugs. Antibiotic selection was further complicated by
her penicillin allergy, and ID recommended transfer to the ICU
for meropenem desensitization which was completed on [**2204-12-3**]. On
day of discharge she is on day 3 of meropenem, and should
complete a 2 week course ending on [**2204-12-16**].
3. COPD: The patient was continued on flovent and nebulizer
treatments. Initially, she required 3-4L O2 (increased from home
2LO2) though possibly secondary to fluid overload or COPD flare.
She was started on steroids in the setting of her ICU admission
for hypotension, and these were continued via a slow taper as it
was thought they may have improved her COPD. Eventually, she
stabilized on 1-2L NC. She is on 40 mg Prednisone daily on the
day of discharge ([**12-5**]). She should receive 1 more day of 40 mg
and then 3 days of 20 mg, 3 days of 10 mg, 3 days of 5 mg, then
off.
4. CRI: Her creatinine was elevated on admission at 2.1. This
eventually trended down to normal with hydration. Her
electrolytes were repleted as necessary.
5. HYPONATREMIA: The patient has long standing hyponatremia,
most likely due to dehydration. She was admitted with a Na of
128 and this normalized with hydration.
6. SHORT GUT SYNDROME: She was continued on a lactose free diet.
Initially, her bismuth and loperimide were held for the
possibility of infectious colitis. Stool cultures were sent for
c. diff and returned negative. She was also tested for giardia
which was negative. C. Diff B toxin was sent and found to be
negative. She continued to have high output from her ostomy. A
PICC was placed for hydration and electrolyte repletion.
Further work-up was initiated with stool studies including
giardia/camphylobacter/OP were all negative. GI was also
consulted and reccommended dietary changes (low
fat/carb/lactose, small freq feedings), anti-motility agents
(immodium, cholestyramine), and also suggested that her ostomy
output may be w/in the normal range for a patient w/ a total
colectomy. The patient's ostomy output declined in the days
prior to d/c and ranged from 700-1500cc/day with formed stool.
.
7. CODE: The patient was full code at the time of admission.
After a discussion with the patient, she decided to change her
status to DNR/DNI.
8. PPX: Protonix, SC heparin.
Medications on Admission:
Albuterol
ASA
Lactobacillus
Loperimide
Flagyl
Mag gluconate
Lopressor 12.5 TID
Kaopectate
Lipitor 10mg
Flovent
Zantac
Levaquin
Allergies:
PCN, ACE, Tobramycin, Eggs, Shrimp
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Titrate up as bp allows.
4. Meropenem 1 g Recon Soln Sig: One (1) Recon Soln Intravenous
Q12H (every 12 hours) for 11 days: Last dose [**2204-12-16**].
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
7. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) INH
Inhalation every six (6) hours.
9. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO daily () for 1
days: 1st.
10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for
3 days: 2nd.
11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for
3 days: 3rd.
12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO daily () for 3
days: 4th. To finish on [**2204-12-15**].
13. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for headache.
15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-26**] Sprays Nasal
[**Hospital1 **] (2 times a day) as needed for dry nose.
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
17. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
18. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
19. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day).
20. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO BID
(2 times a day).
21. Bismuth Subsalicylate 262 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
22. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
23. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
24. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
25. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
26. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Klebsiella urinary tract infection
E. Coli urinary tract infection
Urosepsis
Pneumonia
Supraventricular tachycardia
Coronary artery disease
Chronic obstructive pulmonary disease
Short gut syndrome
Chronic renal insufficiency
Discharge Condition:
Improved. Continues to have occasional chest pain, but refusing
intervention. On TPN, transfers with assist, currently on 1L O2
via NC. Colostomy in place. No foley.
Discharge Instructions:
You will be on antibiotics for another 11 days for your urinary
tract infection.
Seek medical help if you have more chest pain, shortness of
breath, or any other symptoms that are concerning to you.
You should follow up with your primary care doctor as listed
below.
Followup Instructions:
Test for consideration post-discharge: anti-Tissue
Transglutaminase Antibody, IgA
Please call to schedule an appointment with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 61280**]
[**Telephone/Fax (1) 93344**], within the next 1-2 weeks.
|
[
"584.9",
"038.9",
"V45.82",
"276.8",
"275.3",
"995.92",
"414.8",
"276.52",
"276.51",
"276.1",
"V44.2",
"579.3",
"491.21",
"486",
"413.9",
"275.2",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"00.14"
] |
icd9pcs
|
[
[
[]
]
] |
15344, 15416
|
7775, 12646
|
280, 286
|
15685, 15856
|
3539, 7752
|
16173, 16435
|
3021, 3039
|
12871, 15321
|
15437, 15664
|
12672, 12848
|
15880, 16150
|
3054, 3520
|
230, 242
|
314, 1816
|
1838, 2616
|
2632, 3005
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,546
| 194,805
|
6903
|
Discharge summary
|
report
|
Admission Date: [**2162-1-19**] Discharge Date: [**2162-1-23**]
Date of Birth: [**2082-7-30**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Aspirin
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Sinus bradycardia
Major Surgical or Invasive Procedure:
Temporary pacer wire
CEnrtal venous line
Balloon pump
TEE
History of Present Illness:
79M CHF EF 25%, h/o left sided effusion s/p tap [**7-5**] (thought to
be [**3-4**] chf), CAD w/ NSTEMI [**7-5**], HTN, who presents after having
7-second pause while on Coreg 25mg; dose decreased, led to afib
with RVR; transferred for ? pacer for tachy-brady syndrome vs
also BiV placement given low EF and potential exacerbation of
CHF secondary to dysynchrony. Hypotensive requiring pressors,
elevated lactate. Intubated for pulmonary edema.
On [**1-20**], pt witnessed to go into asystole -> externally paced
with low BP requiring chest compressions, atropine and
epinephrine -> BP up and stable without compression -> emergent
temp wire placed at bedside. Pt taken to cath lab for R ht cath,
found to have PWCP 40 and IABP was placed. Pt resumed on heparin
drip given possible PCI to eval for ischemia. Patient with MAP
60-70's however anuric. Patient given IV lasix 80mg x1 with no
increase in UOP -> started on milrinone drip and transferred to
the CCU.
Past Medical History:
1. Coronary artery disease s/p cath with PCI stent to LCx, RCA
2. Hypertension
3. Crohn's disease
4. Hypercholesterolemia
5. BPH
6. Macular degeneration both eyes - legally blind
7. Hypothyroidism
8. s/p 2 hip surgeries
9. s/p back surgery
[**66**]. s/p knee surgery
[**67**]. history of GI bleed d/t PUD
12. Colonic polyps
13. Chronic renal insufficiency baseline creat 1.3
Social History:
Former [**Year (2 digits) 26009**]. Married with two daughters, lives with his wife.
Smoked 1-1.5 ppd x 35 years. Quit in [**2137**]. EtOH: ~ once a week,
socially. No drugs.
Family History:
Mother with MI in 70s. Father with MI 80s. Brother and Sister
with "heart problems".
Physical Exam:
Exam in ED
T: 97.8 HR: 110s-120s BP: 106/89 O2: 99% on 2L NC
Gen: pleasant, blind elderly man in NAD
HEENT: NCAT Dry MM, No exudates or thrush, PERRL, No carotid
bruits, No JVD
CV: RRR, distant heart sounds, 2/6 SEM LUSB, prominent lateral
PMI
Lungs: crackles [**2-2**] way up b/l
Abd: NT ND R inguinal bandage in place
Ext: 1+ pitting edema. Weak, dopplerable DP pulses b/l, R>L,
good femoral pulses, No bruits b/l
GU: Tender L testicle, no masses, varicoceles or enlarged
epididymis palpated. Nontender shaft w/o evidence of discharg.
Normal appearing meatus.
Neuro: AAO x 3
Pertinent Results:
[**2162-1-19**]:PORTABLE AP CHEST RADIOGRAPH: Again seen is stable
cardiomegaly. Mediastinal contours are stable in appearance.
There is minimal perihilar haziness, without any overt
prominence of the pulmonary vasculature. There is a probable
left pleural effusion. There is opacity in the left retrocardiac
area which may represent atelectasis.
IMPRESSION: Stable cardiomegaly and probable left pleural
effusion. No definite CHF
.
ECHO [**2162-1-19**]:
Conclusions:
1. The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
2. Left ventricular wall thicknesses are normal. Left
ventricular cavity is dilated, with severely depressed systolic
function. There is severe global hypokinesis, with relative
preservation of the basal inferolateral wall. [Intrinsic left
ventricular systolic function may be more depressed given the
severity of valvular regurgitation.]
3.There is moderate global right ventricular free wall
hypokinesis.
4.There are simple atheroma in the aortic arch and the
descending thoracic aorta.
5.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. Moderate to
severe (3+)
mitral regurgitation is seen.
7.The tricuspid valve leaflets are mildly thickened.
IMPRESSION: No intracardiac thrombus. Severely depressed left
ventricular
systolic function. Moderately severe mitral regurgitation.
Compared to the previous report of [**2161-12-23**], the MR is more
severe and the RV function appears worse.
.
[**2162-1-22**]: CXR
FINDINGS: A right subclavian Swan-Ganz catheter ends in the mid
right pulmonary artery. An endotracheal tube ends in
satisfactory position 4 cm above the carina. An NG tube passes
beyond view into the stomach. A pacemaking device overlies the
right chest with pacing electrodes in unchanged position
compared to [**2162-1-21**]. An intra-aortic balloon pump ends 1 cm
from the roof of the aortic arch. Moderate cardiomegaly is
unchanged. CHF is slightly improved compared to the previous
day. Left lower lobe atelectasis and small bilateral effusions
(left greater than right) are unchanged. No pneumothorax is
identified.
IMPRESSION:
1. Improved CHF. Unchanged left lower lobe atelectasis and
bilateral effusions.
2. The tip of an intra-aortic balloon pump ends 1 cm from the
roof of the aortic arch as previously communicated to Dr [**First Name (STitle) **] on
[**2162-1-21**]
.
Urine Culture:
URINE CULTURE (Final [**2162-1-24**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
CHLORAMPHENICOL------- 8 S
LEVOFLOXACIN---------- =>8 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 32 S
VANCOMYCIN------------ =>32 R
Brief Hospital Course:
79 yo m with ischemic cardiomyopathy (EF: 15-25%), s/p NSTEMI,
hx of AFib, HTN recently admitted to [**Hospital1 18**] for CHF exacerbation
and treated with lasix was readmitted after 7 second pause while
on COreg at rehab (digoxin was d/cd at this time). After
decreasing the coreg to 6.25mg [**Hospital1 **], he experienced RVR to
130s-140s. He received 10mg IV diltiazem with good rate control
and was referred here for ICD placement. On admission, his
troponin was up to 0.58 from 0.18 8 days PTA without EKG
changes.
On night of admission, patient was "Triggered" for increased HR
and decreased urine output. His rate responded to metoprolol
(4mg IV). He subsequently developed a 9 second pause on tele.
Pacer pads were placed and patient was evaluated for the CCU and
transferred for closer monitoring. EP was consulted and he was
started on heparin for ACS.
In the CCU:
# TACHY/BRADY
- In the CCU, patient developed asystole and required atropine
and chest compressions -> emergent pacer wire placed by EP.
WIth this asystolic episode, he went into cardiogenic [**Hospital1 **] and
[**Hospital1 **] liver and ARF on CRF.
## HYPOTENSION
- This was felt to be a mixed picture of cardiogenic [**Hospital1 **] and
sepsis
- He was placed on pressors, cultured and given empiric Abx
given rising WBC - Vancomycin and Aztreonam. The question arose
of a possible biliary source given elevated LFTs.
.
# Cardiogenic [**Hospital1 **]:
- TTE showed 15-20% EF with 3+ MR with severe global
hypokinesis.
- WIth the development of [**Last Name (LF) **], [**First Name3 (LF) **] emergent bedside TEE was
done which shoed 10-15% EF with 4+ MR and no clots were seen.
- He was placed on a balloon pump x 1 day -> Dcd on [**1-22**] along
with milrinone [**1-22**]
.
# CARDIAC ? ISCHEMIA
- Troponin elevated; 0.53 on admission and rose to 0.73. With
his worsening renal insufficiency, decreased GFR may have
accounted for his rise in troponins.
- Since this was Elevated beyond what is expected from CRI and
CHF. HOwever, his CKs were not elevated. He was on heparin for
Afib/Potential ACS.
- It was felt that ischemia was one potential source of his
cardiogenic [**Month/Year (2) **] and catheterization was to be considered if
patient stabilized.
.
# ARF on CRF
- Diuresing with lasix and diuril
- This was felt to be a byproduct of his hypotensive episode.
.
# Elevated Transaminases:
- Initially, the elevations were thought to be [**3-4**] CHF -> as
they were initially in vicinity of 1500-1700. However, with his
hypotensive episode, they bumped to [**Numeric Identifier 2249**] on [**1-21**] -> hence, the
rise was likely [**3-4**] [**Month/Day (2) **] liver from asystolic episode ->
decreased on [**1-22**]. It wa snot felt that he was in DIC given
elevated INR and high LFTs and no schistocytes on smear
.
# End of life: With his grave multiorgan system failure, the
family in discussions with the CCU team decided to withdraw
pressor support. IT was planned to continue to keep the patient
comfortable. He passed peacefully a few minutes after pressor
withdrawl. Autopsy was deferred.
Medications on Admission:
. Atorvastatin 20 QD - recently d/ced on last hospital
admission [**3-4**] elevated LFTs
2. Aspirin 81 mg QD - recently d/ced on last hospital admission
[**3-4**] GIB
3. Sulfasalazine 1500 PO BID
4. Ferrous Sulfate 325 QD
5. Docusate Sodium 100 mg [**Hospital1 **]
6. Cyanocobalamin 50 mcg QD
7. Multivitamin QD
8. Lisinopril 5 mg QD - recently d/ced on last hospital
admission [**3-4**] elevated Cr
9. Paroxetine HCl 10 mg QD
10.Carvedilol 25mg [**Hospital1 **].
11. Azathioprine 50 mg QD
12. Pantoprazole 40 mg QD
13. Furosemide 40mg QD - recently changed from 60 mg qAM and 40
PO qhs
14. Levothyroxine Sodium 50 mcg QD
15. Albuterol INH PRN
16. Atrovent INH
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2162-6-9**]
|
[
"411.1",
"584.5",
"427.5",
"038.9",
"608.9",
"V45.82",
"414.01",
"276.7",
"555.9",
"570",
"412",
"244.9",
"427.81",
"995.94",
"276.2",
"785.51",
"428.0",
"414.8",
"427.31",
"401.9",
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icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.62",
"00.17",
"89.64",
"37.78",
"96.71",
"37.61",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
9700, 9709
|
5870, 8961
|
300, 359
|
9761, 9771
|
2658, 5847
|
9822, 9854
|
1957, 2045
|
9673, 9677
|
9730, 9740
|
8987, 9650
|
9795, 9799
|
2060, 2639
|
243, 262
|
387, 1349
|
1371, 1747
|
1763, 1941
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,646
| 189,568
|
41617
|
Discharge summary
|
report
|
Admission Date: [**2128-3-29**] Discharge Date: [**2128-4-2**]
Date of Birth: [**2072-11-8**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Codeine / morphine
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
T9-S1 posterior fusion
History of Present Illness:
Ms. [**Known lastname **] has a long history of back pain due to scoliosis.
She elects to proceed with surgical intervention.
Past Medical History:
Scoliosis, Liver disease, history of ulcer, mumps, measles,
chicken pox as child, hepatitis A,
PSH: R inguinal hernia repair at age 8, laparoscopic tubal
ligation, R knee arthroscopy, R foot surgery, L 3rd digit cyst
removal, tonsillectomy
Social History:
Denies tobacco, occassional EtOH; denies illicit drug use
Family History:
N/A
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; -clonus, reflexes
symmetric at quads and Achilles
Pertinent Results:
[**2128-4-1**] 06:30AM BLOOD WBC-4.8 RBC-3.29* Hgb-10.1* Hct-30.9*
MCV-94 MCH-30.7 MCHC-32.7 RDW-14.9 Plt Ct-130*
[**2128-3-31**] 05:20AM BLOOD WBC-5.8 RBC-3.35* Hgb-10.3* Hct-31.6*
MCV-94 MCH-30.7 MCHC-32.5 RDW-15.4 Plt Ct-101*
[**2128-3-30**] 06:00AM BLOOD WBC-5.7 RBC-2.70* Hgb-8.4* Hct-26.2*
MCV-97 MCH-31.2 MCHC-32.2 RDW-14.0 Plt Ct-102*
[**2128-3-29**] 05:19PM BLOOD WBC-7.7 RBC-3.25* Hgb-10.2* Hct-30.9*
MCV-95# MCH-31.5 MCHC-33.1 RDW-14.2 Plt Ct-112*
[**2128-3-31**] 05:20AM BLOOD Glucose-108* UreaN-4* Creat-0.5 Na-142
K-3.4 Cl-109* HCO3-29 AnGap-7*
[**2128-3-29**] 05:19PM BLOOD Glucose-162* UreaN-8 Creat-0.6 Na-140
K-3.8 Cl-109* HCO3-24 AnGap-11
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for
a posterior thoracolumbar fusion with instrumentation. She was
informed and consented and elected to proceed. Please see
Operative Note for procedure in detail.
Post-operatively she was given antibiotics and pain medication.
An epidural was placed intraoperatively and this was removed POD
1. A hemovac drain was placed intra-operatively and this was
removed POD 2. Her bladder catheter was removed POD 3 and her
diet was advanced without difficulty. She was able to work with
physical therapy for strength and balance. She was discharged
in good condition and will follow up in the Orthopaedic Spine
clinic.
Medications on Admission:
vicodin 7.5/750 one tab daily
fosamax
diltiazem 120mg 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. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*8 Tablet(s)* Refills:*0*
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
7. zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for sleep.
Disp:*60 Tablet(s)* Refills:*0*
8. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for spasm.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Scoliosis and kyphosis
Acute post-op blood loss anemia
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: Posterior
thoracolumbar fusion T9-S1
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2128-4-15**]
|
[
"738.5",
"E878.1",
"285.1",
"721.3",
"458.29",
"996.49",
"737.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.35",
"80.99",
"81.64",
"81.37",
"84.52"
] |
icd9pcs
|
[
[
[]
]
] |
3889, 3895
|
2049, 2800
|
292, 317
|
3994, 4001
|
1367, 2026
|
5976, 6056
|
828, 833
|
2908, 3866
|
3916, 3973
|
2826, 2885
|
4025, 4108
|
848, 1348
|
4144, 4337
|
243, 254
|
4373, 4840
|
4852, 5953
|
345, 472
|
494, 736
|
752, 812
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,208
| 166,923
|
23611
|
Discharge summary
|
report
|
Admission Date: [**2191-10-6**] Discharge Date: [**2191-10-10**]
Date of Birth: [**2120-10-4**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Hydralazine
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Cough and Shortness of breath
Major Surgical or Invasive Procedure:
central venous femoral catheter placed [**2191-10-6**]
Central venous femoral catheter dc'd [**2191-10-10**]
PICC line placed [**2191-10-10**]
History of Present Illness:
71 yo M with multiple medical problems including diastolic HF,
[**Name (NI) 7792**], CVA in [**5-20**] with baseline L hemiparesis and limited
vocalization, alzheimer's dementia, and hx of multiple resistant
infections, recent admission in [**8-21**] with similar presentation,
admitted from nursing home with fever, dyspnea, hypoxia, and
hyperglycemia. Patient had a recent admission and was treated
for pneumonia with vancomycin and ceftazidime for 7 days for
which a PICC was placed which finished [**2191-8-27**].
In the ED, initial VS: 97.1 110 159/79 24 92 on 8L. Noted to be
rhonchorous BS with CXR with PNA. High white count. Worsened
dyspnea and BP dropped to 90/60 almost intubated started on NRB.
Given 3L NS fluid. Now on 5L nasal cannula. BG at 721. Got 10
units of insulin, no Gap ? HONK. At noon 401. Also trop 0.33,
TWI in V4 started on hep gtt. 96 119/37 33 99% 5L. Right femoral
TL placed. Given levo and Vanc. He was weaned to venti and then
to 5L NS.
Currently, patient not responsive at baseline. Family at bedside
which confirms this. Per nursing home notes, patient was noted
to be tachypnic to 30s, tachy to 116 and to have temp of 101.1
when he was sent from nursing home.
ROS: Unable to obtain secondary to patient nonverbal at
baseline.
Past Medical History:
1. Coronary artery disease
- [**Month/Day/Year 7792**] ([**9-/2190**])
2. Diastolic CHF, last Echo [**2190-9-24**]
3. Hypertension
4. Hypercholesterolemia
5. h/o bradycardia
6. Diabetes
7. History of CVA ([**2190-6-3**]), baseline L hemiparesis & limited
vocalization
8. Hydrocephalus, s/p VP shunt (~[**2182**] @ [**Hospital3 **], no
revisions, unknown cause)
9. History of hyperkalemia ([**6-20**] and [**9-20**], [**10-20**]). Etiology
unclear though acute renal failure and hypoaldosterone states
considered.
10. Alzheimer's dementia
11. Bipolar disorder
12. History of subdural hemorrhages
13. Hearing loss, with hearing aids
14. Cataracts
15. History of iron deficiency anemia anemia
16. PVD
17. h/o SIADH, with fluid restriction of 1L per day
18. h/o recurrent aspiration PNAs
20. h/o Multiple Resistant Infections:
- VRE UTI ([**2190-7-7**])
- h/o ESBL Klebsiella UTI ([**2190-9-23**]) & Sputum/endotracheal
([**2190-8-19**])
- MRSA, Sputum/endotracheal ([**2190-8-19**])
- Recurrent Clostridium difficile colitis ([**2187-3-12**])
21. Skin:
- Stage II sacral wounds
- Unstageable left heel decubitus
- [**Female First Name (un) 564**] (groin & perineum)
22. h/o Partial SBO, resolved with bowel rest ([**1-/2189**])
23. h/o BRBPR ([**9-/2190**])
24. h/o +PPD, s/p INH rx
25. h/o Elevated LFTs
26. right suprahilar lung mass [**8-21**]
Social History:
Resides in NH. Used to work as an accountant, 100 pack year
smoking history, He is nonverbal at baseline with a PEG tube. He
is dependent on others for ADLs.
Family History:
Type 2 diabetes mellitus, Alzheimer's and Bipolar Disease.
Physical Exam:
General Appearance: Thin
Eyes / Conjunctiva: PERRL, Pupils dilated
Head, Ears, Nose, Throat: Poor dentition, Jtube
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : , Hyperresonant: )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Musculoskeletal: Unable to stand
Skin: Warm
Neurologic: Responds to: Verbal stimuli, Movement: Non
-purposeful, Tone: Decreased, L side paralyzed
PHYSICAL EXAM ON TRANSFER FROM MICU TO FLOOR:
Vitals - T 98.9 BP 126/37 HR 86 RR 19 O2Sat 100%4L
GENERAL: Awake, not responding to verbal stimulation, groaning
constantly
HEENT: PERRLA, moving eyes well but unable to do full EOM exam,
MM appear slightly dry, with nasal cannula
CARDIAC: RRR no apparent murmurs rubs or gallops although
difficult to hear given groaning
LUNG: Mild rhonchi bilaterally
ABDOMEN: Slightly firm and with ?tenderness to palpations
around umbilical area although hard to determine, BS+, mild
distention
EXT: In pneumoboots, with 1+ edema to ankles.
Pertinent Results:
BlooD cx [**2191-10-6**] x3, NGTD
Urine Cx [**10-6**], [**10-7**], NGTD
Stool Cx [**10-7**] -ve
C.diff toxin (stool) [**10-8**] - ve
[**2191-10-7**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
[**2191-10-8**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY {STAPH AUREUS COAG +}
[**2191-10-8**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL INPATIENT
[**2191-10-7**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS} INPATIENT
[**2191-10-10**] 05:55AM BLOOD WBC-13.2* RBC-3.70* Hgb-9.2* Hct-31.8*
MCV-86 MCH-24.9* MCHC-29.0* RDW-15.1 Plt Ct-284
[**2191-10-10**] 05:55AM BLOOD Plt Ct-284
[**2191-10-10**] 01:48PM BLOOD Na-145 Cl-114*
[**2191-10-10**] 05:55AM BLOOD Calcium-7.7* Phos-2.8 Mg-2.1
[**2191-10-6**] 06:50AM WBC-32.2*# RBC-4.81# HGB-12.6*# HCT-42.4#
MCV-88 MCH-26.1* MCHC-29.7* RDW-15.9*
[**2191-10-6**] 06:50AM PLT COUNT-432
[**2191-10-6**] 06:50AM GLUCOSE-721* UREA N-72* CREAT-1.1 SODIUM-157*
POTASSIUM-4.5 CHLORIDE-110* TOTAL CO2-36* ANION GAP-16
[**2191-10-6**] 07:06AM LACTATE-3.8*
EKG: sinus tach, NA, NI, V4 TW now upright but likely lead
placement, no acute STTW changes
[**2191-10-6**] CHEST, PORTABLE UPRIGHT FRONTAL VIEW: The suprahilar
right lung mass is again identified, now measuring 3.9cm
(previously 2.9cm). Right apical opacity may reflect
atelectasis, pneumonia or pulmonary infarct. The cardiac
silhouette is unchanged. Hilar contours are stable. There is no
effusion on this frontal view. Shunt catheter courses over the
right lung into the peritoneum.
IMPRESSION:
1. Interval growth of right suprahilar lung mass.
2. Right apical opacity is a non-specific finding, may reflect
atelectasis, pneumonia, or pulmonary infarct.
A wet read was entered into the ED Dashboard on [**2191-10-6**].
CHEST XRAY [**2191-10-7**]:
Left lung is clear. Right infrahilar consolidation slightly
worse today
compared to [**10-6**]. Right suprahilar mass noted. Heart
size is normal though increased over 24 hours. Right pleural
effusion is small if any. No pneumothorax.
Brief Hospital Course:
71 year old male with multiple medical problems including
diastolic HF, [**Name (NI) 7792**], CVA in [**5-20**] with baseline L hemiparesis
and limited vocalization, Alzheimer's dementia, and hx of
multiple resistant infections, recent admission in [**8-21**] with
similar presentation, admitted from nursing home with fever,
dyspnea, hypoxia, and hyperglycemia found to have sepsis/PNA.
1. Hypovolemic Shock and Sepsis:He was originally admitted to
the medical ICU with leukocytosis and tachypnea. A central
venous femoral catheter was placed for access. He was noted to
have a right apical infiltrate and enlarging right upper lobe
mass on chest x-ray. This was most consistent with
post-obstructive vs. health-care associated pneumonia. Given
his history of MRSA and ESBL Klebsiella pneumonia, he was
started on vancomycin and meropenen for a total course of 14
days. He was given IV fluids in the ED and in the ICU. Despite
this, he became hypotensive and Levophed was started. A few
hours after Levophed initiation, he became bradycardic with a
heart rate in the 30s and systolic blood pressure noted to be as
low as 65. He was given 1 amp of atropine and 1 amp of sodium
bicarbonate. Levophed was increased and 2 liters of normal
saline were bolused. His heart rate and blood pressure
recovered and he never lost his pulse. He was thought to be
significantly hypovolemic given an increased BUN/Cr ratio,
hypernatremia and physical exam. He was given IVF boluses and
the levophed was weaned. He subsequently remained
hemodynamically stable for the duration of hospitalization. He
had a PICC line placed in order to receive IV antibiotics at his
extended care facility, and his central venous femoral catheter
was discontinued.
2. Hypernatremia: He had persistent hypernatremia after fluid
resuscitation and antibiotic initiation. He was felt to be
hypovolemic and his hypernatremia improved with free water
boluses via his G tube and D5W administration.
3. Leukocytosis: He had a leukocytosis on admission that was
likely secondary to pneumonia. He had stool cultures negative
for C Diff. He also has a stage II sacral decubitus ulcer which
did not appear infected but was considered as a possible cause
of his leukocytosis. His leukocytosis has trended down
consistent with resolving infection in the setting of successful
antibiotic therapy.
4. Hypertension: He is on captopril, metoprolol, and clonidine
as outpatient. These were initially held due to hypotension on
presentation. He was restarted on low dose metoprolol 12.5 mg
po BID during his stay and his blood pressure tolerated this
well. He is being discharged on his home doses of metoprolol,
clonidie, and captopril.
5. Hyperglycemia: His blood glucose was in the 700s on admission
without an anion gap. He was managed with his home Lantus and
insulin sliding scale and did not require an insulin drip.
After initial fluid resuscitation and treatment, his blood
sugars remained well-controlled.
6. CAD: EKG initially showed TWI in V4. He was started on
heparin gtt in ED. Cardiac enzymes were cycled and he was
monitored on telemetry. The heparin drip was discontinued in the
MICU as it was not believed he had an ischemic event. telemetry
monitoring was discontinued. He was continued on daily aspirin.
7. Code Status: He remained FULL CODE during this
hospitalization.
Medications on Admission:
-Captopril 12.5 mg Tab Oral Three times daily via J-tube
-Reglan 5 mg Tab Oral Four times daily via J tube
-Multi-Day Tab Oral Once Daily via J tube
-Levothyroxine 25 mcg Tab Oral Once Daily via J tube
-Ascorbic Acid 500 mg Tab Oral Once Daily via J tube
-Omeprazole 20 mg Oral Packet Oral Twice Daily via J tube
-Clonidine 0.3 1 Patch Weekly(s) once per week on wednesday
-Metoprolol Tartrate 25 mg Tab Oral Three times daily via J tube
-JUVEN Oral Packet Oral1 Packet(s) Twice Daily via J tube
-Heparin (Porcine) 5,000 unit/mL Syringe Injection Three times
daily SC
- Albuterol Sulfate 2.5 mg/3 mL (0.083 %) Neb Solution
Inhalation
1 Solution for Nebulization(s) Every 6 hrs
- [**Doctor Last Name 1819**] Aspirin 325 mg Tab Oral 1 Tablet(s) Once Daily
- Peridex 0.12 % Mouthwash Mucous Membrane 15ml Mouthwash(s)
Twice Daily
-Lantus 100 unit/mL Sub-Q Subcutaneous 30units Solution(s) Once
Daily, at bedtime
-Humalog 100 unit/mL Sub-Q Subcutaneous sliding scale
Solution(s) unk times daily
Discharge Medications:
1. Captopril 12.5 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO three times a
day.
2. Reglan 5 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO four times a day.
3. Levothyroxine 25 mcg Tablet [**Doctor Last Name **]: One (1) Tablet PO DAILY
(Daily).
4. Multi-Day Tablet [**Doctor Last Name **]: One (1) Tablet PO once a day.
5. Ascorbic Acid 500 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO DAILY
(Daily).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Doctor Last Name **]: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
7. Clonidine 0.3 mg/24 hr Patch Weekly [**Doctor Last Name **]: One (1) Patch
Transdermal once a week.
8. Metoprolol Tartrate 25 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO three
times a day.
9. JUVEN Packet [**Doctor Last Name **]: One (1) Packet PO twice a day.
10. Heparin (Porcine) 5,000 unit/mL Solution [**Doctor Last Name **]: One (1)
Injection Injection TID (3 times a day).
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Doctor Last Name **]: One (1) Nebulization Inhalation Q6H (every 6
hours).
12. Aspirin 325 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO DAILY (Daily).
13. Chlorhexidine Gluconate 0.12 % Mouthwash [**Doctor Last Name **]: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
14. Lantus 100 unit/mL Solution [**Hospital1 **]: Thirty (30) Units
Subcutaneous at bedtime.
15. Humalog 100 unit/mL Solution Subcutaneous
16. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
17. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Hospital1 **]: One (1)
gram Intravenous Q 12H (Every 12 Hours): Please give through
[**2191-10-19**].
18. Meropenem 500 mg Recon Soln [**Year (4 digits) **]: One (1) Recon Soln
Intravenous Q6H (every 6 hours): Please give through [**2191-10-19**].
Discharge Disposition:
Extended Care
Facility:
Roscommons
Discharge Diagnosis:
Primary Diagnosis:
Pneumonia
Sepsis
Secondary Diagnosis:
Chronic diastolic heart failure
Alzheimer's dementia
Chronic diastolic congestive heart failure
Hypernatremia
Hyperglycemia
Hypertension
Bradycardia
Discharge Condition:
Good, vital signs stable
Discharge Instructions:
You were admitted to the hospital due to difficulty breathing
and low blood pressure. You were found to have a pneumonia and
you are being treated with IV antibiotics. You also have a mass
in your lung that could have caused you to have pneumonia. You
were also given IV fluids to help rehydrate you.
Changes to your medications:
ADDED vancomycin 1000 mg IV twice daily through [**2191-10-19**]
ADDED meropenem 500 mg IV four times daily through [**2191-10-19**]
If you experience worsening shortness of breath, chest pain,
worsening cough, or fevers greater than 101 degrees, you should
call 911 or go to the nearest hospital. If you have abdominal
pain or constipation, you should call your primary care doctor.
Followup Instructions:
please follow up with your primary care provider, [**Name10 (NameIs) **]
[**Last Name (STitle) **],[**Name12 (NameIs) **] K at [**Telephone/Fax (1) 13745**]
You have the following appointments scheduled:
Provider: [**Name10 (NameIs) 454**],ONE [**Name10 (NameIs) 454**] Date/Time:[**2191-12-2**] 8:30
Provider: [**Name10 (NameIs) 6122**] WEST OUTPATIENT RADIOLOGY Phone:[**Telephone/Fax (1) 8243**]
Date/Time:[**2191-12-2**] 10:00
|
[
"162.8",
"428.0",
"412",
"294.10",
"518.81",
"785.52",
"707.03",
"414.01",
"486",
"331.0",
"V45.2",
"250.00",
"707.22",
"428.30",
"707.20",
"995.92",
"296.80",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.60"
] |
icd9pcs
|
[
[
[]
]
] |
13060, 13097
|
6750, 10114
|
317, 462
|
13348, 13375
|
4669, 6727
|
14143, 14580
|
3320, 3380
|
11155, 13037
|
13118, 13118
|
10140, 11132
|
13399, 13704
|
3395, 4650
|
13733, 14120
|
248, 279
|
490, 1760
|
13176, 13327
|
13137, 13155
|
1782, 3128
|
3144, 3304
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,232
| 102,652
|
31312
|
Discharge summary
|
report
|
Admission Date: [**2179-7-14**] Discharge Date: [**2179-8-20**]
Date of Birth: [**2114-8-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Abdominal pain, concern for mesenteric ischemia
Major Surgical or Invasive Procedure:
[**7-17**]:
1. Exploratory laparotomy.
2. Segmental ileal resection.
3. Mesenteric vessel exploration.
1. Resection 8 cm distal ileum
2. Resection of terminal ileum and right colon.
3. Ileotransverse colostomy.
4. [**State 19827**] patch temporary abdominal wall closure.
[**7-18**]:
1. Superior mesenteric artery stenting
[**7-27**]
1. Closure of abdominal wound
2. Tracheostomy with insertion of 8Fr tracheostomy tube
[**8-4**] cardiac catheterization
[**8-16**] EGD
[**8-19**]
1. inferior vena cava filter (Bard G2) via left femoral route.
with Fluoroscopic control for IVC filter placement.
History of Present Illness:
Transfer from OSH with concern for mesenteric ischemia
HNP 64 yo male with 14 days of colicky abdominal pain now
constant. Associated with brown maroon vomiting, and melena.
No [**Month/Year (2) **]. Patient was admitted to [**Hospital3 26615**] hospital with a
WBC of 5 increasing to 28. Ct scan was concerning for mesenteric
ischemia showing fluid around the spleen, [**Female First Name (un) 899**] not identified,
SMA severely diseased.
Patient was reported to have a Troponin leak at outside
hospital, concerning for myocardial ischemia.
Past Medical History:
PVD
DM
Bladder CA
COPD
Surgical History:
Open Chole
Aorto [**Hospital1 **] Fem Bypass
Social History:
90 pack/year smoker
6-12 beers/week
Retired highway heavy equipment operator
Family History:
non-contributory
Physical Exam:
GEN: Pt alert, in NAD
HEENT: PERRLA, trach in place, no erythema or drainage, on
ventilator
RESP: Slight wheezing bilaterally
CV: RRR
AB: + BS, soft, non tender, non distended. Abdominal incision
healing by secondary intention, no erythema or drainage.
Dressed with gauze and ab binder
EXT: 2+ edema, chronic changes on lower legs bilat
Neuro: follows commands
Pertinent Results:
CARDIAC CATH [**8-4**]
FINAL DIAGNOSIS:
1. Severe left main and three vessel coronary artery disease.
2. Moderate systolic left ventricular dysfunction.
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated left
main and 3 vessel disease. The LMCA had a distal 70% lesion. The
LAD
had an 80% ostial lesion with mid/distal 80% lesion. The LCx
system had an occluded OM2 with collateral filling. The RCA was
proximally occluded with left coronary collaterals.
2. Resting hemodynamics revealed normal left ventricular
systolic
pressure of 104 mm Hg and normal LVEDP of 12 mm Hg. Sytemic
arterial
systolic and diastolic pressures were normal.
3. Left ventriculography revealed no mitral regurgitation, mild
global
hypokinesis, and LVEF of 45%.
ECHO [**2179-7-29**]
Overall preserved left ventricular systolic function. Mild
mitral regurgitation. Mildly dilated ascending aorta.
ECHO [**7-14**]:
There is mild regional left ventricular systolic dysfunction
with inferior and apical hypokinesis. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
EGD: [**8-19**]
Normal mucosa in the whole esophagus; Erythema and congestion
in the stomach body and antrum compatible with mild gastritis;
Superficial ulcer -second part part of the duodenum at previous
BICAP site; Small hiatal hernia; Otherwise normal EGD to second
part of the duodenum
EGD [**8-16**]:
Erythema and congestion in the gastroesophageal junction
compatible with mild esophagitis; Erythema and congestion in
the antrum compatible with mild gastritis; Angioectasia in the
second part of the duodenum; Small hiatal hernia; Otherwise
normal EGD to second part of the duodenum
Brief Hospital Course:
Mr. [**Known lastname **] is a pleasant 64-year-old male with a significant past
medical history of diabetes, hypertension, prior bladder cancer
and a hiatal hernia who had signs and symptoms of progressive
chronic mesenteric ischemia. Of note, the patient had previously
undergone an aortobifemoral bypass approximately 15 years prior
to presentation for bilateral aorto-iliac occlusive disease. He
now had a several week to month history of progressive
postprandial angina and food fear and weight loss. However, the
patient presented to the vascular service on [**2179-7-14**] with
a several day history of nausea, vomiting, abdominal distention
and obstipation. Initial workup revealed leukocytosis and a CT
scan revealing evidence of a transition point in the right lower
quadrant. Suspicion for a high grade
small bowel obstruction was noted. However, given the
constellation of findings of his prior chronic mesenteric
ischemia, it was unclear as to whether or not this was also a
potential etiology of his pain presentation.
1 Mesenteric ischemia: On the morning of [**2179-7-17**], the
patient was noted to be focally tender with a 23,000 white count
and bandemia. In lieu of his CT scan done the prior day showing
a transition point in the right lower quadrant with the physical
constellation as described, an urgent general surgery
consultation was made by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] covering for Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1391**]. Dr. [**Last Name (STitle) **] approached Dr. [**Last Name (STitle) **] and discussed the plan
of care. After review, it was determined that the patient
required urgent exploration. The patient was consented and risks
including bleeding, infection, bowel in discontinuity, open
abdomen, myocardial infarction, stroke and death, intracutaneous
fistula, recurrent abscesses, possible short bowel were
described.
He was taken to the OR on [**7-17**] and underwent an exploratory
laparotomy, segmental ileal resection, and mesenteric vessel
exploration. Abdomen was left open for a planned second look
operation. The patientleft the operating room hemodynamically
stable. However, he was quite volume outed. He was not on
vasopressors at the
completion of this operation. He was left intubated in critical
condition and returned to the trauma SICU for further monitoring
and care. The vascular surgery service had performed the
catheter-based revascularization of the superior mesenteric
artery. On [**7-18**] the patient then underwent resection 8 cm distal
ileum, resection terminal ileum and right colon. Ileotransverse
colostomy and [**State 19827**] patch temporary abdominal wall closure.
On [**7-27**] patient returned to the OR for definitive abdominal
wound closure and tracheostomy.
2. Myocardial infarction: Incidentally noted to have ST
depressions on telemetry, confirmed with 12-lead in V3-V6 on
[**7-25**]. Troponin leak: TnT baseline 0.05 on [**7-14**] noted to be
0.62=>0.51. Also with severe pulmonary edema on CXR. Once he
became hemodynamically stable, he was agressively diuresed with
lasix/spironolactone. Patient had a repeat ECHO that showed the
left atrium to to be normal in size. Left ventricular wall
thicknesses and cavity size are normal. Overall left ventricular
systolic function appeared normal (LVEF 55%). Mild (1+) mitral
regurgitation was seen. ST-T changes were though to be a result
of cardiac demand. It was thought that patient would benefit
from a cardiac catherization to better ellucidate his disease
process and defect. On [**8-4**] he underwent a cardiac catherization
that showed a right dominant system demonstrating left main and
3 vessel disease. The LMCA had a distal 70% lesion. The LAD
had an 80% ostial lesion with mid and distal 80% lesions. The
LCx system had an occluded OM2 with collateral filling. The RCA
was
proximally occluded with left coronary collaterals. Because of
this pathology, cardiac surgery team was consulted for
evaluation for CABG. Because of Mr. [**Known lastname **]' co-morbidities and
his recent illness, he was deamed to be at high risk for
procedure. He will be managed medically and will be re-evaluated
in several months after he heals from his recent insults.
Respiratory failure: Patient remained intubated after
procedure. He failed to wean from the ventilator and underwent a
tracheostomy on [**7-27**]. He remained on ventilatory support
throughout the remainder of the hospitalization and failing
weaning to trach mask secondary to respiratory muscle fatigue
and hypercarbia.
ID: Yeast in urine and sputum [**7-30**]. Patient was started on a
course of IV fluconazole and will finish on [**2179-8-7**]. On [**8-8**]
sputum cultures showed MRSA, and he began treatment with vanc
and zosyn
GI: Had several episodes of diarrhea, which were C. diff
negative x 3. On [**8-15**] pt began to have large melanotic stools
and his hct dropped from 27-21. GI was consulted and pt was
transfused several units of blood. EGD performed on [**8-16**] showed
a bleeding angioectasia in the second part of the duodenum which
was sucessfully cauterized. Otherwise, EGD revealed mild
esophagitis, mild gastritis, and a small hiatal hernia. Repeat
EGD on [**8-19**] showed Normal mucosa in the whole esophagus
Erythema and congestion in the stomach body and antrum
compatible with mild gastritis
Superficial ulcer -second part part of the duodenum at previous
BICAP site
Small hiatal hernia; Otherwise normal EGD to second part of the
duodenum. He was switched from famotidine to protonix. When
not NPO for procedures, the pt recieved tube feeds - most
recently - replete with fiber at 80 cc/hr
Heme: An IVC filter was placed [**8-19**] secondary to prolonged bed
rest, and unable to continue SQ heparin secondary to GI bleed.
Before the filter was placed, bilateral LENI's were performed,
showing no DVT and patent femoral veins.
He is being discharged to a rehabilitation facility with
instructions for follow-up.
Medications on Admission:
Albuterol, aspirin
Discharge Medications:
1. Insulin
Fingerstick Q6HInsulin SC Fixed Dose Orders
Breakfast Dinner
NPH 15 Units NPH 15 Units
Insulin SC Sliding Scale
Q6H
Regular
Glucose Insulin Dose
0-65 mg/dL [**1-5**] amp D50
66-120 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
241-260 mg/dL 14 Units
261-280 mg/dL 16 Units
> 280 mg/dL Notify M.D.
Instructons for NPO Patients: [**1-5**] when NPO
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
4. Albuterol 90 mcg/Actuation Aerosol Sig: Ten (10) Puff
Inhalation Q2H (every 2 hours) as needed.
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**6-11**]
Puffs Inhalation Q4H (every 4 hours).
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for [**Month/Day (3) **].
8. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
12. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
15. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
Mesenteric ischemia requiring bowel resection, arterial stenting
Myocardial infarction
Discharge Condition:
Stable to rehabilitation facility
Discharge Instructions:
Please call doctor [**First Name (Titles) **] [**Last Name (Titles) **] greater than 101, nausea/vomiting,
inability to eat, wound redness/warmth/swelling/foul smelling
drainage, abdominal pain not controlled by pain medications or
any other concerns.
Please follow-up as directed.
No heavy lifting ([**10-18**] lbs)for 4 weeks or until directed
otherwise. [**Month (only) 116**] leave wound open to air.
Diet: Tube feeding
Wound Care: [**Month (only) 116**] shower/sponge bathe (no bath or swimming) if no
drainage from wound, if clear drainage cover with dry dressing
IF severe pain, persistent nausea and vomiting, [**Month (only) **]>101.5,
redness of wound??????call surgeon.
[**Month (only) 116**] restart asprin in [**1-5**] weeks depending on recommendations of
cardiology/PCP
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **]/Surgery clinic. Call to schedule
your appointment. [**Telephone/Fax (1) 600**] in 2 weeks.
Please follow up with Cardiac surgery in [**2-6**] months with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**]: [**Telephone/Fax (1) 170**].
Per GI, needs capsule or colonoscopy as outpatient to evaluate
for additional AVMS call [**Telephone/Fax (1) 41066**] for appt
|
[
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"518.5",
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"496",
"482.41",
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"537.83",
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"305.1",
"789.5",
"557.0",
"428.0",
"250.00",
"578.1",
"557.1",
"560.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"31.1",
"37.22",
"47.19",
"39.50",
"54.72",
"88.56",
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"99.04",
"96.6",
"88.53",
"38.7",
"00.40",
"39.90",
"00.45"
] |
icd9pcs
|
[
[
[]
]
] |
12048, 12118
|
4180, 10213
|
362, 965
|
12249, 12285
|
2175, 2198
|
13126, 13567
|
1760, 1778
|
10282, 12025
|
12139, 12228
|
10239, 10259
|
2215, 4157
|
12309, 12738
|
1793, 2156
|
275, 324
|
12750, 13103
|
993, 1539
|
1561, 1650
|
1666, 1744
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,231
| 135,691
|
29609
|
Discharge summary
|
report
|
Admission Date: [**2127-7-19**] Discharge Date: [**2127-8-6**]
Date of Birth: [**2061-10-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
PCP: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Hospital3 **])
Oncologist: [**First Name8 (NamePattern2) 916**] [**Last Name (NamePattern1) **] ([**Hospital1 18**])
CC: Abdominal Pain
Major Surgical or Invasive Procedure:
liver biopsy
History of Present Illness:
65 yo Mandarin-speaking F with stage IIIc melanoma (recently
diagnosed and site of origin was urethra) here with 10 days of
abdominal pain. Her pain is epigastric and radiates to her back.
It is exacerbated by food. She also notes nausea and anorexia.
She was taking 650mg of Tylenol without much improvement. She
presented to her PCP on Thursday and blood work showed an
elevated lipase and amylase.
Vials on arrival to [**Hospital1 18**] ED: T 98.0, P 76, BP 120/77, RR 16 99%
on RA. In the ED, she received morphine for pain and 2 L of IV
fluids.
While inpt improved, went for transcutaneous ultrasound guided
liver biopsy and suffered significant pain following it, then
developed hypovolemic shock, was resuscitated with IVF and
underwent a CT scan which revealed a large subcapsular hematoma.
Her bleeding stopped, she rec'd 3 units PRBC and her hct
improved and remained stable. The patient was in the ICU
following her development of shock, remained in the ICU for 2
days and was transferred to the regular medical floor on
[**2127-7-24**].
Review of Systems: No recent illnesses. No fevers or chills. No
jaundice. Appetite is poor and has lost her taste for food. She
has not gained weight post-op. No SOB, cough, or chest pain. She
has constipation. She reports good urine output via ileal
conduit. Reports no problems filling or taking prescriptions.
Other systems reviewed in detail and all otherwise negative.
Past Medical History:
1. Primary mucosal melanoma of the urethra. Presented [**2-/2127**]
with bleeding from her urethra and a urethral mass was
identified in the anterior-aspect of her urethra. On [**2127-5-23**],
she underwent total abdominal hysterectomy, bilateral
salpingo-oophorectomy, bilateral pelvic lymphadenectomy and
ileal conduit urinary diversion. Pathology from the surgery was
notable for 0/20 sampled pelvic lymph nodes contained tumor and
the margins were free of tumor. No chemotherapy administered to
date.
2. Nephrolithiasis s/p left ureteroscopy, laser lithotripsy on
[**2126-6-11**] with stent removal on [**2126-6-27**].
3. Type 2 Diabetes
4. Hypertension
5. Hypercholesterolemia
Social History:
Originally from [**Country 651**], lives with daughter. [**Name (NI) **] tobacco, alcohol,
or drug use.
Family History:
Her parents are deceased. Her mother died at age 72 from
complications of a fall and her father died at age 66 also from
complications of a fall. She had five siblings, two of whom are
deceased. One sister died at age 62 from complications of a
fall and her other sister who is deceased died at age 53
complications of a motor vehicle accident. The patient reports
no family history of cancer.
Physical Exam:
VS: T 98.7 BP 140/82 HR 78 RR 16 O2 98% Ra
GEN: NAD, AOX3
HEENT: MMM, OP clear
CARD: JVP 9cm
PULM: bibasilar rales
ABD: soft, RUQ tenderness - moderate, no bruising, non
distended, no organomegaly
EXT: WWP, no c/c/e
NEURO: AOx3, grossly normal
Pertinent Results:
Chemistries:
- [**2127-7-19**] 07:05PM GLUCOSE-132* UREA N-20 CREAT-0.4
SODIUM-140 POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-20* ANION
GAP-15 ALT(SGPT)-48* AST(SGOT)-46* ALK PHOS-123* TOT BILI-0.3
LIPASE-2782* ALBUMIN-4.5 CALCIUM-9.6 PHOSPHATE-3.4 MAGNESIUM-2.0
LACTATE-1.1
Hematology:
- [**2127-7-19**] 07:05PM WBC-10.1 (NEUTS-77.5* LYMPHS-15.9*
MONOS-4.2 EOS-2.0 BASOS-0.4) RBC-3.71* HGB-10.3* HCT-31.3*
MCV-84 MCH-27.8 MCHC-33.0 RDW-14.6 PLT COUNT-257
Coags:
- [**2127-7-19**] 07:05PM PT-12.9 PTT-29.0 INR(PT)-1.1
Urine Studies:
- [**2127-7-19**] 08:15PM URINE COLOR-Straw APPEAR-Clear SP
[**Last Name (un) 155**]-1.010 BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG
KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM RBC-[**3-14**]*
WBC-[**6-19**]* BACTERIA-FEW YEAST-NONE EPI-<1
[**2127-7-19**] RIGHT UPPER QUADRANT ULTRASOUND:
- There are innumerable new hypoechoic masses throughout the
right and left lobes of the liver, the largest in the right
lobe, measuring up to 5.3 x 4.9 cm. There is prominence of the
common bile duct at the aorta, measuring up to 1.4 cm, without
intrahepatic ductal dilation. The gallbladder is slightly
distended, but without wall thickening, cholelithiasis, or
sludge. There is no pericholecystic fluid identified. Normal
antegrade flow is seen in the main portal vein.
Multiple new hypoechoic masses are also seen involving the head
and body of the pancreas. There is prominence of the pancreatic
duct, measuring up to 4 mm. There is no free fluid in the
abdomen.
IMPRESSION: Numerous new hypoechoic masses throughout the liver
and the
pancreas, with associated prominence of the pancreatic duct (4
mm) and common bile duct (1.3 cm). Given the history of
melanoma, these findings are most compatible with metastatic
disease, with an element of associated biliary and pancreatic
ductal obstruction.
CTA ABD/PELVIS [**2127-7-22**]:
CT ABDOMEN FOLLOWING INTRAVENOUS CONTRAST: Bibasilar dependent
atelectasis, right worse than left. A well-circumscribed
pulmonary nodule measuring 7mm is present in the right middle
lobe, seen on image 209 of series 3B. More inferiorly in the
right middle lobe, a second pulmonary nodule is present
measuring 7 mm. Dedicated CT of the thorax can be obtained
especially given primary carcinoma with known intraabdominal
metastases.
Interval development of a moderate right subcapsular hematoma
with
heterogeneous components, most likely mixed hemorrhage and
fluid. Small amount of heterogeneous fluid is also seen adjacent
to the liver. Small amount of mixed hyperdense fluid extends
into the right paracolic gutter and right mid abdomen. A larger
amount of diluted hemorrhagic fluid is seen dependently within
the pelvis. This is likely the sequelae of recently performed
targeted liver biopsy. No active extravasation of contrast.
Innumerable predominantly necrotic hypoattenuating metastases
are scattered throughout the liver. They demonstrate
heterogeneous predominantly peripheral enhancement. Lesions are
randomly scattered and both intraparenchymal and subcapsular in
location. Particularly a large hepatic metastases in the
anterior right liver measures
4.0 x 4.8 cm. Another large metastasis in the posterior right
liver measures 4.7 x 7.0 cm. Hepatic veins are attenuated,
especially the right branch, by a focus of hepatic metastasis.
Portal vein is patent. The gallbladder is distended, without
radiopaque gallstones. Intrahepatic and proximal extrahepatic
common ductal dilatation is present, now moderate in severity.
Previously, this was mild in appearance. No radiopaque biliary
stones are seen. The very distal common duct becomes normal in
caliber just proximal to the ampulla. Multiple hypodense lesions
are seen within the pancreas concerning for metastases. The
largest in the uncinate process measures 1.9 x 2.4 cm. The
largest within the body of the pancreas measures 1.2 x 1.8 cm.
Worsening pancreatic ductal dilatation, likely due to pancreatic
metastasis.
The right adrenal gland is normal. The left adrenal gland
demonstrates a
large heterogeneous centrally necrotic mass measuring 2.8 x 2.9
cm, compatible with metastases. The spleen is normal in size and
opacification. Multiple wedge-shaped areas of hypoattenuation
involving both kidneys, may represent sequela of multifocal
infarcts. A more nodular area of ill-defined hypoattenuation and
heterogeneous enhancement in the upper pole of the right kidney
is seen concerning for an additional site of metastases. No
hydronephrosis bilaterally. In the superior right perirenal
space, a 1.1 cm soft tissue nodule is seen and may represent a
retroperitoneal focus of metastases. The abdominal aorta is
normal in caliber and opacification. Subcentimeter aortocaval
lymphnodes are present. Proximal branch vessels are normally
opacified.
The stomach, duodenum, and small bowel loops are normal in
caliber. No
evidence of bowel obstruction. Multiple soft tissue nodules are
scattered
throughout the small bowel mesentery and within the omentum
compatible with intraperitoneal metastases. No extraluminal air
or discrete fluid
collections are seen. Large amount of stool within the
nondistended colon
CT OF THE PELVIS FOLLOWING INTRAVENOUS CONTRAST: Status post
cystectomy and ileal loop diversion. Status post hysterectomy
and bilateral
salpingo-oophorectomy. Large amount of mixed density fluid
within the pelvis concerning for hemorrhage. At least two
enteroenteric anastomoses are present within the pelvis which
appear intact. Subcentimeter bilateral
inguinal, and iliac chain lymph nodes are seen.
Superficial soft tissues: Post-procedural change involving the
infraumbilical anterior midline soft tissues. No abnormal fluid
collections.
Bones: Mild multilevel degenerative changes of the visualized
spine. No
suspicious osseous blastic or lytic lesions are seen.
IMPRESSION:
1. Large subcapsular mixed density hematoma with hemorrhage
extending in to the right lateral perihepatic space, right
paracolic gutter within the right mid abdomen and settling
dependently within the pelvis. This appears to be at the site of
ultrasound-guided targeted liver biopsy from earlier [**2127-7-22**]. No
active extravasation of contrast is noted.
2. Significant interval progression of innumerable hepatic and
multiple
pancreatic metastases. Enlarged left adrenal metastases.
Multiple soft
tissue nodules are scattered throughout the abdomen, with a few
peritoneal and omental metastasis. Right perirenal soft tissue
nodule, concerning for
retroperitoneal metastasis.
3. Nodular heterogeneously region upper pole of the right kidney
concerning for additional metastatic involvement. Additional
wedge shaped areas of hypoenhancement are seen in both kidneys,
like sequeale of infarcts.
4. 2 pulmonary nodules are seen in the right middle lobe. Given
history of
known primary malignancy with metastasis, consider performing a
dedicated
chest CT or PET/CT.
[**2127-7-24**] 02:48AM BLOOD WBC-10.1 RBC-3.42* Hgb-10.0* Hct-30.0*
MCV-88 MCH-29.1 MCHC-33.1 RDW-14.5 Plt Ct-177
[**2127-7-23**] 06:53PM BLOOD Hct-25.5*
[**2127-7-23**] 01:08PM BLOOD Hct-26.1*
Brief Hospital Course:
65 yoF w/ a h/o stage IIIC mucosal melanoma of the urethra who
presented with acute pancreatitis and abnormal LFTs.
Ultimately, she was found to have obstructing lesions revealed
to be metastatic melanoma. She had a liver biospy on [**7-22**],
post-IR complicated by hypotension and radiographic evidence of
hepatic hematoma. CT showed innumerable mets in the liver. She
received a dose of chemotherapy (Dacarbazine)on [**7-29**] under the
guidance of Dr. [**First Name8 (NamePattern2) 916**] [**Last Name (NamePattern1) **].
.
Her post-chemo course was remarkable for periodic nausea,
constipation, and some initial delirium. Her pain was
ultimately well-controlled with oral dilaudid. Her bowel
regimen was enhanced after abdominal x-ray on [**8-3**] showed no
evidence for bowel obstruction but significant amounts of stool.
.
She was ambulating out of bed with her family/minimal assistance
and reported feeling alright. She was interviewed daily with
the assistance of the Chinese interpreter services.
.
Her blood pressure was well-controlled off her ACE-inhibitor and
this was not continued.
.
Her sugars were controlled with insulin in house. After a
family meeting on [**2127-8-4**], it was decided that pt would not go
home on insulin due to concerns regarding patient limitations of
intake due to concern for blood sugar control. We have
encouraged her to liberalize her diet and have started Glyburide
twice daily. She will need VNA education around maintaining
adequate hydration while taking this medication.
.
She will be discharged to home with outpatient follow-up with
Dr. [**First Name8 (NamePattern2) 916**] [**Last Name (NamePattern1) **] later in the week.
.
For the time being her code status is FULL.
Medications on Admission:
HOME MEDICATIONS
1. GLIPIZIDE 10 mg Tablet - 1 Tablet(s) by mouth twice a day
2. LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth daily
3. LOVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth daily
4. METFORMIN - 500mg [**Hospital1 **]
5. NIFEDIPINE - 60 mg Tablet Sustained Release - 1 Tablet(s) by
mouth daily
6. TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime
7. Tylenol 650mg q4 hours for pain
8. ASA 81mg
9. Colace
10. Senna
TRANSFER MEDICATIONS
traZODONE 25 mg PO HS:PRN Insomnia
Docusate Sodium 100 mg PO BID
Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
Insulin NPH 5u sc bid and sliding scale
Ondansetron 4 mg IV Q8H:PRN nausea
Prochlorperazine 10 mg IV Q6H:PRN nausea
HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q2H:PRN pain
Discharge Medications:
1. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for Insomnia.
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
5. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
BID (2 times a day): if you are having loose stool, you should
stop this medication.
Disp:*qs * Refills:*0*
6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
do not take this medication if you are having loose stool.
Disp:*60 Tablet(s)* Refills:*0*
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation: take if you have not had a bowel movement in 3
days.
Disp:*10 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Acute pancreatitis
Acute Blood loss anemia [**2-11**] Hepatic Hepatoma
Metastatic Melanoma
Secondary:
Delirium
Hypertension
Paroxysmal atrial fibrillation
Diabetes mellitus, controlled
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you. You were admitted for
abdominal pain and were found to have pancreatitis which is
resolving. For your metastatic melanoma, you were given
chemotherapy called dacarbazine.
.
Your metformin and your GLIPIZIDE were not given during your
admission and you have been started on ** Glyburide ** for your
blood sugars. Please continue checking your blood sugars at
least once daily and call your doctor if the sugars are over
400. Do not take the glyburide if your sugar is less than 70.
.
Your lisinopril and LOVASTATIN were also stopped.
.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2127-8-8**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
You have a follow up appointment with Dr. [**Last Name (STitle) **] at [**Hospital3 **]
on Thursday, [**8-7**] at 11am to review your blood sugars.
.
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2127-8-6**] at 9:00 AM
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: OSTOMY/[**Hospital **] CLINIC
When: WEDNESDAY [**2127-8-6**] at 9:00 AM
With: WOUND/OSTOMY NURSE [**Telephone/Fax (1) 13760**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital3 8233**]
Address: [**State 8234**], [**Location (un) **],[**Numeric Identifier 4809**]
Phone: [**Telephone/Fax (1) 8236**]
Appointment: Thursday [**2127-8-14**] 2:15pm
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2127-8-13**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2127-8-13**] at 4:00 PM
With: [**First Name4 (NamePattern1) 4912**] [**Last Name (NamePattern1) 4913**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
Completed by:[**2127-8-6**]
|
[
"197.0",
"285.1",
"998.12",
"272.0",
"250.02",
"998.0",
"577.0",
"401.1",
"V44.6",
"189.3",
"E878.8",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"88.74",
"99.04",
"50.11"
] |
icd9pcs
|
[
[
[]
]
] |
14400, 14458
|
10694, 12429
|
560, 574
|
14697, 14697
|
3561, 10671
|
15515, 17612
|
2878, 3277
|
13229, 14377
|
14479, 14676
|
12455, 13206
|
14880, 15492
|
3292, 3542
|
1675, 2031
|
276, 522
|
602, 1656
|
14712, 14856
|
2053, 2740
|
2756, 2862
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,771
| 146,567
|
48570
|
Discharge summary
|
report
|
Admission Date: [**2178-12-22**] Discharge Date: [**2179-1-2**]
Date of Birth: [**2122-3-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
L rib pain,
Major Surgical or Invasive Procedure:
Intubation
Central line placement
History of Present Illness:
This 56 year old gentleman with a history of hypertension,
asthma, hepatitis C, and alcohol abuse presents with increased L
chest pain s/p [**2122**]0 days ago. At that time the patient says
he had slipped on some ice and fell on his L side, developing a
bruise on his L side. He saw his PCP who believed he may have
had rib fractures and prescribed percocets for pain control. The
patient has not had any falls or trauma since that time, but
reports the pain has gotten worse; it localizes to the L side,
rating [**9-22**] and worsened by breathing. No radiation or
associated diaphoresis. No dyspnea, altough the patient says the
pain makes it harder to breath.
The patient reports he does not abuse alcohol and last had a
drink 3 days ago drinking 2 beers on Saturday night. He denies
any history of delirium tremens, blackouts, or admission to
detoxification facilities. Per his aunt and uncle, however, the
patient continues to be a heavy drinker. Furthermore, they
report on the day prior to admission, they had a phone
conversation with the patient and said that he was incoherent.
On review of systems, the patient reports he has not eaten in 2
days. He denies nausea, vomiting/hematemesis, melena, or brbpr.
In the ED, the patient was initially afebrile with SBP in 90's
and heart rate in 100's. O2 sat was 95 on room air. He was
complaining of L sided chest pain. Laboratories revealed a cr of
4 and a K of 5.5 with peaked T waves on EKG, bicarb 18. CK 6600.
Hematocrit returned as 38.5 down from 48 a week ago. CT scan
revealed RLL opacities in lung and small hematoma along L rib
cage. 2 rib fractures were seen in that area. WBC was elevated
to 12.1 lactate was 1.1. The patient received 6L NS and 1 unit
pRBC. Also rec'd bicarb and kayexelate. Blood pressure rose to
110 systolic, morphine 4mg IV was given for pain control.
Levofloxacin and flagyl were given due to concern for pneumonia.
Past Medical History:
1) Asthma
2) HTN
3) Status post Nissen Fundoplication.
4) Hepatitis C, followed by Dr. [**First Name (STitle) 679**], has failed interferon and
ribavarin trials twice.
Social History:
Works in food industry (fish [**Doctor Last Name 360**])
History of alcohol abuse, denies any recent abuse (see HPI),
recently quit smoking.
Denies illicit drug use.
Lives alone, not in any relationship.
Family History:
Unknown, pt cannot recall
Physical Exam:
T 97.2, BP 116/45, P 122, R 25, O2 97 on 2L, 95 on RA.
Gen: WD/WN male Caucasian. Alert, very anxious, complaining of
pain.
Head: NCAT.
Eyes: Anicteric
Mouth: MM dry
Neck: Supple, nl JVP
Chest: Area of ecchymosis on L chest/flank, tender to palpation.
Lungs rhonchorous, no rales or wheezes.
Heart: Tachycardic, no murmur.
Abd: Obese, nl bowel sounds, non tender, non distended.
Ext: No edema, good distal pulses.
Rectal: Guaiac negative per ED.
Neurol: Initially no tremor or asterixis. Later he developed a
tremor.
Pertinent Results:
[**2178-12-22**] 09:20PM TYPE-ART TEMP-38.4 O2-35 O2 FLOW-10 PO2-94
PCO2-39 PH-7.23* TOTAL CO2-17* BASE XS--10 INTUBATED-NOT INTUBA
COMMENTS-VENTIMASK
[**2178-12-22**] 09:20PM LACTATE-1.1
[**2178-12-22**] 05:19PM URINE HOURS-RANDOM CREAT-91 SODIUM-LESS THAN
[**2178-12-22**] 05:19PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2178-12-22**] 05:19PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-4* PH-5.0 LEUK-TR
[**2178-12-22**] 05:19PM URINE RBC-[**2-15**]* WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2178-12-22**] 05:19PM URINE AMORPH-MOD
[**2178-12-22**] 05:19PM URINE MUCOUS-FEW
[**2178-12-22**] 01:05PM GLUCOSE-105 UREA N-72* CREAT-2.8*# SODIUM-141
POTASSIUM-5.4* CHLORIDE-114* TOTAL CO2-16* ANION GAP-16
[**2178-12-22**] 01:05PM CK(CPK)-5832*
[**2178-12-22**] 01:05PM CK-MB-40* MB INDX-0.7
[**2178-12-22**] 01:05PM CALCIUM-7.6* PHOSPHATE-3.5 MAGNESIUM-2.5
[**2178-12-22**] 01:05PM WBC-8.5 RBC-4.54* HGB-14.9 HCT-42.5 MCV-94
MCH-32.8* MCHC-35.1* RDW-14.6
[**2178-12-22**] 01:05PM PLT COUNT-220
[**2178-12-22**] 12:38PM URINE HOURS-RANDOM
[**2178-12-22**] 12:38PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2178-12-22**] 08:28AM LACTATE-1.1
[**2178-12-22**] 08:10AM URINE HOURS-RANDOM SODIUM-33
[**2178-12-22**] 08:10AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2178-12-22**] 08:10AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG
[**2178-12-22**] 08:10AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0
[**2178-12-22**] 08:10AM URINE HYALINE-0-2
[**2178-12-22**] 06:50AM GLUCOSE-125* UREA N-89* CREAT-4.0*#
SODIUM-136 POTASSIUM-5.5* CHLORIDE-103 TOTAL CO2-17* ANION
GAP-22*
[**2178-12-22**] 06:50AM ALT(SGPT)-110* AST(SGOT)-270* CK(CPK)-6652*
ALK PHOS-79 AMYLASE-128* TOT BILI-1.0
[**2178-12-22**] 06:50AM LIPASE-96*
[**2178-12-22**] 06:50AM CK-MB-44* MB INDX-0.7 cTropnT-<0.01
[**2178-12-22**] 06:50AM CK-MB-44* MB INDX-0.7 cTropnT-<0.01
[**2178-12-22**] 06:50AM LIPASE-96*
[**2178-12-22**] 06:50AM ALBUMIN-3.9 CALCIUM-9.4
[**2178-12-22**] 06:50AM WBC-12.1*# RBC-4.11* HGB-13.6* HCT-38.8*
MCV-94 MCH-33.2* MCHC-35.2* RDW-13.5
[**2178-12-22**] 06:50AM NEUTS-79.1* LYMPHS-9.5* MONOS-8.1 EOS-3.1
BASOS-0.3
[**2178-12-22**] 06:50AM PLT COUNT-301#
[**2178-12-22**] 06:50AM PT-13.5* PTT-28.4 INR(PT)-1.2*
.
CT Chest [**12-22**]: IMPRESSION:
1. Nondisplaced left ninth rib fracture, displaced left tenth
rib fracture, with associated left-sided soft tissue hematoma.
2. Poorly defined multi focal areas of ground-glass opacity and
consolidation seen scattered throughout the lungs, with smaller
nodular density is also seen. These findings possibly represent
infectious versus inflammatory process, although followup
imaging is recommended to document resolution.
3. Mediastinal, mesenteric, and retroperitoneal lymphadenopathy
with enlarged right hilar and right retrocrural lymph nodes
identified. Followup imaging is recommended to document
resolution.
.
[**12-29**] ECHO: Conclusions: The left atrium is normal in size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). 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 (probably 3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion. No vegetation seen
(cannot definitively exclude).
.
CXR [**12-22**]: IMPRESSION: IMPRESSION: Vague opacity in the right mid
to lower lung zone could represent pneumonia and is probably
unchanged.
.
CXR [**12-26**]: Multifocal airspace disease consistent with multifocal
pneumonia/aspiration slightly improved since the prior
examination
.
CXR [**12-31**]: IMPRESSION: AP chest compared to [**12-24**] through
14: Several of the nodular areas of consolidation seen
previously have cleared. Background interstitial abnormality,
probably edema, and mediastinal vascular engorgement are
unchanged. Tip of the left subclavian line ends at the junction
of brachiocephalic veins. No pneumothorax or pleural effusion.
Brief Hospital Course:
This is a 56 year old gentleman with hypertension, asthma,
hepatitis C and a history of alcohol abuse who presented s/p
[**2178**]0 days prior to admission with associated rib fractures.
He was found to be in ARF with hyperkalemia, with CK to 6600 and
admitted to the MICU originally for that reason found to have
DTs and briefly intubated for change in MS.
.
# Withdrawl/Delerium: Soon after admission, the patient
developed florid DT's with hypertension, tachycardia, and
combative behavior. Metoprolol was started as was valium per
CIWA scale. Over the next two days, the patient required
extremely high amounts of valium. This was weanes as his DTs
improved. He was intubated from [**Date range (1) 81448**] for DTs and he was
weaned well when his MS started to clear and extubaed without
event. His residual change in mental status has persisted and
he sundowns dramatically each night. He calms down with Haldol
PRN and soft restraints have been occasionally used as well.
This is improving daily. His change in MS is no longer
considered secondary to withdrawl and is concerning for
Wernicke's, etc. He may require MRI eventually or a neuro
consult but is still in need of more clearing first. We have
made several attempts to minimize sedating medications. His
most recent sedative was a 2mg dose of Ativan on the day of
discharge to facilitate PICC line placement.
.
#) Hypotension, was transient after admission and was responsive
to fluids. Has been hypERtensive at times this admission, no
further evidence of hemodynamic instability in house.
.
#) PNA: He had radiographic evidence of worsening R perihilar
and LLL multifocal PNA. Grew staph aureus in sputum, which was
MRSA. Possibly [**1-15**] aspiration due to agitation in context of
EtOH withdrawal. Recent flu possible, given s. aureus, though
DFA negative. Intubated as above. Had d/c'd levo/flagyl on HD
and covering with Vanc pending final sputum speciation which was
MRSA for a 14 day course to be completed at rehab. Have
continued on Zosyn as well for concern for aspiration but this
is finished tomorrow.
.
#) Bacteremia: He also grew s. aureus in [**12-17**] bottles from
admission. This was covered by vanc which will continue for a
14 day course as outlined above.
.
#) ARF- On admission and improved with Improving. Most likely
prerenal, improved with IVF. Thought by renal to be a prerenal
physiology. Improved to baseline at time of discharge.
.
#) Hyperkalemia, pt had some peaked T waves on init, now
resolved as renal function has resolved.
.
#) Elevated CK - Had a mild rhabdo thought due to recent fall
with CK around 6000 which trended steadily down with fluids. Low
-MB index and [**Last Name (LF) **], [**First Name3 (LF) **] not thought to be of cardiac etiology.
.
#) Elevated liver enzymes- AST>ALT, has hx of hep C. LFTs
trended down. Per Dr. [**First Name (STitle) 679**] (PCP) has been elevated in past.
Recent renal u/s with fatty fibrotic liver c/w hepatitis.
.
#) Rib fracture- 9th rib. This healed steadily throught
admission. Pain meds were minimized as per MS changes (see
above).
.
#) Asthma- hx of smoking, no pft's on file. We continued
alb/atrovent nebulizers. Pt declined nicotine patch.
.
FEN: TPN as he failed a video speach and swallow eval. Per
nutrition, this can be repeated as his MS clears. He has a PICC
in place for his TPN, placed on [**1-2**] prior to transfer.
.
Prophylaxis- Pneumoboots, hep SC, protonix IV throughout
admission
.
Code- Full
.
DISP- To rehab
.
Medications on Admission:
1) Albuterol PRN
2) Hydrochlorothiazide
3) Percocet PRN
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Budesonide 0.25 mg/2 mL Solution for Nebulization Sig: Two
(2) ML Inhalation [**Hospital1 **] ().
11. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 4 days.
12. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 1 days.
13. Haloperidol 0.5-2 mg IV Q4H:PRN agitation
14. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
15. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
ETOH intoxication
Delerium Tremens
Pneumonia
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed.
.
Seek medical attention if you experience new symptoms including
seizures, shortness of breath, falls, worsening cough, etc.
.
Take all medications as prescribed.
.
Seek medical attention if you experience new symptoms including
seizures, shortness of breath, falls, worsening cough, etc.
.
Followup Instructions:
With MD at rehab, then with PCP
|
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icd9cm
|
[
[
[]
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[
"96.6",
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[
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55,753
| 142,676
|
1675
|
Discharge summary
|
report
|
Admission Date: [**2117-10-2**] Discharge Date: [**2117-10-11**]
Date of Birth: [**2037-6-14**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
shortness of breath, cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 2331**] is an 80 y.o. F s/p L total knee replacement on
[**2117-9-22**] and has been at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] (NH) since [**2117-9-26**],
presented on [**2117-10-2**] with increasing shortness of breath. She
denied chest pain, but endorsed a cough productive of green
sputum. Denied fever at nursing home. She did endorse sick
contacts at her nursing home. Sleeps in hospital bed always and
HOB is elevated. Denied any swelling in legs, but did say she
got dypenic with talking. Could not say how long these symptoms
had been going on for. Per daughter, visited [**Name (NI) **] on [**2117-10-1**] and
said "oxygen was low". Pt started on Levofloxacin 500 mg daily
on day of admission due to infiltrates on [**2117-10-1**] [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1188**]
[**Last Name (NamePattern1) **] form. Noted O2 sat 79% then increased to 4 L NC with neb
treatment --> 90% O2, back to 71% and pt was placed on 8 L NRB.
.
In the ED, initial VS: T 97.8 HR 95 BP 129/62 RR 18 94% 10 L
NRB. Pt noted to desat to 73% but up to 100% on NRB in ED.
Spiked fever of 101.2 in ED. Labs, BCx x 2, UA and urine culture
were completed. EKG, portable CXR, and CT chest were performed
significant for stomach herniated into chest without
obstruction. The patient was given Levofloxacin 750 mg IV x 1,
Furosemide 40 IV x 2 (725 cc UOP), Acetaminophen PR 650 mg x 1,
Ceftriaxone 1 gm IV x 1, and Fentanyl 25 mg IV x 1 and morphine
4 mg IV x 1 for pain. Surgery consulted for hiatal hernia.
.
In the MICU, the patient was started on levofloxacin 750 mg IV
Q48H, cefepime 1 gm IV Q24H, and vancomycin 1 gm IV Q48H. On
[**10-3**], levofloxacin was discontinued, and Flagyl 500 mg PO Q8H
was started. The patient was initially on a non-rebreather but
was eventually weaned to nasal cannula O2.
.
On arrival to the floor, the patient reported that her cough and
shortness of breath had improved. She denied chest pain or
dizziness/lightheadedness.
Past Medical History:
s/p L TKR on [**2117-9-22**]
Hiatal hernia
Coronary Artery Disease
Congestive Heart Failure, diastolic
Esophagitis
Restrictive cardiomyopathy
Restrictive lung disease
GERD
OSA
Osteoarthritis
Gout
Anemia
Colon adenomas
Spinal Stenosis
Carpal Tunnel syndrome
Chronic Renal Failure (not on dialysis)
Chronic Pain
.
s/p Appendectomy
s/p Cholecystectomy
s/p Hysterectomy
s/p Oophorectomy
s/p Uterotomy
s/p cataract extraction
Social History:
Nonsmoker, quit smoking in [**2097**], nondrinker.
Family History:
Pertinent for gastric cancer, lymphoma
Physical Exam:
Vitals - BP 104/56 HR 90 RR 17 Sat 95%/RA
GENERAL: well-appearing, elderly female in NAD, not tachypneic
HEENT: EOMI, anicteric
CARDIAC: RRR, nl S1, S2, no m/r/g
LUNG: Bibasilar rales R>L
ABDOMEN: NDNT, soft, NABS
EXT: no c/c/e
NEURO: A+O x 3
Pertinent Results:
Laboratory:
.
[**2117-10-2**] WBC-10.7 RBC-3.43* Hgb-10.0* Hct-31.1* MCV-91 MCH-29.3
MCHC-32.3 RDW-18.3* Plt Ct-583*
[**2117-10-2**] Neuts-82.8* Lymphs-11.6* Monos-5.1 Eos-0.3 Baso-0.3
[**2117-10-2**] PT-13.1 PTT-24.4 INR(PT)-1.1
[**2117-10-2**] Ret Aut-2.5
[**2117-10-2**] Glucose-138* UreaN-35* Creat-1.6* Na-130* K-5.2* Cl-89*
HCO3-30 AnGap-16
[**2117-10-5**] 06:15AM CK(CPK)-24* CK-MB-NotDone cTropnT-<0.01
[**2117-10-3**] 04:45AM CK(CPK)-57 CK-MB-NotDone cTropnT-0.01
[**2117-10-2**] 01:30PM CK(CPK)-81 CK-MB-2 cTropnT-0.02* proBNP-3628*
[**2117-10-2**] 09:10PM CK(CPK)-104 CK-MB-NotDone cTropnT-<0.01
[**2117-10-2**] 09:10PM Calcium-9.2 Phos-4.0 Mg-2.7*
[**2117-10-2**] 01:30PM Iron-51 calTIBC-335 Ferritn-166* TRF-258
[**2117-10-3**] 05:34PM TSH-2.2 Cortsol-25.7*
[**2117-10-2**] URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
[**2117-10-2**] URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD
[**2117-10-2**] URINE RBC-0-2 WBC-[**11-26**]* Bacteri-FEW Yeast-NONE Epi-0
RenalEp-0-2
[**2117-10-2**] URINE Eos-NEGATIVE
[**2117-10-2**] URINE Hours-RANDOM UreaN-330 Creat-33 Na-41
[**2117-10-4**] URINE Osmolal-435
.
Microbiology:
[**2117-10-2**] Blood cultures x 2: Pending
[**2117-10-2**] Urine culture: gram-negative rods 7000 cells/mL
[**2117-10-2**] Legionella antigen: negative
[**2117-10-2**] MRSA screen: negative
[**2117-10-3**] Expectorated sputum: Gram stain - no organisms, culture
- commensual respiratory flora (rare growth), yeast (sparse
growth)
.
Reports:
.
[**2117-10-2**] EKG: Sinus rhythm. Left anterior fascicular block.
Non-specific intraventricular conduction delay. Poor R wave
progression. Non-specific ST-T wave changes. No previous tracing
available for comparison.
.
[**2117-10-2**] CXR (portable AP): There is a large amount of abnormal
gas lucency projected over the mid left lung field extending to
the mediastinum, likely a large hiatal hernia. There is adjacent
atelectasis secondary to mass effect. The cardiac controur
appears mildly enlarged. The right lung and the left upper lobe
are well aerated without pneumothorax. No pleural effusion is
present. There is no free air seen underneath the right
hemidiaphragm. Degenerative changes are noted in the underlying
spine. The right humeral head is inferiorly positioned relative
to the glenoid, possibly due to the presence of a an effusion.
IMPRESSION: Large hiatal hernia with associated atelectasis.
.
[**2117-10-3**] CXR (Portable AP): Stable cardiomegaly and large hiatal
hernia. Improved aeration at both lung bases, and apparent
slight decrease in small left pleural effusion.
.
[**2117-10-2**] CT Chest w/o constrast: 1. Large hiatal hernia
containing nearly the entire stomach, without evidence of
obstruction. There is adjacent atelectasis in bilateral lungs;
infection within these regions would be difficult to exclude. 2.
Cannot assess for pulmonary embolism as no IV contrast was
administered.
.
[**2117-10-5**] CTA Chest: The quality of vascular contrast allows to
exclude the presence of pulmonary embolism in the main and
central pulmonary arteries. In the more peripheral parts of the
pulmonary arterial tree, the presence of PE can neither be
confirmed nor excluded. Moderate enlargement of the main
pulmonary artery, unchanged to the previous
examination. Moderate increase in size of the pre-existing
large diaphragmatic hernia. Minimal increase of the
pre-existing left lower lobe consolidation with air
bronchograms. The enhancement pattern suggests atelectasis
rather than pneumonia. Unchanged aspect of the pre-existing left
lower lung parenchymal opacity. No indication of right heart
strain. No evidence of pleural effusion. No newly occurred focal
parenchymal opacities. IMPRESSION: No evidence of central
pulmonary embolism. Minimal increase of left lower lobe
consolidation that are suggestive of atelectasis rather than
pneumonia. Minimal increase in size of the pre-existing large
hiatal hernia. Unchanged aspect of the left lung consolidation.
No newly occurred focal parenchymal opacities. No evidence of
changes in the abdomen or the skeleton.
.
[**2117-10-3**]: Bilateral lower extremity venous ultrasound: No
evidence of DVT in the bilateral lower extremities.
.
[**2117-10-4**]: Echocardiogram, transthoracic: The left atrium is
dilated. Left ventricular wall thicknesses and cavity size are
normal. The left ventricular cavity is unusually small. There is
no ventricular septal defect. The right ventricular cavity is
moderately dilated with mild global free wall hypokinesis. There
is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is severe pulmonary artery systolic hypertension. There is
no pericardial effusion. IMPRESSION: At least moderate
dilatation of the right ventricle with mild hypokinesis,
evidence of pressure/volume overload and severe pulmonary
hypertension. The left ventricle is small, due to compression by
the right ventricle. The inferior wall of the left ventricle is
also being externally compressed by the large hiatal hernia.
Regional and global LV systolic function is, however, normal.
Brief Hospital Course:
1. Pneumonia, health-care associated: The differential diagnosis
of the patient's increased oxygen requirement initially included
pneumonia given fever and productive cough, pulmonary embolism
given recent L TKR and likely immobility, congestive heart
failure exacerbation, or ischemic event. Troponin was 0.02 on
admission, and subsequently trended downward to <0.01. CXR and
CT chest showed a large hiatal hernia with associated area of
atelectasis versus consolidation. BNP was elevated at 3628.
Bilateral lower extremity ultrasounds were negative for DVT, and
CTA chest showed no evidence of central pulmonary embolism,
although the study was of poor quality and peripheral pulmonary
embolism could not be excluded. Echocardiogram showed evidence
of right-sided pressure/volume overload and compression of the
inferior wall of the left ventricle by the patient's large
hiatal hernia.
The patient was admitted to the medical intensive care unit,
where she was initially on a non-rebreather. She had
improvement in her oxygenation over the first few hours, and by
[**2117-10-4**], she was satting well on nasal cannula and was
transferred to the medical floor. The patient was treated
empirically for health-care associated pneumonia given fever,
cough, and recent hospitalization and rehab stay. Initial
antibiotics were vancomycin, levofloxacin, and cefepime.
Metronidazole was added on [**2117-10-3**], but discontinued the
following day. On the medical floor, vancomycin was
discontinued, and cefepime was changed to cefpodoxime. Sputum
culture grew only respiratory commensuals and yeast. Blood
cultures showed no growth. The patient was given an incentive
spirometer. She received albuterol and ipratropium nebs as
needed. Lasix was given as tolerated at patient's home dose.
.
2. Chest pain: The patient had an episode of chest pain on
[**2117-10-5**] that was not associated with ischemic EKG changes or
cardiac enzyme elevation. The chest pain was felt to be
secondary to the hiatal hernia and improved with IV morphine.
.
3. Congestive heart failure, diastolic: The patient was treated
with her home Lasix and isosorbide dinitrate.
.
4. HTN: The patient's blood pressure was well-controlled on
nifedipine ER. Diltiazem was restarted on the medical floor.
.
5. Hyperlipidemia: The patient continued simvastatin at her home
dose.
.
6. Gout: The patient's allopurinol dose was decreased from 200
to 100 mg daily in the setting of acute renal failure, and was
subsequently increased to 150 mg daily in the setting of
improved renal function.
.
7. Hiatal Hernia: Supposedly old from 5 years ago, but may have
some contribution to worsening dyspnea given stomach in chest.
General surgery was consulted, but the patient was not
interested in surgical intervention.
.
8. s/p L TKR: The patient's pain was treated with oxycontin, IV
morphine, and a Lidocaine patch. She received Lovenox for DVT
prophylaxis.
.
9. Hoarseness: Patient was evaluated by ENT but unable to
tolerate bedside laryngoscopy. It is recommended if this
persists that she follow up as an outpatient for further
evaluation.
.
10. Hyponatremia: The patient was initially hyponatremic, likely
secondary to her lung problems vs. pain. Serum sodium had
returned to [**Location 213**] by the time of discharge.
.
11. Acute renal failure: On admission, the patient's creatinine
was 1.6. This decreased to 0.9 by the time of discharge.
Medications were dosed accordingly throughout her stay.
.
12. Anemia: The patient presented with anemia (baseline
unknown). Her hematocrit remained stable throughout the hospital
stay. Iron studies were suggestive of anemia of chronic disease.
.
13. Spinal stenosis/chronic pain: The patient ocntinued
neurontin for her chronic pain, along with the opioids that she
received s/p TKR. The Neurontin dose was adjusted for
creatinine clearance during her stay.
Medications on Admission:
MVI 1 tab po daily
Calcium 600 / Vitamin D 400 1 tab po daily
Lovenox 40 mg SQ daily (stop [**2117-10-9**])
Colace 100 mg po BID
Senokot 2 tabs po BID
Miralax prn
Oxycodone 5 mg po q3 hours prn pain
Oxycodone 10 mg po q3 hours prn pain
Prune juice daily
Lactulose 30 cc po q6 hours prn constipation
Decubivite 1 tab po daily x 30 days until [**2117-10-28**]
Dulcolax 10 mg PR prn
Isosorbide Dinitrate 30 mg po TID
Nifedipine ER 30 mg po BID
Cardiazem CD 240 mg po daily
Furosemide 120 mg po daily at 6 AM
Furosemide 80 mg po daily at 2 PM
NTG prn
Lidoderm 5% TP
Duonebs QID prn SOB
Neurontin 800 mg po TID
Allopurinol 200 mg po daily
K-Dur 40 meq po daily
Folic acid 1 mg po daily
Simvastatin 20 mg po qhs
Omeprazole 20 mg po BID
Fluticasone Proprionate 50 mcg 2 puffs INH nasally daily
Sucralfate 1 gm po BID
Discharge Medications:
1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Adhesive Patch, Medicated(s)
2. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One (1)
Inhalation four times a day as needed for shortness of breath
or wheezing.
3. Isosorbide Dinitrate 20 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
4. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
10. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO once daily
(in the morning).
13. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO once daily
(at 2 p.m.).
14. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
15. Caltrate-600 Plus Vitamin D3 600-400 mg-unit Tablet Sig: One
(1) Tablet PO once a day.
16. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
17. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every
6 hours) as needed for cough.
18. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for Constipation.
19. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for dry skin.
20. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) injection
Subcutaneous DAILY (Daily): please continue until discontinued
by orthopedist or patient sufficiently active in rehab.
21. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
22. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
23. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
24. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
25. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
26. Oxycodone 5 mg Tablet Sig: 2-3 Tablets PO Q4H (every 4
hours) as needed for Pain: please titrate as needed.
27. Morphine Sulfate 2 mg IV Q4H:PRN pain
hold for rr<12 or oversedation, please give PO pain meds first
28. Decubi Vite Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary:
- Healthcare associated pneumonia
- Acute renal failure
Secondary:
- S/P total knee replacement
- Large para-esophageal hernia
- Coronary artery disease
- Diastolic heart failure
- Severe pulmonary artery hypertension
- GERD/Esophagitis
- Obstructive sleep apnea
- Anemia of chronic disease
- Hypertension
- Hyperlipidemia
- Osteoarthritis
- Spinal stenosis
Discharge Condition:
hemodynamically stable, satting well on room air, alert and
oriented, tolerating oral diet
Discharge Instructions:
You came to the hospital with cough and difficulty breathing and
were found to have a fever. X-ray and CT of your chest showed
pneumonia and a large hiatal hernia. You had tests for heart
attack and blood clots, which did not evidence of either. You
were admitted to the intensive care unit, where you were treated
with antibiotics and supplemental oxygen. Your breathing
improved, and you were transferred to the medical floor.
.
Your pneumonia was treated with antibiotics. You were on two
antibiotics, levofloxacin and cefpodoxime. You finished your
antibiotics on [**2117-10-11**].
.
The x-rays and CT of your chest showed a large hiatal hernia,
which is a protrusion of the stomach above the diaphragm (the
muscle that separates the chest from the abdomen). You were seen
by the surgery consult service but declined surgical
intervention. You should alert your primary care physician if
you decide to consider surgery in the future.
.
When you arrived at the hospital, you had decreased renal
function. This resolved as your clinical condition improved.
.
Please note your doses of allopurinol and gabapentin have been
changed (decreased) in accordance with your kidney function.
Please discuss resuming your prior home dose with your primary
care physician. [**Name10 (NameIs) 2351**] your stay, you did not require potassium
supplementation do your potassium supplement was discontinued.
.
You should take all of your medicines as prescribed. You should
follow up with your primary care doctor within 1 week of
discharge from rehab. Call your primary care doctor to make an
appointment.
.
You were also complaining of hoarseness. This may be related to
reflux from your known hiatal hernia. You were seen by the ear,
nose, and throat service, but you were unable to tolerate a
laryngoscopic exam. You should follow up with an ear, nose, and
throat doctor as an outpatient. You can arrange this through
your primary care physician.
.
You should also follow up with your orthopedist, Dr. [**Last Name (STitle) **],
which you have arranged for [**2117-10-14**].
.
You should return to the hospital if you develop chest pain,
worsening breathing, fever, or any symptom that is concerning to
you.
Followup Instructions:
Please schedule a follow up appointment with your primary care
doctor 1 week after discharge from rehab. Also follow up with
Ear, Nose, and Throat and orthopedics, as explained above.
You should also follow up with your orthopedist, Dr. [**Last Name (STitle) **],
which you have arranged for [**2117-10-14**].
If you decide that you would like have your hernia repaired,
please contact:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
[**First Name (Titles) 18**] [**Last Name (Titles) 9686**] Surgery
[**Location (un) 830**], [**Hospital Ward Name 23**] 9
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3020**]
|
[
"784.42",
"486",
"585.9",
"553.3",
"276.1",
"327.23",
"V43.65",
"599.0",
"274.9",
"272.4",
"285.21",
"338.29",
"584.9",
"530.81",
"425.4",
"428.0",
"403.90",
"715.90",
"428.32",
"518.89",
"724.00",
"416.8",
"530.10",
"V12.72"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16220, 16305
|
8794, 12665
|
298, 304
|
16717, 16810
|
3207, 8771
|
19069, 19743
|
2888, 2928
|
13525, 16197
|
16326, 16696
|
12691, 13502
|
16834, 19046
|
2943, 3188
|
232, 260
|
332, 2359
|
2381, 2804
|
2820, 2872
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,097
| 165,854
|
22405
|
Discharge summary
|
report
|
Admission Date: [**2180-6-29**] Discharge Date: [**2180-7-1**]
Date of Birth: [**2118-3-14**] Sex: F
Service: [**Hospital Unit Name 196**]
Allergies:
Tetanus Toxoid
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
elective right carotid stent
Major Surgical or Invasive Procedure:
Carotid Stent per CREST trial
History of Present Illness:
62 yo F w/ h/o CVA (slurred speech [**5-21**]), CEA at OSH ([**8-20**]),
HTN, IDDM w/ recent carotid duplex study done on [**2180-5-30**]
revealing a tight stenosis of R ICA 80-99% and minimal stenosis
on the Left <20%. Pt had episode of slurred speech and upper
extremetiy incoordination with b/l CVA's on MRI. Pt now reports
some neurological improvement with some mild speech difficulty
and questionable short-term memory problems. TEE w/o clot. Pt
underwent cath with successful stenting of her R ICA. Cath: 0%
residual w/ normal flow.
Past Medical History:
PVD, HTN, CVA, s/p CEA, s/p R fem-[**Doctor Last Name **]
Social History:
She lives alone. Children provide emotional support for her.
She does drink alcohol approximately "a few drinks a week" but
no more than one drink a day. She does smoke tobacco.
Family History:
Negative for stroke. Mother deceased of unclear etiology.
Father deceased of complications of diabetes and coronary
disease.
Physical Exam:
VITAL SIGNS: Blood pressure is 130/72, pulse 76, respirations
18.
HEENT: Sclerae anicteric, oropharynx without erythema.
NECK: Supple, midline trachea, right carotid bruit is
auscultated.
CARDIAC: Regular rate and rhythm; no murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses are
palpable.
NEUROLOGIC: Mental status: She is alert and oriented x3. With
NIH stroke scale card, her naming and repetition are intact,
however, with spontaneous speech, she does make occasional
paraphasic errors, and she does make paraphasic errors with
[**Location (un) 1131**] words aloud from the card. She is able to read and
write
and to distinguish left from right on herself and on the
examiner. Her attention testing as before, she is able to spell
"world" forwards appropriately but not backwards. Recall is [**12-21**]
at 3 minutes. She was able to perform calculations and follow
3-step commands. She is oriented times the month, year, her own
name, the current president, and the previous president as well
as today's date and place and floor.
Cranial nerves PERRLA, EOMI, visual fields full. V1, V2, V3
intact to light touch. Face symmetric. Hearing intact.
Oropharynx elevates symmetrically. Tongue protrudes midline.
Motor: No pronator drift. Strength is [**3-22**] throughout all 4
extremities including deltoid, biceps, triceps, wrist flexion,
wrist extension, finger flexion, grip, finger extension, hip
flexion, knee flexion, knee extension, plantar flexion,
dorsiflexion. Normal muscle tone and bulk. No tremor,
fasciculation, or atrophy observed. Sensory intact to light
touch times all 4 extremities, no sensory neglect,
proprioception
intact. Deep tendon reflexes are trace throughout downgoing
toes
bilaterally. Coordination intact finger-to-nose and
heel-to-shin. Gait was unable to be tested, as she is currently
hooked up to cardiac monitoring in the cardiology holding area,
and an IV is currently being placed.
(exam performed by Dr. [**Last Name (STitle) **]
Pertinent Results:
[**2180-6-29**] 05:44PM PT-15.4* INR(PT)-1.5
[**2180-6-29**] 08:15AM PT-18.2* INR(PT)-2.1
[**2180-6-30**] 12:50PM BLOOD WBC-12.5* RBC-4.38 Hgb-12.5 Hct-36.4
MCV-83 MCH-28.5 MCHC-34.2 RDW-13.9 Plt Ct-344
[**2180-6-30**] 12:50PM BLOOD Glucose-218* UreaN-12 Creat-0.5 Na-139
K-4.0 Cl-104 HCO3-24 AnGap-15
MRI scan of the brain, bilateral infarcts on diffusion-weighted
imaging including the right centrum semiovale, left posterior
parietal temporal region. Previous infarct left frontal
consistent with left frontal encephalomalacia and deep white
matter disease were also observed. On [**2180-5-29**], MR
angiography of the cerebral vessels was reportedly within normal
limits.
Brief Hospital Course:
62 yo Female w/ DM2, HTN, hypercholesterolemia, diffuse
vasculopathy, and h/o recent CVA admitted for elective R carotid
stent.
1. Pt underwent cath with successful stenting of her R ICA with
0% residual stenosis and normal blood flow.
Her SBP was kept above 110 during her hospital stay.
Phenylephrine was initially needed to keep her BP at goal,
however was able to be d/c'ed several hours after her procedure.
She had no evidence of vagotonia. [**Year (4 digits) **], Plavix, and lipitor
were started after the procedure. No heparin was administered.
Neuro checks were done q 4 hrs, w/o evidence of deficits. Pt
denied visual changes, lightheadedness, numbness, weakness, or
confusion. She will follow up with Drs. [**Last Name (STitle) 911**] and [**Name5 (PTitle) **] in the
next week for BP check, she will hold her outpt BP meds until
that time. She will be rechecked by Dr. [**First Name (STitle) **] in 1 month.
2. HTN. Anti-hypertensives held post procedure until follow up
with Dr. [**First Name (STitle) **] within one week. Phenylephrine given initially
as needed to keep BP > 110.
3. DM. Blood sugars well controlled on ISS. Her oral
hypoglycemics were held initially but restarted prior to
discharge.
Medications on Admission:
Actos 45 qd, Metformin 1000 mg [**Hospital1 **], Lisinopril 20 qd, Lovastatin
80 [**Last Name (LF) **], [**First Name3 (LF) **] 325, MVI, Ca, Coumadin, Lantus 60 U q pm
Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
2. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO Q DAY ().
4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
6. Insulin Glargine 100 unit/mL Solution Sig: 0.6 ml
Subcutaneous at bedtime.
7. MED CHANGE
PLEASE
STOP TAKING YOUR ZESTRIL/LINISOPRIL
STOP TAKING YOUR COUMADIN
8. Actos 45 mg Tablet Sig: One (1) Tablet PO once a day.
9. Metformin HCl 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
10. Physician #
[**First Name11 (Name Pattern1) 487**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] MD
([**Telephone/Fax (1) 7236**]
Discharge Disposition:
Home
Discharge Diagnosis:
HTN
Hypercholesteremia
DM
PVD
CVA, Bilateral
s/p cea rt
Discharge Condition:
good
Discharge Instructions:
Please call Drs. [**Last Name (STitle) 911**] [**Name5 (PTitle) **] [**Name5 (PTitle) **] if you have any
lightheadedness, change in vision or any otherr neurological
symptoms His # is ([**Telephone/Fax (1) 7236**]
Call your primary care doctor Dr. [**Last Name (STitle) 8521**] at [**Telephone/Fax (1) 54268**] if you
have fever>101, chills or feel unwell
Followup Instructions:
Please see Drs. [**Last Name (STitle) 911**] and [**Name5 (PTitle) **] this week for a blood pressure
check. His assistant will contact you. If you do not hear from
him by Wed [**7-5**] then please call him at ([**Telephone/Fax (1) 7236**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
"250.00",
"998.89",
"272.0",
"V15.82",
"443.9",
"401.9",
"438.19",
"433.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.90",
"39.50",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
6472, 6478
|
4158, 5383
|
323, 355
|
6578, 6584
|
3452, 4135
|
6990, 7362
|
1220, 1348
|
5602, 6449
|
6499, 6557
|
5409, 5579
|
6608, 6967
|
1363, 1744
|
255, 285
|
383, 925
|
1760, 3433
|
947, 1006
|
1022, 1204
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,119
| 136,906
|
14317
|
Discharge summary
|
report
|
Admission Date: [**2145-4-30**] Discharge Date: [**2145-5-5**]
Date of Birth: [**2095-1-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine / Pollen Extracts
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional chest pressure/Fatigue/Lightheadedness
Major Surgical or Invasive Procedure:
[**4-30**]: Coronary Artery Bypass Graft Surgery x
3(LIMALAD,SVG-diag,SVG-OM, resection of left atrial appendage
and MAZE procedure
History of Present Illness:
This is a 50-year-old male with a prominent family history of
coronary artery disease. He also has a history of
supraventricular tachycardia as well as paroxysmal atrial
fibrillation. Mr. [**Known lastname **] has a history of palpitations dating back
to his teenage years. He has had multiple episodes of atrial
fibrillation which have required cardioversions or treatment
with Sotalol. Recently he had complained of exertional chest
pressure and lightheadedness on a follow-up visit with Dr. [**Last Name (STitle) 7389**].
The last time he had been seen was two years prior. The chest
pain and lightheadedness beagn in early [**2144-12-18**]. A stress
test was performed which was positive and he was referred for a
cardiac catheterization. This revealed left main and severe
three vessel disease. He was referred for surgical evaluation.
Past Medical History:
Hypertension
Hyperlipidemia
Paroxysmal Atrial fibrillation
h/o pulmonary embolism
s/p Ruptured patella tendon s/p surgical repair
s/p Appendectomy
Social History:
Race: Caucasian
Last Dental Exam: Several years ago
Lives with: Wife in [**Name2 (NI) 745**], MA
Occupation: Construction/Home renovation
Tobacco: Former smoker. 15 pack year history.
ETOH: Rare use. 2 ddrinks per week.
Family History:
Father and several uncles all died of CAD in their 40's. Brother
with CABG at 53.
Physical Exam:
admission:
Pulse: 79 SR Resp: 16 O2 sat: 99% RA
B/P Right: 138/97 Left: 148/93
Height: 76" Weight: 229
General: WDWN in NAD
Skin: Dry, warm and intact
HEENT: PERRLA [X] EOMI [X] NCAT, Sclera anicteric, OP benign.
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X], I/VI Midsystolic murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: Right varicosities just below knee. Left appears
suitable.
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right: None Left: None
Pertinent Results:
[**2145-4-30**] TEE
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 (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB: On infusion of phenylephrine. Apacing. Preserved
biventricular systolic function. MR is trace. Aortic contour is
normal post decannulation.
[**2145-5-2**] 09:37AM BLOOD Hct-25.7*
[**2145-5-2**] 03:14AM BLOOD WBC-7.7 RBC-3.07* Hgb-9.1* Hct-25.6*
MCV-84 MCH-29.7 MCHC-35.6* RDW-14.2 Plt Ct-134*
[**2145-5-2**] 03:14AM BLOOD Glucose-123* UreaN-22* Creat-1.1 Na-132*
K-4.1 Cl-97 HCO3-27 AnGap-12
[**2145-5-3**] 05:55AM BLOOD WBC-7.9 RBC-3.03* Hgb-8.8* Hct-25.2*
MCV-83 MCH-28.9 MCHC-34.7 RDW-13.7 Plt Ct-156
[**2145-5-3**] 05:55AM BLOOD Glucose-108* UreaN-20 Creat-1.1 Na-133
K-4.2 Cl-97 HCO3-27 AnGap-13
[**2145-5-5**] 05:40AM BLOOD WBC-5.9 RBC-3.09* Hgb-8.9* Hct-25.7*
MCV-83 MCH-28.8 MCHC-34.6 RDW-13.8 Plt Ct-219
[**2145-5-5**] 05:40AM BLOOD PT-19.6* INR(PT)-1.8*
[**2145-5-4**] 05:17AM BLOOD PT-14.4* INR(PT)-1.3*
[**2145-5-2**] 03:14AM BLOOD PT-16.0* PTT-28.3 INR(PT)-1.4*
[**2145-4-30**] 05:11PM BLOOD PT-15.0* PTT-34.0 INR(PT)-1.3*
[**2145-4-30**] 03:31PM BLOOD PT-15.8* PTT-24.1 INR(PT)-1.4*
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
Operating Room on [**4-30**] where he underwent coronary artery bypass
graft surgery, left atrial appendage resection and MAZE. He
weaned from bypass on Neo Synephrine and was admitted to the
CVICU in stable condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. A right pleural chest tube was placed
for large pneumothorax post operative day 1 and the lung was
reexpanded after placement. This tube was removed on post
operative day 2 after water seal trial. The patient was
neurologically intact and hemodynamically stable on no inotropic
or vasopressor support having been weaned from Neo Synephrine
post operative day 1.
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 post operative day 2.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the Physical Therapy
service for assistance with strength and mobility. Oxygen
saturation on post operative day 4 was 96% on room air and 78%
with ambulation. He was diuresed aggresively and chest xray
showed only minimal atelctasis. On post operative day 5,
oxygenation had improved with ambulation. By the time of
discharge on POD 5 the patient was ambulating freely, the wounds
were healing and pain was controlled with oral analgesics. The
patient was discharged in good condition with appropriate follow
up instructions. Diuretics were continued for a week at
discharge as he remained 5 kilograms above his preoperative
weight.
Amiodarone and Coumadin were given for his paroxysmal atrial
fibrillation and will be managed by his cardiologist, Dr. [**Last Name (STitle) 7389**].
The target INR is 2-2.5 and the first outpatient blood draw will
be on [**5-7**]. VNA to call results to [**Telephone/Fax (1) 14525**] (fax
[**Telephone/Fax (1) 42487**]).
Medications on Admission:
Cardizem CD 180 mg daily
Aspirin 325 mg daily
Lisinopril 30mg daily
Lipitor 20 mg daily
SL TNG PRN
Morphine (pruritis/Rash)
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
Disp:*30 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:*2*
9. Warfarin 2.5 mg Tablet Sig: as directed Tablet PO Once Daily
at 4 PM: INR 2-2.5.
Disp:*100 Tablet(s)* Refills:*2*
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Arterty Disease
Paroxysmal Atrial Fibrillation
s/p coronary artery bypass grafts,maze, left atrial ligation
hypertension
hyperlipidemia
s/p repair patellar tendon
h/o pulmonary embolism
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ([**Telephone/Fax (1) 170**])
*take 5mg of Coumadin (2 tablets) on [**5-5**] and 20, then as
directed by Dr. [**Last Name (STitle) 7389**]*
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**6-3**] at 1:30pm
Primary Care/Cardiology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7389**] ([**Telephone/Fax (1) 14525**]) in [**12-19**]
weeks
[**Hospital Ward Name 121**] 6 wound clinic ([**Telephone/Fax (1) 3071**]in 2 weeks, your nurse [**First Name (Titles) **] [**Last Name (Titles) 10542**]e.
Labs: PT/INR for Coumadin ?????? atrial fibrillation
Goal INR: 2-2.5
First draw: [**2145-5-7**]
Results to: Dr. [**Last Name (STitle) 7389**]
phone: [**Telephone/Fax (1) 14525**] fax:[**Telephone/Fax (1) 42487**]
Completed by:[**2145-5-5**]
|
[
"E878.2",
"V45.82",
"V17.3",
"401.9",
"458.29",
"518.0",
"272.4",
"427.31",
"414.01",
"423.8",
"780.4",
"427.0",
"794.31",
"512.1",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.34",
"37.36",
"39.61",
"34.04",
"36.12",
"36.15",
"37.27"
] |
icd9pcs
|
[
[
[]
]
] |
7693, 7751
|
4182, 6199
|
342, 476
|
7990, 8089
|
2628, 4159
|
8742, 9426
|
1773, 1857
|
6375, 7670
|
7772, 7969
|
6225, 6352
|
8113, 8719
|
1872, 2609
|
252, 304
|
504, 1348
|
1370, 1519
|
1535, 1757
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,486
| 167,545
|
49207
|
Discharge summary
|
report
|
Admission Date: [**2113-7-13**] Discharge Date: [**2113-8-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
plasmapheresis
placement of right internal jugular quinton catheter
History of Present Illness:
Ms. [**Known lastname 18806**] is an 81 year-old female with generalized
myasthenia [**Last Name (un) 2902**], who presents from home with complaints of
worsening shortness of breath. She was last admitted to [**Hospital1 18**] in
[**4-/2113**] with shortness of breath and gradual decline, at which
time she was plasmapheresed. Her shortness of breath was felt to
be multifactorial, secondary to mild restrictive lung
disease/COPD, MG, and cardiac contribution with mild diastolic
dysfunction. A CTA was negative for pulmonary embolism.
*
She reports chronic shortness of breath and dyspnea on exertion,
with worsening over the past week. At baseline, she can walk
about 10 feet, and was able to only walk about [**4-1**] feet without
halting in the past week. She denies chest pain. She sleeps in a
hospital bed at home, with HOB elevated at 30 degrees or so. She
reports chronic LE edema, without significant worsening over the
past 2 weeks. Minimal activity. No cough, no fever or chills at
home. No recent travel (last flight [**3-/2113**] when flew from South
[**Doctor First Name **]).
*
She was evaluated in the pulmonary clinic yesterday, at which
time PFTs were repeated with ABG, which returned 7.44/41/56.
Plan was made to obtain an out-patient sleep study with
neuromuscular montage in [**2113-7-29**]. She was then seen today in
the neuromuscular unit, and subsequently referred to the ED for
further evaluation.
*
In ED, initial vitals T98.4, HR 88, BP 94/56, RR 21, Sat 98% on
2L NC. ABG performed 7.45/47/108 on 2L NC. A CTA was obtained,
remarkable for bilateral PEs. She was started on heparin, with a
heparin bolus at midnight. NIF checked, negative 34-44 cm H20.
Past Medical History:
1. Myasthenia [**Last Name (un) **] diagnosed in [**11-1**], status post plasma
exchange, CellCept, Mestinon and prednisone. She last had plasma
exchange in 04/[**2113**]. + AChR Ab, EMG consistent with MG.
2. Thymus resection [**2111-12-1**] with pathology consistent with
follicular B-cell hyperplasia.
3. Severe sensorimotor polyneuropathy. Work-up with unremarkable
LP [**2111**] (0W, 0R, 24 prot, 82 gluc, lyme neg, VDRL NR, negative
oligoclonal bands, cultures negative), normal SPEP/UPEP, and
normal folate. B12 borderline low.
4. Essential tremor
5. Glaucoma
6. Mild restrictive lung defect, last PFTs with FVC 0.92 (39%),
FEV1 0.63 (40%), FEV1/FVC 68 (102%). DlCo 49% in 04/[**2113**].
7. Osteoarthritis of hands bilaterally
8. Urinary incontinence9. Preserved systolic function with
EF>75% on echo 04/[**2111**].
Social History:
Widowed x 15 years, no kids. She is currently living with her
cousin in [**Name (NI) 18825**], [**State 350**]. She is retired from working as
a supervisor for an insurance company in [**Location (un) 86**]. She does not
drink alcohol or use illicit drugs. She smoked from one to one
and a half packs per day for approximately 30 years but quit 30
years ago.
Family History:
No history of myasthenia in family.
Physical Exam:
VITALS: T97.3, HR 90, BP 136/66, RR 24, Sat 100% on 4L NC.
GEN: Tachypneic, no accessory muscle use, speaks with full
sentences.
HEENT: Anicteric, MMM.
NECK: JVP approximately 4cm ASA.
RESP: Few scattered wheezes, otherwise clear to auscultation.
CVS: Frequent ectopy, normal S1 and S2 (not prominent), no S3/S4
appreciated. No murmur heard.
GI: Obese abdomen, soft, non-tender.
DRE: Performed in ED, negative guaiac.
EXT: [**3-3**] bilateral pitting lower extremity edema, symmetrical,
with mild discoloration.
NEURO: A&O X3. Complete neurological exam not performed.
*
Pertinent Results:
HCM: Not up to date with age appropriate cancer screening. No
prior colonoscopy, no prior mammogram.
*
LABS: See below.
*
EKG in ED: NSR, rate 89 bpm, borderline LAD, occasional PAC, no
ST-T changes.
*
RELEVANT IMAGING DATA:
[**2113-7-13**] CTA: There are filling defects in the right main
pulmonary artery, as well as right segmental pulmonary arteries
of the lower and upper lobes. In addition, there are filling
defects in the LUL segmental pulmonary arteries as well as the
LLL segmental arteries.
*
Brief Hospital Course:
ASSESSMENT AND PLAN: 81 year-old female with myasthenia [**Last Name (un) 2902**]
on MMF and high dose Prednisone, status post plasma exchange in
[**4-/2113**], who presents with progressive SOB, found to have
bilateral PEs on CTA.
*
1. Bilateral PEs:
Submassive, hemodynamically stable with stable saturation on low
flow oxygen. Given her poor pulmonary reserve secondary to MG
and significant lower extremity edema, pt was admitted to the
[**Hospital Unit Name 153**] for observation and serial ABGs. On arrival to the ED, her
p02 was 105, and no high flow non/interventional oxygen therapy
was required. Pt was started on a heparin gtt, which was
titrated to a goal of 60-80. Given her initation of
plasmapheresis as below for MG flare, coumadin was held pending
completion of treatments. Her LENIs were negative and no
further intervention was required. An echo was obtained which
did not show any RV strain or any clot in transit. Pt was
transferred to the floor. She was maintained on a heparin drip
while undergoing plasmapheresis and it was difficult to achieve
PTTS within the goal range of 60-100 given that her
plasmapheresis extracted 60% of her plasma coagulation proteins
daily. She had PTT checks every 4 hours and was monitored
carefully without significant bleeding. After completion of
plasmapheresis, her catheter was removed and initiation of
coumadin therapy began. Goal INR [**3-3**].
*
2) Shortness of breath/DOE:
Likely multifactorial with neuromuscular weakness secondary to
MG, obesity, emphysema, and diastolic dysfunction all
contributing, with an acute exacerbation in the setting of her
bilateral PEs. She also likely has a component of
hypoventilation during sleep, and is scheduled for a sleep study
with neuromuscular montage to be done on [**2113-8-14**], in the
[**Hospital1 18**] sleep lab. Neuromuscular consult requested the initiation
of plasmapheresis given her tenous status in their impression.
A Quinton catheter was placed and plasmapheresis was initated on
[**7-15**], with plans for 5 sessions QOD. NIFs were checked daily
with improvment from 30s to 50s. Plasmapheresis continued
without event. She was given an appointment to see Dr. [**Last Name (STitle) **] 6
weeks after discharge and recommended she continue current
immunosupression without dosing changes. She was also diuresed
for CHF and diastolic dysfunction with much improvement in
symptoms. Titrated off oxygen well to room air sats > 95%.
3) Myasthenia [**Last Name (un) 2902**]:
Continued out-patient regimen with MMF, Prednisone and Mestinon.
Plasmapheresis for treatment of her MG flare as above.
*
4) Atrial fibrillation:
Unclear if this is a new diagnosis, she was noted to have Afib
with RVR to 140s with activity. She was started on metoprolol
25mg [**Hospital1 **] with good effect, well rate controlled and directed to
continue anticoagulation.
.
5) Anemia:
Chronic due to disease and blood loss due to oozing from
pheresis catheter and frequent phlebotomy
-she was maintained on iron therapy and hcts were checked daily
.
Prophylaxis:
Bactrim prophylaxis while on high dose Prednisone and MMF
therapy. Ranitidine [**Hospital1 **] was changed to protonix given greater
safety in elderly populations, colace prn kept bowels working in
order.
*
Code: Discussed with patient and her cousin, DNR/[**Name2 (NI) 835**].
.
She was seen daily by PT with recommendation for continued care
at rehab for stregth and gait training.
Medications on Admission:
1. Prednisone 50 mg PO DAILY
2. Mycophenolate Mofetil 1000 mg PO BID
3. Furosemide 20 mg PO DAILY
4. Ranitidine HCl 150 mg PO BID
5. Calcium Carbonate 500 mg PO BID
6. Cholecalciferol (Vitamin D3) 800 units PO DAILY
7. Multivitamin 1 Cap PO DAILY
8. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
9. Pyridostigmine Bromide 30 mg PO TID
10. Bactrim DS 1 tab PO DAILY
Recently prescribed Duonebs, which she has not yet used (just
received the equipment at home).
Discharge Medications:
1. Prednisone 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Multivitamin,Tx-Minerals Tablet Sig: One (1) Cap PO DAILY
(Daily).
6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
8. Pyridostigmine Bromide 60 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: take
as directed for goal INR of [**3-3**].
Discharge Disposition:
Home With Service
Facility:
Bayada Nurses Inc
Discharge Diagnosis:
pulmonary embolism
myasthenia [**Last Name (un) 2902**] crisis
chronic obstructive pulmonary disease exacerbation
congestive heart failure diastolic failure
atrial fibrillation
anemia due to blood loss
Discharge Condition:
good, ambulating with assist, normal room air saturation
Discharge Instructions:
Take all of your medications as directed. Take your coumadin and
be sure to have your INR checked every 3-4 days until the level
is consistently [**3-3**]. Call your doctor or go to the ER if you
have trouble breathing, bleeding, or are unable to care for
yourself well.
As your INR was slightly high (4.4) on day of discharge, you
should skip your dose on [**7-31**] and resume with the newer low dose
coumadin (1mg) on [**8-1**]. You should have your doctor check your
INR in [**4-1**] days.
Followup Instructions:
See your doctors as noted below. Please call your PCP for an
appointment 1-2 weeks after discharge.
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2113-9-11**] 3:30
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3172**]/DR. [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2113-10-4**] 10:00
|
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"280.0",
"427.31",
"415.19",
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] |
icd9cm
|
[
[
[]
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[
"93.90",
"38.93",
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icd9pcs
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[
[
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265, 335
|
10055, 10114
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3931, 4437
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10138, 10634
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222, 227
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363, 2049
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2911, 3271
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,870
| 154,064
|
48807
|
Discharge summary
|
report
|
Admission Date: [**2164-12-12**] Discharge Date: [**2165-1-12**]
Date of Birth: [**2095-7-26**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Anemia
Major Surgical or Invasive Procedure:
esophagoduodenoscopy with feeding tube placement, then removal
History of Present Illness:
Mr. [**Known lastname 4020**] is a 69 y/o male with a history of cirrhosis [**1-3**]
HBV diagnosed on [**6-/2164**] who presents with a Hct of 22.9. Patient
receives large volume paracentesis weekly and was noted to have
a bloody tap on [**2164-12-12**]. He was also noted to be weak and
unsteady on his feet according to ED referral. Labs were
performed which revealed a Hct of 22.9 down from 24.7 on [**2164-12-5**].
He denied having any symptoms. He specifically denied having any
lightheadedness, chest pain, shortness of breath or abdominal
pain. He denied any hematochezia, hematuria or epistaxis. He did
have a fall approximately one week ago and sustained multiple
ecchymoses and skin abrasions, unknown head strike but denied
LOC. He did not have a medical evaluation after the fall. There
is concern that patient has been having difficulty taking care
of himself at home and is declining.
.
He also notes that his Dobhoff "broke" early this week. He is
not sure why this happenned but notes that it just fell apart.
He states that there was no plan to place another dobhoff.
According to patient he is able to eat but feeding tube was
placed because he was significantly malnourished.
.
In the ED, initial VS: 96.9 100 82/38 16 100% RA. He was given a
tetanus booster and given a dose of ceftriaxone. He had a
diagnostic tap which showed 500 WBC and 65% polys. His blood
pressure improved without intervention. He had a head CT which
was negative for an acute intracranial process.
.
On the floor, he noted that he was doing well and denied any
discomfort. He notes that he feels as if things are going well
at home and denied that he required any further assistance.
Past Medical History:
# Cirrhosis with portal hypertension/ascites/[**Location (un) **]
# HBeAG-positive HBV - Diagnosed [**6-/2164**]
# Pancreatic cyst - S/p EUS with FNA pancreatic head cyst on
[**8-/2164**] with negative cytology but Red Path testing suggestive of
mucinous cyst.
# History of at least moderate alcohol
# Hypertension
# Hyperlipidemia
#History of rectal CA (around [**2153**])- s/p resection diagnosed
approximately 10 years ago. Managed through GI at [**Hospital1 2292**]. He states he undergoes q5 year colonoscopy. Per
outside notes, his last colonoscopy was [**4-/2161**] with three polyps
(one of which was an adenoma.)
# History of SCC/BCC
# Elevated CA [**71**]-9n - 85 ([**7-/2164**])
# ECHO [**8-/2164**] notes borderline pulmonary artery systolic
hypertension
# Cholelithiasis
# OSH Chest CT [**6-/2164**] with features of bronchiectasis
Social History:
Lived with his partner [**Name (NI) **] of 40 years who is also health care
proxy. [**Name (NI) **] children. Retired patient account manager at [**Location (un) 70873**] [**Hospital3 28900**]. No needle sticks. Alcohol - not
currently drinking (last 6/[**2163**]). Hx of [**12-5**] glasses wine daily x
40 years.Born in U.S.
Family History:
Mother died of renal failure (unknown why). Paternal Aunt with
pancreatic cancer, and Maternal grandmother with pancreatic
cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp F 97.8, BP 97/52, HR 89, 95 O2-sat % RA
GENERAL - cachetic appearing but [**Date Range **] and in NAD,
appropriate
HEENT - EOMI, sclerae anicteric, MMM
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no rebound/guarding
EXTREMITIES - [**12-3**]+ pitting edema, no cyanosis or clubbing
SKIN - multiple ecchymoses noted throughout shoulder and face
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-6**] throughout, sensation grossly intact throughout
Pertinent Results:
Admission Labs:
[**2164-12-12**] 08:10PM BLOOD WBC-12.4* RBC-2.00* Hgb-7.6* Hct-22.4*
MCV-112* MCH-37.9* MCHC-34.0 RDW-16.4* Plt Ct-123*
[**2164-12-12**] 08:10PM BLOOD Neuts-83.3* Lymphs-9.6* Monos-6.2 Eos-0.6
Baso-0.3
[**2164-12-12**] 12:45PM BLOOD PT-18.8* INR(PT)-1.8*
[**2164-12-12**] 08:10PM BLOOD Glucose-158* UreaN-104* Creat-2.1*
Na-129* K-5.2* Cl-99 HCO3-18* AnGap-17
[**2164-12-12**] 08:10PM BLOOD ALT-26 AST-39 AlkPhos-95 TotBili-3.2*
[**2164-12-12**] 08:10PM BLOOD Lipase-141*
[**2164-12-12**] 03:35PM BLOOD Albumin-2.8*
[**2164-12-12**] 08:10PM BLOOD Calcium-8.7 Phos-5.7*# Mg-2.6
[**2164-12-12**] 08:19PM BLOOD Glucose-148* Na-129* K-5.1 Cl-102
calHCO3-19*
[**2164-12-12**] 08:19PM BLOOD Hgb-8.0* calcHCT-24
[**2164-12-12**] 10:50PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2164-12-12**] 10:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2164-12-12**] 10:50PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
[**2164-12-12**] 10:50PM URINE CastHy-12*
Ascites fluid:
[**2164-12-12**] 01:55PM ASCITES WBC-500* RBC-[**Numeric Identifier **]* Polys-65*
Lymphs-16* Monos-15* Eos-1* Macroph-3*
[**2164-12-21**] 12:48PM ASCITES WBC-1000* RBC-[**Numeric Identifier 102558**]* Polys-50*
Lymphs-4* Monos-12* Mesothe-2* Macroph-32*
[**2164-12-26**] 01:30PM ASCITES WBC-1250* HCT,fl-<2.0 Polys-45*
Lymphs-25* Monos-10* Mesothe-1* Macroph-19*
[**2164-12-26**] 01:30PM ASCITES Glucose-138 LD(LDH)-159
Urine:
[**2164-12-18**] 06:35PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
[**2164-12-18**] 06:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2164-12-18**] 06:35PM URINE Hours-RANDOM Na-<10 K-33 Cl-<10
[**2164-12-18**] 06:35PM URINE Osmolal-429
[**2164-12-25**] 01:40PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
[**2164-12-25**] 01:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2164-12-25**] 01:40PM URINE Hours-RANDOM UreaN-860 Creat-51 Na-LESS
THAN K-42 Cl-LESS THAN
[**2164-12-25**] 01:40PM URINE Osmolal-461
Coagulability:
[**2164-12-14**] 06:20AM BLOOD FDP-10-40*
[**2164-12-14**] 06:20AM BLOOD Fibrino-85*
[**2164-12-13**] 11:55PM BLOOD Fibrino-71*
Discharge Labs:
Microbiology:
[**2164-12-12**] PERITONEAL FLUID
GRAM STAIN (Final [**2164-12-12**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2164-12-15**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2164-12-18**]): NO GROWTH.
[**2164-12-13**] URINE CULTURE (Final [**2164-12-15**]): <10,000
organisms/ml.
[**2164-12-16**] BLOOD CULTURE - NO GROWTH
[**2164-12-17**] HBV Viral Load (Final [**2164-12-21**]): 175,000 IU/mL
[**2164-12-17**] BLOOD CULTURE - NO GROWTH
[**2164-12-21**] PERITONEAL FLUID
GRAM STAIN (Final [**2164-12-21**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2164-12-24**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2164-12-27**]): NO GROWTH.
[**2164-12-24**] BLOOD CULTURE - PENDING
[**2164-12-25**] BLOOD CULTURE - PENDING
[**2164-12-25**] 1:40 pm URINE Source: CVS.
**FINAL REPORT [**2164-12-27**]**
URINE CULTURE (Final [**2164-12-27**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
YEAST. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
[**2164-12-26**] 1:30 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final [**2164-12-26**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2164-12-29**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
[**2164-12-26**] BLOOD CULTURE - PENDING
[**2164-12-27**] BLOOD CULTURE - PENDING
[**2164-12-27**] MRSA SCREEN (Final [**2164-12-29**]): No MRSA isolated
.
Imaging:
U/S Para ([**12-12**]):
IMPRESSION: Technically successful diagnostic and therapeutic
paracentesis Preliminary Report yielding 7.5 liters of
serosanguineous ascites. Labs are pending.
.
Head CT ([**12-12**]):
IMPRESSION: No acute intracranial process.
.
CXR ([**12-13**]):
No part of the Dobbhoff tube is visible on the current image.
There is no safe evidence of rib fractures or other traumatic
changes. Normal size of the cardiac silhouette. No pleural
effusions. No pneumothorax. Normal hilar and mediastinal
contours.
.
EGD ([**12-14**]):
Impression:
- Food residue in the lower third of the esophagus
- Food in the stomach body and fundus
- Portal hypertensive gastropathy
- Mild duodenitis
- A 10 Fr [**Last Name (un) **]-jejunal feeding tube was placed successfully
using standard endoscopic technique. A 10 Fr bridle was placed
successfully using starndard technique.
- Otherwise normal EGD to jejunum
Recommendations:
- Portal hypertensive gastropathy may be the source of his
anemia.
- Start PPI 40mg [**Hospital1 **] and carafate slurry 1gram QID.
- Tubefeeds per Nutrition recommendations.
- Return to hospital floor.
.
LENI ([**12-14**]):
IMPRESSION:
1. Bilateral short segment, nonocclusive deep venous thrombosis
in the common femoral veins.
2. Nonvisualization of the popliteal veins bilaterally secondary
to overlying bandages. The superficial femoral and calf veins
are patent bilaterally.
CT Abdomen and Pelvis ([**12-24**]):
1. No perforation.
2. Moderate amount of ascites with the dependent pelvic
component being more hypodense, suggestive of blood products,
possibly from prior paracentesis.
3. New compression fracture at T12.
4. Bibasilar patchy consolidations may reflect infection or
aspiration in the right clinical setting.
5. Unchanged pancreatic cyst and cholelithiasis.
Brief Hospital Course:
Mr. [**Known lastname 4020**] was admitted with worsening liver function, and
his hospital course was complicated. He had a poor prognosis,
and multiple medical co-morbidities. On [**12-28**], while the patient
was in the MICU, a family meeting was held with the patient, his
partner, hospice, and Social Work. During this discussion it
was decided to focus on comfort measures only, given his
worsening clinical status and unlikely recovery. Following this
discussion, antibiotics and most other medications were
discontinued. Tube feeding was stopped in preference for
comfort feeding. Lab draws were stopped. Morphine was used for
pain. Ativan for anxiety. After many ungoing discussions
between the patient, his partner and proxy, and all members of
the medical team, including nursing, physicians, palliative care
and hospice, social work, and case management, the patient was
discharged to [**Location (un) 169**] with the goal of medical care to
focus on comfort.
.
The patient's prognosis is very poor, and he was discharged as
DNR/DNI with focus on comfort measures only. Medically, there
was no further indication to do anything except focus on
measures to keep Mr. [**Known lastname 4020**] [**Last Name (Titles) **]. If he returns to
the emergency room, would strongly consider a discussion with
the patient and his proxy as well as an ethics consult before
initiating aggressive measures.
Medications on Admission:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO QTHUR (every Thursday).
3. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
4. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Isosource 1.5 Cal Liquid Sig: Sixty Five (65) cc/hr PO once
a day: continuous. Flush with 30cc free water q6 hrs. .
6. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Eight
Hundred (800) mg PO once a day.
Discharge Medications:
1. white petrolatum-mineral oil Cream Sig: One (1) Appl
Topical QID (4 times a day) as needed for Dry skin.
2. lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for anxiety.
3. morphine 10 mg/5 mL Solution Sig: 5-10 mg PO Q2H as needed
for pain.
4. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-3**] Sprays Nasal
QID (4 times a day) as needed for nasal dryness.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Hospital1 8218**] - [**Location (un) **]
Discharge Diagnosis:
End stage liver disease
Cirrhosis
Hepatitis B
Anemia
Deep vein thrombosis
Hepatorenal syndrome
Spontaneous bacterial peritonitis
Urinary tract infection
Hepatic encephalopathy
Sepsis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname 4020**],
You were admitted to the hospital with worsening liver failure.
After many discussion with you, [**Doctor Last Name **], and all members of the
medical team, the decision was made to focus foremost on your
comfort. As such, you are being discharged to a facility with
hospice, with the goal of your care to be to make you as
[**Doctor Last Name **] as possible.
.
From all of us here at [**Hospital1 18**], it was a pleasure taking care of
you, and getting to know you better.
Please make the following changes to your medications:
1. Start lorazepam as needed for anxiety and shortness of
breath.
2. Start morphine as needed for pain and shortness of breath.
3. Use vaseline as needed for dry skin.
Followup Instructions:
None- you will be following with hospice
Completed by:[**2165-1-12**]
|
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icd9cm
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[]
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] |
[
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icd9pcs
|
[
[
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12687, 12788
|
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|
311, 376
|
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|
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|
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|
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8259, 10251
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13030, 13169
|
2105, 2952
|
2968, 3296
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,752
| 153,534
|
42328
|
Discharge summary
|
report
|
Admission Date: [**2165-6-20**] Discharge Date: [**2165-7-18**]
Date of Birth: [**2096-4-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Elevated WBC count, chest heaviness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr [**Known lastname 91697**] is a 69yoM with h/o t2DM, hyperlipidemia, HTN, who
presented to PCP [**Last Name (NamePattern4) **] [**2165-6-18**] with complaint of generalized
fatigue x1 month with sore throat and conjunctivitis, as well as
chest pain and dyspnea when exerting. Labs found glucose 718,
hct 28, WBC 87,000 with 13% blasts. Pt could not be reached by
phone with results, so EMS was sent to his house and had to
break a window to get in, where he was found resting comfortably
on the couch. He was brought to [**Hospital6 33**] ER. Denied
SOB, palpitations, melena, BRBPR, fevers, chills, night sweats.
He was hydrated. In S. Shore ER, WBC 42,500, hct 24.6, mcv 98,
plt 130, 10-15% blasts. He was transfused pRBCs and there is
note about planning to rule out for MI. He was transferred to
[**Hospital1 18**] for bone marrow biopsy and further care.
Past Medical History:
- t2dm on oral meds
- hyperlipidemia
- HTN
- b/l hearing loss
Social History:
lives alone. Single never married. No children. Worked in a
machine shop for 44 years. Has had exposure to aerosolized
chemicals. Came from Poland at age 16 in [**2110**]. Stopped smoking 1
month ago (40 pack year history). Enjoys coffee brandy, beer,
says he drinks more than he should. States that last drink was 1
month ago. He expressed his desire to be DNR/DNI.
Family History:
father with diabetes. Brother is next of [**Doctor First Name **].
Physical Exam:
Admission Physical Exam:
VS: T 101 P 96 BP 104/70 RR18 O2sat 97%ra
GEN: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. No cervical,
supraclavicular, or axillary LAD
Cards: RRR, no m/r/g, S1/S2 normal
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**]
sign
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs
2+ BL. sensation intact to LT, cerebellar fxn intact (FTN, HTS).
gait WNL.
ICU Admission Physical Exam:
Vitals: T: 98.1 BP: 86/50 --> 94/40 P: 109 (--> 160s, in AF) RR:
24 SpO2: 95% RA
General: Alert, oriented, no acute distress with sensation of
palpitations; very hard of hearing
HEENT: PERRL, EOMI, sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bibasilar crackles, no wheezes or rhonchi
CV: irregularly irregular, normal S1/S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: [**11-25**]+ LE edema (R slightly > L), warm, well perfused, 2+
pulses, no clubbing or cyanosis.
ICU Discharge Physical Exam:
Pertinent Results:
Admission labs
[**2165-6-20**] 04:11PM URINE MUCOUS-RARE
[**2165-6-20**] 04:11PM URINE GRANULAR-2*
[**2165-6-20**] 04:11PM URINE RBC-0 WBC-5 BACTERIA-NONE YEAST-NONE
EPI-0
[**2165-6-20**] 04:11PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2165-6-20**] 04:11PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.010
[**2165-6-20**] 05:00PM IPT-DONE
[**2165-6-20**] 05:00PM RET AUT-1.4
[**2165-6-20**] 05:00PM CD34-DONE CD3-DONE CD4-DONE CD8-DONE
[**2165-6-20**] 05:00PM CD5-DONE CD33-DONE CD41-DONE CD56-DONE
CD64-DONE CD71-DONE CD117-DONE CD45-DONE HLA-DR[**Last Name (STitle) 7735**] [**Name (STitle) 31151**]
A-DONE KAPPA-DONE CD2-DONE CD7-DONE CD10-DONE CD11c-DONE
CD13-DONE CD14-DONE CD15-DONE CD19-DONE CD20-DONE LAMBDA-DONE
[**2165-6-20**] 05:00PM FIBRINOGE-681*
[**2165-6-20**] 05:00PM PT-16.9* PTT-29.0 INR(PT)-1.5*
[**2165-6-20**] 05:00PM PLT SMR-NORMAL PLT COUNT-145*
[**2165-6-20**] 05:00PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2165-6-20**] 05:00PM I-HOS-AVAILABLE
[**2165-6-20**] 05:00PM NEUTS-2* BANDS-2 LYMPHS-17* MONOS-9 EOS-1
BASOS-0 ATYPS-3* METAS-0 MYELOS-0 OTHER-66*
[**2165-6-20**] 05:00PM WBC-60.1* RBC-3.67* HGB-11.6* HCT-33.9*
MCV-92 MCH-31.6 MCHC-34.2 RDW-15.6*
[**2165-6-20**] 05:00PM %HbA1c-11.6* eAG-286*
[**2165-6-20**] 05:00PM ALBUMIN-3.6 CALCIUM-7.9* PHOSPHATE-2.9
MAGNESIUM-1.3* URIC ACID-6.2
[**2165-6-20**] 05:00PM ALT(SGPT)-38 AST(SGOT)-29 LD(LDH)-322* ALK
PHOS-166* TOT BILI-0.4
[**2165-6-20**] 05:00PM estGFR-Using this
[**2165-6-20**] 05:00PM estGFR-Using this
[**2165-6-20**] 05:00PM GLUCOSE-222* UREA N-19 CREAT-1.0 SODIUM-141
POTASSIUM-3.3 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15
[**2165-6-20**] 08:40PM BONE MARROW [**Doctor Last Name **]-G-DONE IRON-DONE
Pathology:
[**6-20**]: Bone marrow immunophenotyping - PB: Immunophenotypic
findings consistent with involvement by acute myelogenous
leukemia with monocytic differentiation.
[**6-20**]: Bone marrow pathology: not finalized
[**6-21**]: Bone marrow cytogenetics: pending
Microbiology:
[**6-20**]: Blood culture pending
[**6-20**]: Urine culture negative
[**6-21**]: Blood culture pending
[**6-22**]: Blood culture pending
[**6-23**]: MRSA screen pending
Imaging:
TTE [**6-20**]: The left atrium is moderately dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild regional left ventricular systolic dysfunction
with distal septal, anterior and apical akinesis (distal LAD
territory). The remaining segments contract normally (LVEF =
40-45%). No masses or thrombi are seen in the left ventricle.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**11-25**]+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
CXR [**6-20**]: Heart size is normal. Widening of the azygos contour
and convexity within the aorticopulmonary window are present, as
well as apparent thickening of the posterior wall of the
bronchus intermedius on the lateral view and symmetrical
narrowing of the lower trachea on the frontal view. Lungs are
clear except for minimal linear atelectasis versus scar at the
bases. Apparent bronchial wall thickening is noted in the lower
lungs on the lateral view, and note is also made of small
pleural effusions on this projection. Skeletal structures
demonstrate mild scoliosis and degenerative changes in the
spine, as well as healed right rib fractures.
CXR [**6-21**] s/p port placement: Interval placement of a right PICC
line with the tip in the distal superior vena cava. Cardiac and
mediastinal contours are essentially unchanged although hilar
contours are slightly prominent and have previously raised the
possibility of lymphadenopathy. Correlation with more remote
chest films would be advised. In the absence of a stability or
clinical explanation for this finding, consideration should be
given to further evaluation with CT. Patchy opacity at the left
lung base may reflect an area of patchy atelectasis, although an
early pneumonia cannot be excluded. Clinical correlation
advised. No pleural effusions or pneumothoraces.
ECHO [**2165-7-15**]:
The left atrium is dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with distal
septal, anterior and apical akinesis. 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) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**11-25**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Regional LV systolic dysfunction consistent with
distal LAD ischemia/infarction. Mild to moderate mitral
regurgitation. Mild PA hypertension.
Compared with the prior study (images reviewed) of [**2165-6-24**], no
change.
[**2165-7-18**] Bone Marrow Flow Cytometry:
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: CD antigens 7,
13, 15, 33, 34, 117.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.
Cell marker analysis demonstrates that 2-4% of cells isolated
from this bone marrow express immature antigen, CD34, and
myeloid associated antigens CD33 and CD117.
INTERPRETATION
Immunophenotypic findings reveal 2-4% marrow events are CD34
positive myeloblasts. While suggestive of regeneration,
correlation with morphology (bone marrow) S11-[**Numeric Identifier 91698**] W is
recommended for definitive diagnosis.
Bone Marrow Biopsy [**2165-7-18**]
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY:
DIAGNOSIS:
Hypercellular marrow for age bone marrow with
megakaryocytosis, myeloid predominance and left shift in myeloid
lineage
Note: The findings are consistent with recovering marrow post
chemotherapy. By immunohistochemistry CD34 highlights
approximately 2-5% of blasts, while CD117 highlights
approximately 10% of blasts and promyelocytes and occasional
mast cells. CD33 staining abundant immature and mature myeloid
elements (20%). Glycophorin A stain highlights abundant
collections of erythroid precursors
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation. Erythrocytes exhibit
aniso- and poikilocytosis. Echinocytes and dacrocytes are seen.
Frequent polychromatophils are noted. The white blood cell count
appears decreased. Numerous dysplastic (monolobulated)
neutrophils with toxic granulations are present. Immature
monocytes are present. Platelet count appears increased;
multiple large and occasional giant forms are seen.
Differential count shows 55% neutrophils, 1% bands, 22 %
lymphocytes, 18% monocytes, 0% eosinophils, 0% basophils, 4%
blasts. Blasts exhibit open nuclear chromatin , 1 - 2 prominent
nucleoli and scant amount of light-blue cytoplasm.
Aspirate Smear:
The aspirate material is adequate for evaluation. However,
specimen quality appears to be compromised due to poor
preservation. The M:E ratio is 2.5:1 (normal). Erythroid
precursors are normal in normal in number with dyspoietic
maturation. Forms with asymmetric nuclear budding and irregular
nuclear contours are noted. Myeloid precursors appear normal in
number and show left-shifted maturation. Megakaryocytes are
present in increased numbers, abnormal forms are seen including
micromegakaryocytes, hypolobated and monolobated forms.
Differential (200 cells) shows: <1% Blasts, 5% Promyelocytes,
15% Myelocytes, 11% Metamyelocytes, 33% Bands/Neutrophils, 0%
Plasma cells, 10% Lymphocytes, 25% Erythroid. Rare blasts
(less than 1%) similar to the ones in the diagnostic marrow are
seen on scan.
Clot Section and Biopsy Slides:
The biopsy material is adequate for evaluation and consists of a
core biopsy specimen that measures 1.5 cm and length and
contains periosteum trabecular bone and bone marrow elements.
Bone marrow cellularity is approximately 70%. The M:E ratio
estimate is increased. Erythroid precursors are normal in
number and have normoblastic maturation. Mild dysplasia seen.
Myeloid elements are increased in number and exhibit
left-shifted maturation. Megakaryocytes are present in markedly
increased numbers, are focally loosely and tightly clustered.
Several small interstitial aggregates comprised of small
lymphocytes are present and account for less than 5% of marrow
cellularity. Marrow clot section is not submitted. Numerous
hemosiderin-laden macrophages are noted.
ADDITIONAL STUDIES:
Cytogenetics studies: See separate report.
Flow cytometry studies: See separate report.
[**2165-7-18**] Cytogenetics:
Specimen Type: BONE MARROW - CYTOGENETICS
Lab #: [**Numeric Identifier 91699**]
Date and Time Taken: [**2165-7-18**] 12:30 PM Date Processed: [**2165-7-18**]
Requesting Physician: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. Location: OUTPATIENT
KARYOTYPE: 46,XY[20]
INTERPRETATION:
No cytogenetic aberrations were identified in 20
metaphases analyzed from this unstimulated specimen.
This normal result does not exclude a neoplastic
proliferation.
Mosaicism and small chromosome anomalies may not be
detectable using the standard methods employed.
-------------------INTERPHASE FISH ANALYSIS, 100-300
CELLS-------------------
nuc ish(D5S23,D5S721,EGR1)x2,(D7Z1,D7S522)x2,
(D20S108x2)[100]
FISH evaluation for a 5q deletion was performed with the
Vysis LSI EGR1/D5S23, D5S721 Dual Color Probe ([**Doctor Last Name 7594**]
Molecular) for EGR1 at 5q31 and D5S721/D5S23 at 5p15.2 and
is interpreted as NORMAL. Two EGR1 hybridization signals
were observed in 97/100 nuclei examined, which is within
the normal range established for this probe in the
Cytogenetics Laboratory at [**Hospital1 18**]. Up to 3% of cells in
normal samples can show apparent 5q deletion using this
probe set. A normal EGR1 FISH finding can result from
absence of a 5q deletion, from a 5q deletion that does not
involve the region to which this probe hybridizes, or from
an insufficient number of neoplastic cells in the specimen.
FISH evaluation for a 7q deletion was performed with the
Vysis D7S522/CEP7 Dual Color Probe ([**Doctor Last Name 7594**] Molecular) for
D7S522 at 7q31 and CEP7 (D7Z1) (chromosome 7 alpha
satellite DNA) at 7p11.1-q11.1 and is interpreted as
NORMAL. Two D7S522 hybridization signals were observed in
99/100 nuclei, which is within the normal range
established for this probe in the Cytogenetics Laboratory
at [**Hospital1 18**]. Up to 3% of cells in normal samples can show
apparent 7q deletion using this probe set. A normal
D7S522 FISH finding can result from the absence of a 7q
deletion, from a 7q deletion that does not involve the
region to which this probe hybridizes, or from an
insufficient number of neoplastic cells in the specimen.
FISH evaluation for a 20q deletion was performed with the
Vysis LSI D20S108 Probe ([**Doctor Last Name 7594**] Molecular) at 20q12 and is
interpreted as NORMAL. Two hybridization signals were
observed in 95/100 nuclei examined, which is within the
normal range established for this probe in the Cytogenetics
Laboratory at [**Hospital1 18**]. Up to 8% of cells in normal samples
can show apparent 20q deletion using this probe set. A
normal 20q FISH finding can result from absence of a 20q
deletion, from a 20q deletion that does not involve the
region to which this probe hybridizes, or from an
insufficient number of neoplastic cells in the specimen.
This test was developed and its performance
determined by the [**Hospital1 18**] Cytogenetics Laboratory
as required by the CLIA '[**41**] regulations. It has not
been cleared or approved by the U.S. Food and Drug
Administration. This test is used for clinical
purposes.
The D5S23/D5S721 probe
The EGR1 probe
The D7S522 probe
The D7Z1 probe
The D20S108 probe
Discharge labs:
[**2165-7-18**] 06:15
COMPLETE BLOOD COUNT
White Blood Cells 3.9* 4.0 - 11.0 K/uL
Red Blood Cells 3.24* 4.6 - 6.2 m/uL
Hemoglobin 9.5* 14.0 - 18.0 g/dL
Hematocrit 27.1* 40 - 52 %
MCV 84 82 - 98 fL
MCH 29.3 27 - 32 pg
MCHC 35.0 31 - 35 %
RDW 15.2 10.5 - 15.5 %
DIFFERENTIAL
Neutrophils 44* 50 - 70 %
Bands 2 0 - 5 %
Lymphocytes 24 18 - 42 %
Monocytes 23* 2 - 11 %
Eosinophils 0 0 - 4 %
Basophils 0 0 - 2 %
Atypical Lymphocytes 0 0 - 0 %
Metamyelocytes 2* 0 - 0 %
Myelocytes 4* 0 - 0 %
Blasts 1* 0 - 0 %
RED CELL MORPHOLOGY
Hypochromia 1+
Anisocytosis OCCASIONAL
Poikilocytosis OCCASIONAL
Macrocytes NORMAL
Microcytes 1+
Polychromasia NORMAL
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Smear VERY HIGH
Platelet Count 687* 150 - 440 K/uL
MISCELLANEOUS HEMATOLOGY
Granulocyte Count [**2181**]* 2200 - 8250 #/uL
[**2165-7-18**] 06:15
RENAL & GLUCOSE
Glucose 84 70 - 100 mg/dL
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
Urea Nitrogen 9 6 - 20 mg/dL
Creatinine 0.5 0.5 - 1.2 mg/dL
Sodium 143 133 - 145 mEq/L
Potassium 4.2 3.3 - 5.1 mEq/L
Chloride 106 96 - 108 mEq/L
Bicarbonate 29 22 - 32 mEq/L
Anion Gap 12 8 - 20 mEq/L
ENZYMES & BILIRUBIN
Alanine Aminotransferase (ALT) 28 0 - 40 IU/L
Asparate Aminotransferase (AST) 17 0 - 40 IU/L
Lactate Dehydrogenase (LD) 175 94 - 250 IU/L
Alkaline Phosphatase 239* 40 - 130 IU/L
Bilirubin, Total 0.2 0 - 1.5 mg/dL
CHEMISTRY
Calcium, Total 8.9 8.4 - 10.3 mg/dL
Phosphate 3.2 2.7 - 4.5 mg/dL
Magnesium 1.8 1.6 - 2.6 mg/dL
Brief Hospital Course:
Mr [**Known lastname 91697**] is a 69yoM with h/o t2DM, hyperlipidemia, HTN, who
presented to PCP [**Last Name (NamePattern4) **] [**2165-6-18**] with complaint of generalized
fatigue x1 month with sore throat and conjunctivitis, as well as
chest pain and dyspnea when exerting, diagnosed with new-onset
AML. Admission c/b ICU transfer for afib with RVR in setting of
idarubicin treatment and hypotension s/p beta blocker.
# Newly diagnosed AML: blast count was as high as 80k at
presentation. Was started on hydroxurea, allopurinol, and
bicarb-[**Doctor First Name **] IVF, with a subsequent drop in WBC. Blast count was
as high as 60%. Although there was concern that starting
induction therapy may be risky for his heart, given low EF (see
below), cardiology was consulted and it was felt that the risk
of not treating AML was greater than the potentially cardiac
toxicity. He was started on 7+3 induction therapy
(cytarabine/idarubicin) on [**6-22**]. This was held on [**6-23**] due to
possible cardiac toxicity (see below), but then restarted on [**6-24**]
and completed without further event. Repeat bone marrow biopsy
was performed on [**2165-7-15**] (report attached). Repeat echo on
[**2165-7-15**] showed unchanged LVEF.
#Febrile Neutropenia: spiked to 102.1 on admission ([**6-20**]).
Source is unknown. He did have sore throat and conjunctivitis as
that time which was thought could be viral. More likely is
related to his AML. No source of infection was identified, but
because of persistent febrile neutropenia, he was started on
cefepime, vancomycin, and micafungin. Patient's fever came
down, but on the morning of HD6, he became febrile again to
100.6. He had been noted to have expanding erythema at a site
where his IV had infiltrated, and there was suspicion of
cellulitis/phlebitis at that site. Otherwise, patient received
blood cultures and urine cultures that were all negative. As
the patient was already broadly covered, his antibiotics were
not changed. The fever trended down by itself over the next
day. Following chemotherapy, as his counts approached nadir, he
developed low grade fevers less than 100 F, but CT chest showed
only resolving cryptogenic organising pneumonia. His fevers
resolved and he remained covered with broad spectrum antibiotics
until the end of his hospitalization.
#Atrial Fibrillation: On [**6-23**], the patient was transferred to
the ICU for afib with RVR, possibly secondary to volume overload
vs. anthracycline toxicity vs. electrolyte abnormalities, as
well as hypotension, which resulted from attempted rate control
with beta blocker. In the [**Hospital Unit Name 153**], the patient spontaneously
converted back into NSR and was started on oral metoprolol
tartrate 25mg PO bid. He was closely monitored for hemodyamic
stability through 4 days of idarubicin administration without
cardiac events. He remained in sinus rhythm for the rest of his
hospitalization.
# CHF - TTE on [**6-20**] showed EF 40-45% with anterior wall motion
dyskinesis. Given risk of anthracyclin cardiac toxicity,
cardiology was consulted and felt that chemo was still necessary
at this time, although with increased heart risk. They also felt
that he probably had an MI about 1 month ago. Pt developed chest
pain on [**6-21**], with unchanged EKG and troponin that stayed flat
at 0.05. He was fairly aggressively given bicarb [**Doctor First Name **] IVF in
preparation for chemo, and did 3rd space some fluid into his
lungs but as of [**6-22**] was saturating in high 90's on room air. He
was transfused pRBCs to keep hct >28. Serial TTEs were
performed to monitor for deterioration of cardiac function while
on idarubicin. TTE on [**6-24**] was unchanged from [**6-20**]. Patient
reported throughout admission that he has SOB when lying flat
and that his legs were swollen. On exam, he had decreased lung
sounds in lower lobes bilaterally. He was frequently diuresed
throughout the day with IV Lasix 20mg and kept at a fluid
balance of -500cc. Following transfer to the floor from the ICU,
he had no further problems with dyspnea. Repeat TTE on [**2165-7-15**]
showed an unchanged LVEF and no new abnormalities since
pre-chemo.
#Anemia: Hct was 24 on admission. Patient??????s Hct kept trending
down with no obvious source of blood loss and no evidence of
hemolysis. There is an expected pancyotpenia [**12-26**] chemo, however
twice he had had an abrupt drop that may be in excess of that
expected. Patient denied GI bleeding, but later mentioned that
he had had several episodes of black-colored diarrhea that he
did not mention to medical staff. His hemolysis labs were
negative. He was transfused 2U of blood of [**6-25**] and 2U of blood
on [**6-27**]. During the [**6-25**] transfusion, patient complained of
dyspnea after the first unit of pRBCs and was found to have
congestion CXR, consistent with either pulmonary edema or TRALI.
Blood bank was contact[**Name (NI) **] 2 days later about suspicion of TRALI,
however his symptoms resolved. He received further transfusions
of blood and platelets as required without further event.
# Diabetes: Blood sugar at outside hospital <700, HgbA1c 11.6%.
[**Last Name (un) **] Endocrine was consulted, and started on RISS and standing
lantus, with improvement in blood sugars. His lantus was
downtitrated throughout admission and his ISS was changed to
humalog. He was transitioned to po glimeperide for discharge.
Medications on Admission:
- lisinopril 20mg PO daily
- pravastatin 20mg PO daily (pt does not take this)
- erythromycin eye ointment since [**6-18**] for conjunctivitis
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. glimepiride 2 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
3. fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
5. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Myeloid Leukemia
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname 91697**],
It was a pleasure taking care of you at [**Hospital1 18**].
You were admitted to the hospital because you were found to have
leukemia. You were started on chemotherapy to treat this
leukemia. When chemotherapy was started, you developed an
abnormal heart rhythm. We started you on treatment for this,
but your blood pressure dropped and you were transferred to the
ICU. However, your blood pressure and heart rhythm normalized
spontaneously without additional treatment and we transferred
you back to the [**Hospital1 **] to complete your chemotherapy. You
completed your chemotherapy without any additional problems.
During your hospitalization you also had fevers. We treated you
with antibiotics and your fevers resolved.
Please take the following medications following discharge:
-METOPROLOL. Please take 25mg twice daily.
-GLIMEPIRIDE. Please take 2mg twice daily.
-FLUCONAZOLE. Please take 200mg once daily.
-ACYCLOVIR. Please take one 400mg tablet every 8 hours.
-BACTRIM. Please take one single strength tablet daily.
Please followup with Dr. [**Last Name (STitle) **] for further treatment for your
leukemia, see below.
Followup Instructions:
When: Monday [**2165-7-22**] am.
DIABETES
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**], [**MD Number(3) 22775**]: [**Hospital **] Clinic
One [**Last Name (un) **] Place
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
Department: HEMATOLOGY/BMT
When: THURSDAY [**2165-7-25**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: THURSDAY [**2165-7-25**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], NP [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2165-7-30**]
|
[
"373.2",
"414.01",
"425.4",
"V49.86",
"401.9",
"205.00",
"486",
"288.00",
"692.9",
"272.4",
"372.30",
"E933.1",
"428.0",
"427.31",
"250.00",
"277.88",
"780.61",
"428.22",
"284.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.04",
"99.62",
"99.25",
"38.97",
"41.31"
] |
icd9pcs
|
[
[
[]
]
] |
23187, 23193
|
17033, 22470
|
340, 346
|
23280, 23280
|
3068, 15525
|
24635, 25601
|
1726, 1794
|
22663, 23164
|
23214, 23259
|
22496, 22640
|
23431, 24612
|
15541, 17010
|
2406, 3022
|
265, 302
|
374, 1240
|
23295, 23407
|
1262, 1325
|
1342, 1710
|
3049, 3049
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,872
| 145,799
|
49057
|
Discharge summary
|
report
|
Admission Date: [**2187-8-31**] Discharge Date: [**2187-9-5**]
Service: [**Hospital Unit Name 196**]
Allergies:
Coumadin
Attending:[**First Name3 (LF) 2074**]
Chief Complaint:
falls
Major Surgical or Invasive Procedure:
[**Company 1543**] Dual Chamber Pacemaker placement (A-V sequential
pacer)
History of Present Illness:
Mr. [**Known lastname **] is a [**Age over 90 **] yo male transferred from the MICU, with
PMH AF, RVR, HTN, hyperchol, CAD with fixed LAD stenosis,
diastolic dysfunction, and h/o CVA and GIB on Coumadin. Pt
presented [**8-28**] - [**8-29**] with afib RVR with hypotension that
responded to IVF and rate control with beta blocker. After
being dc'd home he returned after afalling at home. In ED, he
had intermittent PAF with rate up to 140's. ADmitting to floor
medical team with increased rate control. The next AM he was
found to be tachypnic and diaphoretic by RN. RA sats were 39%,
then 70% on NRB. Tachy at 110, hypertensive intitially
150s/100s, then dropped to SBP 80s with increased HR to
140-150s. EKG revealed AFib RVR. ABG at the time revealed
increase A:a gradiet. Presumed pulmonary edema d/t afib RVR and
diastolic dysfuction. IN MICU, pt was diuresed with Lasix, rate
controlled with metoprolo x 1, spontaneously converted to NSR
and then had episodes of bradycardia to 29 without change in
blood pressure. Also has had 2.6 sec conversion pause from AF
converting to NSR. Pt has been NSR x 24 hours with BP
controlled.
Past Medical History:
Hypertension
Coronary artery disease
Cerebellar CVA
Peptic ulcer disease
Chronic obstructive pulmonary disease
Social History:
Lives at home alone in [**Location (un) **]. Denies any current tobacco or
alcohol use. Has a neice who lives nearby who helps out
occasionally with shopping.
Family History:
Non-contributory
Physical Exam:
VS: 97.9, 126/40, 76, 94%RA, 16
Gen: pleasant elderly man, very hard of hearing, up in chair,
nad
HEENT: anicteric, MMM< no jvd, jvp ~8cm, no carotic bruits, +
hematoma on right neck
CV: RR, nl s1 s2, quite, I/VI systolic mumur, no r/g, radial and
dp 2+/2+
Abd: s/nt/nd/nabs/no bruit
Ext: warm, dry skin
Neuro: CN II-[**Doctor First Name 81**] intact, 5/5 strength in upper and lower
extremities, sensation intact to pinprick throughout, no saddle
aneasthesia, good rectal tone
Access: PIV bilaterally UE
Skin: eccymosis on LUE
Pertinent Results:
[**2187-8-30**] 11:05PM NEUTS-74.9* LYMPHS-16.9* MONOS-5.8 EOS-2.0
BASOS-0.4
[**2187-8-30**] 11:05PM WBC-6.4 RBC-3.99* HGB-13.2* HCT-36.4* MCV-91
MCH-33.1* MCHC-36.4* RDW-12.1
[**2187-8-30**] 11:05PM CALCIUM-8.4 PHOSPHATE-2.8 MAGNESIUM-1.8
[**2187-8-30**] 11:05PM GLUCOSE-124* UREA N-23* CREAT-0.9 SODIUM-133
POTASSIUM-4.9 CHLORIDE-97 TOTAL CO2-24 ANION GAP-17
[**2187-8-31**] 02:00AM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2187-8-31**] 06:51AM TYPE-ART PO2-57* PCO2-74* PH-7.16* TOTAL
CO2-28 BASE XS--4
[**2187-8-31**] 09:27AM TSH-3.0
Echo: [**8-29**]: The left atrium is markedly dilated. The right
atrium is moderately dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Left ventricular systolic
function is probably normal but views are technically
suboptimal. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are mildly thickened. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the report of the prior study (tape unavailable
for review) of [**2184-12-7**], there is no definite change.
ELECTROCARDIOGRAM PERFORMED ON: [**2187-8-27**]
Atrial fibrillation with a rapid ventricular response. Left
bundle-branch
block. Since the previous tracing of [**2184-12-1**] sinus rhythm has
been replaced by
atrial fibrillation.
ELECTROCARDIOGRAM PERFORMED ON: [**2187-9-3**]
Sinus rhythm
Conduction defect of LBBB type
Since last ECG, anterior T wave inversion is gone
MRI/MRA:
Subacute infarction in the distribution of the right and middle
cerebral artery.
Occluded right vertebral artery. No evidence of abnormality in
the right middle cerebral artery distribution, although exam is
somewhat limited as discussed above.
Carotid U/S:
Findings as stated above which indicate an approximately 40 to
59% right ICA stenosis, no significant left ICA stenosis (graded
as less than
40%).
Brief Hospital Course:
Mr. [**Known lastname **] is an independently living [**Age over 90 **]yo male with A Fib
with rapid ventricular response (RVR), HTN, hyperchol, CAD with
fixed LAD stenosis, diastolic dysfunction, h/o CVA, and H.
Pylori gastric ulcer GI bleed on Coumadin ([**2180**]). Pt presented
[**8-28**] - [**8-29**] with AFib RVR with hypotension that responded to IVF
and rate control with beta blocker. After being discharged home
he returned [**8-30**] after falling at home. He was found to be in
afib and admitted to medicine, but had pulmonary edema from
rapid rate and diastolic dysfunction and sent to the MICU. There
he had elevated troponins to a peak of 0.07 and T-wave
inversions in leads V2-V4, suggesting ischemia. He has known
reversible defects in his anterior and apical walls in [**2181**]. In
the MICU, he was diuresed with Lasix, rate controlled with
metoprolol x 1, and spontaneously converted to NSR. He had
episodes of bradycardia to 29 and a 2.6 sec conversion pause
from AFib converting to NSR. Pt was transferred to the
cardiology floor for AFib control and evaluation for cardiac
cath and pacer placement. Pt had two subsequent episodes of
AFib with RVR converting to NSR with IV metoprolol x 1.
Additionally, he had 4 seconds of asystole which spontaneously
converted to sinus without symtoms. Pt refused catheterization,
and initially refused pacer placement. However, after some
thought he agreed and had a [**Company **] dual chamber pacemaker
(A-V sequential pacemaker) placed on [**9-4**] without complication.
Pt remained in NSR with a rate of 70 with his pacer. Pt was
started on Sotalol.
Pt's hosptial course was complicated by a TIA on [**9-2**]. His TIA
was thought to be embolic, involving his right MCA territory
with subsequent left limb weakness, neglect, and dysarthria.
His symptoms resolved completely within 12 hours. The source of
his embolism was likely his left atrium, given his paroxysmal
conversion between AFib RVR and tachy/brady sinus rhthym. Pt
has a history of GI bleed d/t H. Pylori gastric ulcer in [**2180**] on
Coumadin, but his H. Pylori was treated appropriately. The
contraindication to anticoagulation in this pt is his risk of
fall. He will be anticoagulated with Heparin/Coumadin while at
rehab, with the understanding that Coumadin will be discontinued
when the patient returns home after rehab given his significant
risk of fall.
The etiology of his falls are likely multifactorial in origin.
Per neurology, it seems pt has some signs of early Parkinsons,
with decreased proprioception in his feet. Also, his conversion
pauses between AFib RVR and NSR could also be owing to his
falls.
Health care proxy is [**Name (NI) 2411**] [**Name (NI) 20562**] [**Telephone/Fax (1) 102953**] (niece).
FULL CODE
Medications on Admission:
Meds in MICU:
Metoprolol
Lasix
Captopril
Lipitor
Famotidine
Bowel regimen
Tylenol
ASA
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
[**Company 1543**] Dual Chamber Pacemaker placement (A-V sequential
pacer)
Transient Ischemic Attack
Atrial Fibrillation with Rapid Ventricular Response
Tachy-Brady Syndrome
Discharge Condition:
Pt was in good to fair condition, with normal and stable vital
signs, a stable hematocrit, full strength in all extremities,
and clear mentation.
Discharge Instructions:
Please call your doctor or return to the hospital if you
experience falls, chest pain, shortness of breath, fever,
weakness, change in mental status, visual changes, weakness in
your limbs, bright red blood in your stool, dark tarry stool, or
other source of bleeding.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2187-9-11**] 5:00
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2187-9-12**] 11:00
|
[
"401.9",
"272.0",
"435.9",
"410.71",
"428.33",
"428.0",
"V58.61",
"427.81",
"496",
"414.01",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.72",
"37.83"
] |
icd9pcs
|
[
[
[]
]
] |
7525, 7596
|
4609, 7389
|
241, 318
|
7814, 7961
|
2402, 4586
|
8279, 8655
|
1821, 1839
|
7617, 7793
|
7415, 7502
|
7985, 8256
|
1854, 2383
|
196, 203
|
346, 1493
|
1515, 1627
|
1643, 1805
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,730
| 111,965
|
9665+56056
|
Discharge summary
|
report+addendum
|
Admission Date: [**2158-7-24**] Discharge Date: [**2158-7-31**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 13159**]
Chief Complaint:
Gastrointestinal bleeding
Major Surgical or Invasive Procedure:
[**2158-7-24**] EGD with clipping of blood vessel
History of Present Illness:
[**Age over 90 **] yo admitted to [**Hospital1 **] [**Location (un) 620**] with cholangitis s/p ERCP with
sphincterotomy, brushings and double pigtail biliary stent
placement on [**2158-7-21**] at [**Hospital1 18**]. Gastric biopsies were also taken
given presence of duodenal ulcers/ erosions. Patient
subsequently developed melanotic stool, HCT dropped from 26.7;
she has received 4 units of prbc's at OSH. Transferred to [**Hospital1 **]
for possible EGD.
On arrival to the MICU, patient's VS 98.7, 84, 146/51, 23, 99%
RA. Patient reported feeling well, but tired. Denied N/V,
fever, sweats, chills. Last BM day prior to arrival.
Past Medical History:
History of C. diff
[**2158-6-4**] -- outside hospitalization for LLL PNA and R leg
cellulitis, CHF, and AMI -- no further details are available
Hypertension
History of breast cancer 27 yrs ago s/p mastectomy
Left cerebellopontine angle hemorrhage in [**2152**] with chronic
small vessel ischemic disease in brain
osteoporosis
Raynaud's syndrome
History of thoracic compression fractures
Social History:
Lives with son and husband. Daughter lives 1 mile away and
patient often walks to visit her without assisted device. Never
smoked or drank per daughter. Was a homemaker and prior to that
was a secretary.
Family History:
No stroke history.
Physical Exam:
Vitals: 98.7, 84, 146/51, 23, 99% RA
General: Alert, oriented, no acute distress, frail appearing,
cachectic
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, systolic ejection
murmur, no rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 4/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
[**2158-7-24**] 08:00PM GLUCOSE-94 UREA N-23* CREAT-0.4 SODIUM-146*
POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-31 ANION GAP-9
[**2158-7-24**] 08:00PM estGFR-Using this
[**2158-7-24**] 08:00PM ALT(SGPT)-84* AST(SGOT)-52* LD(LDH)-193 ALK
PHOS-413* TOT BILI-1.3
[**2158-7-24**] 08:00PM ALBUMIN-2.8* CALCIUM-7.9* PHOSPHATE-2.4*
MAGNESIUM-1.9
[**2158-7-24**] 08:00PM WBC-8.2 RBC-3.88* HGB-11.5* HCT-33.8* MCV-87#
MCH-29.6 MCHC-34.0 RDW-16.3*
[**2158-7-24**] 08:00PM HYPOCHROM-OCCASIONAL ANISOCYT-1+
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL
[**2158-7-24**] 08:00PM PLT COUNT-130*
[**2158-7-24**] 08:00PM PT-11.2 PTT-24.4* INR(PT)-1.0
[**2158-7-30**] 08:20AM BLOOD WBC-8.6 RBC-3.54* Hgb-10.8* Hct-33.1*
MCV-93 MCH-30.6 MCHC-32.8 RDW-16.2* Plt Ct-231
[**2158-7-31**] 07:10AM BLOOD WBC-7.4 RBC-3.44* Hgb-10.3* Hct-32.7*
MCV-95 MCH-29.8 MCHC-31.3 RDW-16.1* Plt Ct-247
[**2158-7-30**] 08:20AM BLOOD Neuts-50.8 Lymphs-6.0* Monos-2.6
Eos-40.4* Baso-0.2
[**2158-7-31**] 07:10AM BLOOD Neuts-48.2* Lymphs-8.3* Monos-3.3
Eos-40.0* Baso-0.3
[**2158-7-31**] 07:10AM BLOOD Glucose-97 UreaN-12 Creat-0.5 Na-139
K-3.8 Cl-102 HCO3-32 AnGap-9
[**2158-7-31**] 07:10AM BLOOD ALT-86* AST-60* LD(LDH)-191 AlkPhos-530*
TotBili-0.7
[**2158-7-30**] 08:20AM BLOOD ALT-106* AST-104* LD(LDH)-222
AlkPhos-519* TotBili-1.2
[**2158-7-30**] 08:20AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.9
[**2158-7-30**] 01:00PM BLOOD STRONGYLOIDES ANTIBODY,IGG-PND
[**2158-7-30**] 01:00PM BLOOD ECHINOCOCCUS ANTIBODY (IGG)-PND
Brief Hospital Course:
[**Age over 90 **] yo admitted to [**Hospital1 **] [**Location (un) 620**] with cholangitis s/p ERCP with
sphincterotomy, brushings and double pigtail biliary stent
placement on [**2158-7-21**] at [**Hospital 18**] transferred to ICU for EGD in
setting of GI bleed.
.
GI BLEED: Patient is s/p ERCP with sphincterotomy for
cholangitis. She developed melena with a HCT drop from mid 30's
to 27 on [**7-22**]. She received 4 units prbcs and has been
hemodynamically stable. Transferred to [**Hospital1 18**] for urgent EGD,
since etiology likely upper GI source given melena and recent
ERCP including biopsy site. Differential includes lower GI
bleed (diverticulosis, AVM, cancer), however unlikely given
recent procedure and likely no need for further workup at this
point. EGD showed a superficial vessel that was not bleeding
and no bleeding at stomach biopsy site. Patient was treated
with IV protonix drip. Her hematocrit drifted down slowly after
the procedure but stabilized at about 29-30. She remained
hemodynamically stable. Her diet was advanced and her proton
pump inhibitor was transitioned to oral. The biopsies from her
initial endoscopy showed "Oxyntic mucosa, within normal limits;
no histologic evidence of H. pylori infection" and the brushings
"NEGATIVE FOR MALIGNANT CELLS." Gastroenterology recommend she
take omeprazole 40mg PO bid for 8 weeks (from [**2158-7-28**]) then
transition to 40mg PO daily. She was restarted on aspirin 7
days after ERCP per GI recommendation. She has follow-up
scheduled with them for repeat ERCP and stent removal in [**Month (only) 359**]
as noted elsewhere.
.
Cholangitis: Diagnosed at outside hospital, s/p ERCP with
sphincterotomy. Diagnosed at [**Hospital3 4107**]. Patient started
on Vancomycin and Zosyn at [**Hospital1 **] on [**7-19**] and changed to Unasyn
on [**7-23**]. Transitioned to Ciprofloxacin 500 mg PO BID to
complete total of 14 days antibiotics (finish [**2158-8-2**]).
.
Eosinophilia: The patient had normal eosinophil count on [**7-20**]
when admitted to [**Hospital1 **] [**Location (un) 620**]. Since that time eosinophils have
trended up daily to peak of 40% of differential (absolute number
3400) on [**7-30**]. They were stable as percentage 40% with improved
absolute number 2900 on [**7-31**]. Most likely this is due to the
beta lactam antibiotics she was taking from [**7-20**] to [**7-27**] (Zosyn
from [**Date range (1) 32684**] and then unasyn from [**2069-7-21**]). She did not have
other findings of allergic reaction such as a rash. Other
potential etiologies were considered such as parasitic diseases
(strongyloidis, echinococcus, toxoplasma serology were sent and
pending at discharge) but are very low likelihood. The degree of
eosinophilia is moderate and there does not appear to be end
organ damage with normal creatinine and urine eosinophils and
normal troponin. She was evaluated by the allergy immunology
service (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 32685**]) who recommended weekly CBC with
differential to trend continued improvement although it may take
up to four weeks to normalize. If she continues to have a
persistent eosoniphilia in one month then she should follow up
with allergy-immunology. Of note, while low dose steroids can be
used to treat eosinophilia, we would recommend against using
steroids at this time, as the patient's comorbidities and
improving eosinophilia increase the risks over the benefits of
this treatment.
.
Delirium: During hospitalization patient experienced delirium
for 1-2 days, mostly at night. Extensive evaluation was
performed to determine the etiology of this and other than her
age, lack of sleep and medical comorbidities as mentioned above,
none was found. She was initally treated with scheduled
quetiapine at bedtime to both prevent confusion and facilitate
sleep but her QTc on this medication (and concomitant
ciprofloxacin) was ~480, so it was stopped. Her delirium
resolved on [**2158-7-29**] and she was at her baseline mental status
per family.
.
Other inactive issues:
HTN -- held home HCTZ, restarted on discharge
CAD -- s/p MI, held ASA for 7 days post ERCP and in setting of
GIB but restarted after discussion with GI. Atorvastatin was
held in the setting of elevated liver enzymes and may be
re-started in the future, she was continued on metoprolol
.
.
TRANSITIONAL ISSUES:
1. Recheck CBC weekly with differential to trend eosinophilia.
REsuls can be faxed to PCP (Dr. [**Last Name (STitle) 4390**] office fax:
[**Telephone/Fax (1) 18820**]
2. Follow up on ERCP in six weeks
3. Consider restart statin pending improvement in liver function
tests
Medications on Admission:
Medications On Transfer:
1. She received potassium 10 mEq IV today.
2. Unasyn 1 1.5 g every 6 hours IV.
3. Lopressor 25 mg p.o. b.i.d.
4. Nexium 80 mg IV every 10 hours.
5. Senna 2 tablets p.o. daily.
6. Colace 100 mg p.o. b.i.d.
Preadmission medications listed are correct and complete.
Information was obtained from Admission note.
1. Aspirin 81 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO 2X/WEEK (MO,TH)
3. Metoprolol Tartrate 25 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
Discharge Medications:
1. Metoprolol Tartrate 25 mg PO BID
hold for SBP<100, HR<60
2. Nystatin Oral Suspension 5 mL PO QID Duration: 7 Days
Swish and spit for oral thrush.
3. Hydrochlorothiazide 12.5 mg PO 2X/WEEK (MO,TH)
4. Omeprazole 40 mg PO BID
Continue this for 8 weeks from [**2158-7-28**], then you can transition
to 40mg PO daily.
5. Aspirin 81 mg PO DAILY
6. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*5 Tablet Refills:*0
7. Docusate Sodium 100 mg PO BID
8. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Gastrointestinal bleeding
Cholangitis
History of C diff
Coronary artery disease
Hypertension
Recent pneumonia
H/o Br CA [**72**] yrs ago s/p mastectomy
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 diagnosed with cholangitis and had an endoscopy to
treat this. Soon thereafter you began to have melena (dark
black stools that indicate gastrointestinal bleeding), and so
you received blood transfusions, and a repeat endoscopy, at
which time a blood vessel in your stomach was "clipped" to
prevent it from bleeding. You were monitored after this
procedure, to ensure that you had stopped bleeding. You also
had some confusion in the hospital, which was attributed to your
fatigue and medical illnesses.
You were found to have a high number of eosinophils on your
white blood cell count. This is likely due to one of the
antibiotics you were taking (zosyn or unasyn). You were seen by
the allergy immunology service. Your numbers were stable to
improving at time of discharge. This lab test will be followed
weekly while at you are at rehab.
Followup Instructions:
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: FRIDAY [**2158-8-4**] at 12:00 PM
With: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: ENDO SUITES
When: FRIDAY [**2158-9-15**] at 9:30 AM
Department: DIGESTIVE DISEASE CENTER
When: FRIDAY [**2158-9-15**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
Name: [**Known lastname 5678**],[**Known firstname 1194**] Unit No: [**Numeric Identifier 5679**]
Admission Date: [**2158-7-24**] Discharge Date: [**2158-7-31**]
Date of Birth: [**2064-11-3**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 5680**]
Addendum:
In the hospital course, please change delirium to acute
delirium.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1502**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 546**] MD [**MD Number(2) 5681**]
Completed by:[**2158-9-27**]
|
[
"576.1",
"998.11",
"112.0",
"414.01",
"V49.86",
"V10.3",
"293.0",
"532.90",
"288.3",
"733.00",
"412",
"781.0",
"V12.54",
"E879.8",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
12343, 12623
|
3938, 7998
|
286, 337
|
9985, 9985
|
2405, 3915
|
11047, 12320
|
1654, 1674
|
9135, 9672
|
9810, 9964
|
8624, 8624
|
10168, 11024
|
1689, 2386
|
8325, 8598
|
221, 248
|
365, 1003
|
8015, 8304
|
10000, 10144
|
8650, 9112
|
1025, 1413
|
1429, 1638
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,904
| 168,867
|
2627
|
Discharge summary
|
report
|
Admission Date: [**2180-8-26**] Discharge Date: [**2180-9-6**]
Date of Birth: [**2104-1-23**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
76 year old male with h/o dementia and schizophrenia presents
with hypotension in setting of decreased PO intake. Patient has
experienced a decline in mental status over last 5-10 years with
prior episodes of wandering. Over last 8 days patient has
started having decreased PO intake of food and fluids. Patient
was recently hospitalized from [**8-22**] - [**8-25**] for failure to
thrive. Following discharge patient was noted to have poor PO
intake. [**Name (NI) **] wife also reports that he appeared to have
some trouble breathing along with a chronic dry cough which has
not worsened in severity. Patient at times endorses pain, but
has not been able to localize the pain at any point and does not
give a consistent history of having any pain. Home VNA evaluated
the patient today and found him to be hypotensive and febrile.
EMS was subsequently called and the patient was transported by
ambulance to the ED.
In the ED, initial VS were: HR67 BP88/53 RR16 98% 4L Nasal
Cannula Temp 101.8 (rectal)
Patient triggered upon arrival to the ED for hypotension. He
received a UA which was questionable for UTI with 13 WBC,
Moderate Leuks, negative nitrites and negative bacteria. CXR
shows interval development of pulmonary edema and concern for
left lower lobe pneumonia vs atelectasis.
Patient received 5L IV fluids and was started on empiric broad
spectrum antibiotics including vanc, cefepime and levofloxacin.
In spite of fluid resuscitation the patient remained
hypotensive. A right IJ line was placed and the patient was
started on Levophed.
While in the ED the patient experienced an episode of
bradycardia to 38bpm, he subsequently received an EKG which
showed bradycardia to 48, diffuse TWF.
On arrival to the MICU, Patient was on pressors, alert but
agitated. Saturating well on O2 by nasal canula.
Past Medical History:
- Schizophrenia: history of paranoia and delusions, previously
treated with Seroquel, but this was discontinued due to
somnolence
- Dementia
Social History:
Lives with Son and wife. [**Name (NI) **] been declining for at least the
past 5-10 years. Previously worked as [**Location (un) 86**] police officer
- Tobacco: none
- Alcohol: none
- Illicits: none
Family History:
[**Name (NI) **] wife is unaware of any family history of heritable
illness.
Physical Exam:
ADMISSION EXAM
VITALS: T 97.8 HR 93 RR 33 O2 Sat 95% BP 135/90 (on norepi
.1mcg/kg/min)
General: laying in bed, appears agitated, answers questions and
follows commands intermittently
HEENT: dry oral mucosa, poor dentition.
Neck: supple, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, severe onychomycosis of all toe nails
Neuro: PERRL, alert but completely disoriented, intermittently
answers questions and mutters, moves all extremities.
Discharge PE:
VS: T 98.6 BP 116-126/64-88 HR 74-89 RR 18-20 O2 96-98%RA
24 I/O: 3BMs, Inc UOP / NR PO
8 I/O: 1BM, Inc UOP / NR PO
General: Alert, oriented x2 (self and year), NAD, resting
comfortably in bed
HEENT: Sclera anicteric
Lungs: Anteriorly clear, with some crackles at Left base, poor
inspiratory effort, pt cannot sit up
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, Nontender, Nondistended, +BS
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+
pedal edema.
Pertinent Results:
ADMISSION LABS
[**2180-8-25**] 05:00AM BLOOD WBC-3.1* RBC-2.81* Hgb-11.8* Hct-31.8*
MCV-113* MCH-41.8* MCHC-37.0* RDW-15.7* Plt Ct-149*
[**2180-8-26**] 01:00PM BLOOD Neuts-62 Bands-1 Lymphs-22 Monos-14*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2180-8-26**] 01:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL
[**2180-8-29**] 06:24AM BLOOD PT-13.2* PTT-33.7 INR(PT)-1.2*
[**2180-8-25**] 05:00AM BLOOD Glucose-89 UreaN-16 Creat-0.8 Na-135
K-4.1 Cl-104 HCO3-23 AnGap-12
[**2180-8-27**] 06:48PM BLOOD CK(CPK)-387*
[**2180-8-29**] 06:24AM BLOOD ALT-45* AST-37 AlkPhos-55 TotBili-0.7
[**2180-8-25**] 05:00AM BLOOD Calcium-7.6* Phos-1.9* Mg-2.0
PERTINENT LABS AND STUDIES
[**2180-8-27**] 02:52AM BLOOD CK-MB-4 cTropnT-<0.01
[**2180-8-27**] 06:48PM BLOOD CK-MB-2 cTropnT-<0.01
[**2180-8-28**] 03:15AM BLOOD CK-MB-2 cTropnT-<0.01
[**2180-8-26**] 03:45PM BLOOD HBsAg-NEGATIVE
[**2180-8-26**] 03:45PM BLOOD HIV Ab-NEGATIVE
[**2180-8-27**] 03:07AM BLOOD Type-[**Last Name (un) **] Temp-37.3 O2 Flow-4 pO2-37*
pCO2-31* pH-7.40 calTCO2-20* Base XS--3 Intubat-NOT INTUBA
[**2180-8-26**] 01:43PM BLOOD Lactate-2.0
[**2180-8-27**] 03:07AM BLOOD Lactate-0.9
CXR [**2180-8-26**]
1. Pulmonary edema, new since [**2180-8-22**]. Mild cardiomegaly.
2. Left lung base consolidation, may represent atelectasis or
infection in the appropriate clinical setting. Follow-up to
resolution.
ECHO [**2180-8-28**]
The left atrium is mildly 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) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. No mass
or vegetation is seen on the mitral valve. The estimated
pulmonary artery systolic pressure is normal. No vegetation/mass
is seen on the pulmonic valve. There is no pericardial effusion.
MICRO
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
STAPHYLOCOCCUS EPIDERMIDIS
| | |
CLINDAMYCIN-----------<=0.25 S <=0.25 S R
ERYTHROMYCIN---------- =>8 R <=0.25 S =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S <=0.5 S
LEVOFLOXACIN----------<=0.12 S 0.25 S <=0.12 S
OXACILLIN-------------<=0.25 S <=0.25 S =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S <=1 S 2 S
VANCOMYCIN------------ <=0.5 S 1 S 2 S
URINE CULTURE (Final [**2180-8-26**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH
SKIN
AND/OR GENITAL CONTAMINATION.
DISCHARGE LABD AND STUDIES:
[**2180-9-5**] 10:20AM BLOOD WBC-7.7 RBC-3.33* Hgb-12.3* Hct-38.1*
MCV-114* MCH-36.9* MCHC-32.3 RDW-15.2 Plt Ct-621*
[**2180-9-5**] 07:35AM BLOOD Glucose-68* UreaN-7 Creat-0.8 Na-135
K-5.4* Cl-103 HCO3-22 AnGap-15
[**2180-9-5**] 07:35AM BLOOD Calcium-7.9* Phos-3.2 Mg-2.3
Brief Hospital Course:
Mr. [**Known lastname 1744**] is 76M with h/o dementia and schizophrenia found to
have coag negative staph bacteremia course c/b HCAP.
ACUTE CARE
# Staph bacteremia: The patient was found to have coag negative
Staph bacteremia, as well as urinary tract infection. He had
recently been hospitalized (discharged just the day prior to
admission) so possible that the source of bacteria is
iatrogenic. On arrival to the ED, a RIJ was placed and the
patient was started on vasopressors because he was hypotensive.
He was empirically treated with vancomycin, cefepime, and later,
Flagyl was started for aspiration PNA coverage (see below). The
patient was initially admitted to the MICU where he was
maintained on vasopressors. A TTE showed no signs of vegetation.
The patient was taken off vasopressors on [**2180-8-30**] and called out
to the floor.
On the floor, the patient was seen by the infectious disease
team who recommended completing a course of antibiotics for
pneumonia (as discussed below) in the hospital and then
switching to oral [**Date Range 11958**] on discharge to complete 4 week
total [**Last Name (un) 10128**] of antibiotics for his bacteremia. The patient was
transitioned to oral [**Last Name (un) 11958**] on [**2180-9-3**] without further event
and will continue [**Date Range **] for three weeks total (END DATE
[**2180-9-24**]). His surveillance blood cultures remained negative and
he was discharged to rehab. The patient should have weekly CBCs
drawn and faxed to Dr. [**First Name (STitle) **] [**Name (STitle) **] at [**Telephone/Fax (1) 1419**].
# Pneumonia: The patient was found to have left lower lobe
infiltrate in the setting of fever and hypotension concerning
for pneumonia, possibly secondary to aspiration. Due to the
patient's very poor dentition, he did meet criteria for
treatment with antibiotics, and was thus treated with Flagyl.
Attempts were made to obtain a Panorex however the patient could
not stand and this was not completed. He was treated with an
8-day course of vanc/cefepime/flagyl. He was then started on a 3
week course of [**Last Name (LF) **], [**First Name3 (LF) **] ID recs. At discharge, his O2 Sat
was 95-96% on RA.
CHRONIC CARE
# B12 Deficiency Anemia: The patient has with known history of
B12 deficiency on recent admission with continued macrocytic
anemia. He was started initially on PO repletion in house, and
was later transitioned to IM B12 injections -> regimen will be
daily injections for one week, weekly injections for one month,
then monthly injections indefinitely after that, as outlined in
his Page 1.
# Bradycardia: Pt had a few brief episodes of bradycardia to
high 30s/low 40s while sleeping, other vital signs normal. EKG
showed prolonged PR interval, consistent with previous EKG
(180-200ms).
# Dementia/Schizophrenia: The patient oriented to himself
primarily during this hospitalization, but as per his family
members, this has been his baseline mental status.
# PO Intake: There was concern that patient's pneumonia could be
related to aspiration events. Speech and swallow evaluated the
patient and recommendation for thin liquids and soft solid diet
were made.
Transitional Issues:
# Code: The patient was DNR/DNI while in house.
- The patient will have to continue [**First Name3 (LF) 11958**] to complete a
4-week course. The patient will follow with the infectious
disease clinic. END date on PO [**First Name3 (LF) 11958**] is [**2180-9-24**]. The
patient should have weekly CBCs drawn and faxed to Dr. [**First Name (STitle) **]
[**Name (STitle) **] at [**Telephone/Fax (1) 1419**]. He has outpatient ID follow up scheduled
for him.
- B12 deficiency: Started on Vitamin B12 injections for anemia
and low B12 levels. Take daily for 1 week ([**2180-9-4**] - [**2180-9-11**]).
Then take weekly for 1 month ([**2180-9-11**] - [**2180-10-12**]). Then take
monthly on an ongoing basis, stop only if instrcuted by your PCP
or other healthcare provider.
- Our speech and swallow specialists felt that there was some
increased risk of aspiration and recommended thin liquids, and
moist, ground solids.
Medications on Admission:
1. Donepezil 5 mg PO HS
2. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1
capsule(s) by mouth Daily Disp #*30 Capsule Refills:*0
3. Cyanocobalamin 250 mcg PO DAILY
Discharge Medications:
1. Donepezil 5 mg PO HS
2. [**Month/Day/Year **] 600 mg PO Q12H
3. Outpatient Lab Work
Please check CBC weekly and fax to [**Telephone/Fax (1) 1419**], ATTN [**Name6 (MD) **]
[**Name8 (MD) **], MD MPH
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Cyanocobalamin 1000 mcg IM/SC DAILY b12 deficiency, anemia
Duration: 1 Weeks
Start [**2180-9-4**], end [**2180-9-11**]
6. Cyanocobalamin 1000 mcg IM/SC 1X/WEEK (MO) b12 deficiency,
anemia Duration: 1 Months
Start [**2180-9-11**], end [**2180-10-12**]
7. Cyanocobalamin 1000 mcg IM/SC QMON b12 deficiency, anemia
Start [**2180-10-12**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**]
Discharge Diagnosis:
primary diagnosis:
Staph bacteremia
pneumonia
secondary diagnosis:
dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**]!
You were admitted due to low blood pressures and were found to
have both a pneumonia and an infection in your blood. You were
initially cared for in the intensive care unit and improved on
antibiotics. You completed your course of antibiotics without
any problems. [**Name (NI) **] are now ready for discharge to an extended
care facility to complete rehabilitation and an extended
antibiotic course.
New Medications:
START [**Name (NI) **] 600 mg by mouth twice daily for three weeks (END
DATE [**2180-9-24**]). Take this medication by crushing it and mixing
with chocolate pudding or applesauce.
START Vitamin B12 1000 mcg intramuscularly for one week daily
(END DATE [**2180-9-11**])
START Vitamin B12 1000 mcg intramuscularly once per week for
four weeks (START [**2180-9-11**], END [**2180-10-12**])
START Vitamin B12 1000 mcg intramuscularly once per month
STOP Vitamin B12 pills by mouth
See below for instructions regarding follow-up care.
Followup Instructions:
Department: GERONTOLOGY
When: TUESDAY [**2180-9-5**] at 1:30 PM
With: [**Name6 (MD) 13202**] [**Name8 (MD) 13203**], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: THURSDAY [**2180-10-5**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2180-9-6**]
|
[
"295.30",
"507.0",
"038.19",
"266.2",
"294.20",
"V49.87",
"427.89",
"599.0",
"110.1",
"785.52",
"995.92",
"V49.86",
"349.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
12422, 12521
|
7440, 10603
|
315, 322
|
12642, 12642
|
3906, 7417
|
13817, 14465
|
2561, 2639
|
11815, 12399
|
12542, 12542
|
11573, 11792
|
12778, 13794
|
2654, 3362
|
10624, 11547
|
3376, 3887
|
264, 277
|
350, 2164
|
12610, 12621
|
12561, 12589
|
12657, 12754
|
2186, 2329
|
2345, 2545
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,226
| 102,417
|
39922
|
Discharge summary
|
report
|
Admission Date: [**2105-11-21**] Discharge Date: [**2105-12-11**]
Date of Birth: [**2053-3-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 87792**] is a 52 year old gentleman with a pmh of DMII,
CRI, multiple neck abscesses, and traumatic brain injuries (SDH)
of unknown etiology who presents after a seizure and fall from
bed at his nursing home.
.
Mr [**Known lastname 87792**] is a Haitian earthquake survivor, who originally
presented to his dentist in [**Country 2045**] with a tooth abscess. He had
the wound opened and required skin grafting for healing. He was
found to have multiple abscesses in his neck. The abscesses
were opened, and after the earthquake he was transferred to an
airport that had been set-up as a health care facility. He
developed a stage IV decubitus ulcer on her coccyx as well as
around his penis from an indwelling catheter. He also was unable
to swallow so a PEG was placed.
.
He was transferred to [**Location (un) 2848**], for better care since [**Country 2045**] did not
have adequate resources. He was stabilized and transferred to a
NH in the [**Location (un) 86**] area in [**Month (only) 205**]. He was progressing and improving,
however he had multiple falls that were not told to the family,
and he developed a foot drop on Friday. In the past few weeks
he was more lethargic than usual. On [**11-20**] he was observed
having a tremor w/ teeth gringding, lasting several minutes.
When EMS arrived he was observed twisting on the right side. At
OSH he was loaded w/ dilantin, treated for hyperkalemia (5.9),
and treated w/ unasyn with concern for aspiration pneumonia.
When head CT and MRI showed small SAH (left parietal) and
subdural hematoma (left frontal, parietal, bilat occipital) he
was transferred to [**Hospital1 18**].
Past Medical History:
DM type 2
CRI (w/ hx hyperkalemia)
anemia
s/p I and D of Left neck abscess
multiple UTI's
Decubitus ulcer
chronic brain injury of unknown nature
G-tube placement (for malnutrition)
Social History:
Patient is a surviver of the Haitian earthquake, who was
transferred to [**Location (un) 2848**] for management of his multiple medical
problems. [**Name (NI) **] was living in a nursing home in Mass prior to
admission.
Family History:
HTN, DMII
Physical Exam:
Admission Exam:
Vitals: T:97.9/97.7 BP:118/75 (108-124/58-86) P: 68 (68-76) R:16
O2:100% on RA
General: Alert,lying in bed in no acute distress, cacchectic
HEENT: Sclera anicteric
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Normal rate and regular rhythm, normal S1 + S2, II/VI SEM
murmur at the RUSB, no rubs or gallops
Abdomen: soft, non-tender, PEG tube in place with dressing C/D/I
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses in radials and DPs
bilaterally, no clubbing, cyanosis or edema
Skin: warm, dry
Neuro: Moving all four extremities in bed, but unable to assess
strength this am
Pertinent Results:
[**2105-11-21**] 10:26PM BLOOD WBC-10.5 RBC-2.86* Hgb-8.6* Hct-25.9*
MCV-91 MCH-30.2 MCHC-33.2 RDW-15.7* Plt Ct-330
[**2105-11-21**] 10:26PM BLOOD PT-12.8 PTT-26.5 INR(PT)-1.1
[**2105-11-21**] 10:26PM BLOOD Plt Ct-330
[**2105-11-22**] 06:19AM BLOOD Ret Aut-0.7*
[**2105-11-21**] 10:26PM BLOOD Glucose-88 UreaN-43* Creat-2.0* Na-147*
K-4.3 Cl-113* HCO3-24 AnGap-14
[**2105-11-23**] 09:00AM BLOOD Glucose-124* UreaN-34* Creat-1.8* Na-142
K-4.8 Cl-112* HCO3-21* AnGap-14
[**2105-11-21**] 10:26PM BLOOD ALT-47* AST-32 LD(LDH)-209 AlkPhos-292*
TotBili-0.3
[**2105-12-10**] 05:55AM BLOOD ALT-85* AST-59* AlkPhos-329* TotBili-0.1
[**2105-11-22**] 06:19AM BLOOD CK(CPK)-136
[**2105-11-23**] 09:00AM BLOOD CK(CPK)-110
[**2105-11-21**] 10:26PM BLOOD cTropnT-0.19*
[**2105-11-22**] 06:19AM BLOOD CK-MB-6 cTropnT-0.17*
[**2105-11-23**] 09:00AM BLOOD CK-MB-4 cTropnT-0.15*
[**2105-11-22**] 06:19AM BLOOD calTIBC-203* Ferritn-573* TRF-156*
[**2105-11-22**] 06:39AM BLOOD %HbA1c-6.2* eAG-131*
[**2105-11-22**] 06:19AM BLOOD TSH-1.6
.
[**2105-12-8**] C. Diff toxin negative
.
Imaging:
NON-CONTRAST HEAD CT, WITH MULTIPLANAR REFORMATS.
There is hyperdense thickening of the falx to the left of
midline, compatible with a thin subdural hematoma, measuring no
more than 3 mm. Equivocal slightly larger idodense component is
also noted, measuring up to 4 mm (2a:22). There is no further
subdural collection identified. There is no subarachnoid,
intraparenchymal or intraventricular blood identified. There is
no parenchymal edema or mass effect. Ventricles and sulci are
prominent, compatible with atrophy, and there are
periventricular white matter hypodensities, compatible with
sequelae of chronic small vessel ischemic disease. The
[**Doctor Last Name 352**]-white matter differentiation is otherwise preserved,
without CT evidence of acute territorial infarction. The
visualized bones are free of fracture. There is scattered
opacification of the mastoid air cells, and mucosal thickening
in the left ethmoids. Remainder of the paranasal sinuses are
clear. The extracranial soft tissues, including the globes and
orbits, are unremarkable.
IMPRESSION:
1. Thickening of the falx, compatible with a subdural hematoma.
A thin
hyperdense component measures no more than 3 mm, with a possible
slightly
larger isodense component also noted, as above. No further
intracranial
hemorrhage is identified.
2. Global atrophy and sequelae of chronic small vessel ischemic
disease are noted.
Comparison with prior imaging reportedly performed at an outside
hospital
would be helpful for evaluation of stability of these findings.
EEG [**11-25**]:
IMPRESSION: This in an abnormal continuous EEG due to the
presence of
frequent brief periods of rhythmic delta activity occurring
maximally
over the bifrontal regions seen more frequently during sleep.
This
pattern is most consistent with FIRDA which is consistent with a
mild
to moderate diffuse encephalopathy or a deep midline structural
defect.
However, given the reduction in frequency and duration of these
events
after the administration of antiepileptic medication yesterday,
these
events could also represent atypical frontal lobe seizures.
EEG [**11-26**]:
IMPRESSION: This in an abnormal modified EEG telemetry due to
the
presence of frequent brief periods of rhythmic delta activity
occuring
maximally over the bifrontal regions. This pattern is most
consistent
with FIRDA which is consistent with a mild to moderate diffuse
encephalopathy or a deep midline structural defect. However,
these may
also represent atypical frontal lobe seizures. While a
comparison with
the previous tracing is limited given that the patient remains
mostly
awake, these periods of rhythmic delta activity appear to be
less
frequent than in the previous tracing.
Liver US [**12-8**]:
IMPRESSION: No focal liver lesion or biliary dilatation seen.
Cholelithiasis
with no sign of cholecystitis. Scant trace of ascites.
CXR [**12-8**]:
SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: The cardiomediastinal
contour is
normal. The heart is not enlarged. Lung volumes are somewhat
low,
accentuating perihilar vascular crowding. Left upper lobe
consolidation is
slightly more prominent. There is no pleural effusion. The bony
thorax is
unremarkable.
IMPRESSION: Left upper lobe consolidation somewhat more
prominent
URINE CULTURE (Final [**2105-12-7**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| PROTEUS MIRABILIS
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- =>32 R <=2 S
CEFAZOLIN------------- <=4 S 8 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- =>4 R 1 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- 64 I <=4 S
TOBRAMYCIN------------ =>16 R <=1 S
TRIMETHOPRIM/SULFA---- 2 S <=1 S
[**2105-12-10**] 05:55AM BLOOD ALT-85* AST-59* AlkPhos-329* TotBili-0.1
[**2105-11-27**] 01:28PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 Polys-0
Lymphs-87 Monos-13
[**2105-11-27**] 01:28PM CEREBROSPINAL FLUID (CSF) TotProt-29 Glucose-69
All CSF cultures were negative for growth and cytology did not
reveal any malignant cells
Brief Hospital Course:
52 year old gentleman with a pmh of DMII, CRI, multiple neck
abscesses, and traumatic brain injuries (SDH) of unknown
etiology who presents after a seizure and fall from bed at his
nursing home.
#Neuro/Mental status changes: Pt was intially admitted to
neurosurgery and it was felt that no surgical intervention was
indicated. Serial head CTs showed stable SDHs. Seizures were
thought most likely related to multiple SDH/trauma. MRI was
obtained to evaluate vasculature for aneurysm given concern for
SAH on CT. Prior images were uploaded for comparison. Pt was
initially started on phenytoin 100mg TID for seizure ppx and
dose was later increased to 200mg PO TID after EEG raised
concern for frontal seizures. An MRI was performed to further
characterize ICH and the previously seen subtle signal
abnormality in the frontal cortical region on diffusion images
was confirmed to be artifactual. Pt was found to have a
persistent encephalopathy and an LP was performed which was
negative (cultures, smear & cytology). Pt has had an early
onset dementia of unclear etiology for the last year and MRI
showed global atrophy and ventricles enlarged out of proportion
to global atrophy. Pt was evaluated for possible NPH, however a
large volume tap was unsuccessful. In the setting of multiple
SDHs, UTI, seizures and renal insufficiency, neuro team
recommended that a dementia work up should be postponed until
medically stable and recovered from multiple SDHs. Pt will
require cognitive neurology outpatient evaluation at [**Hospital1 18**],
number [**Telephone/Fax (1) 50382**].
.
# Acute Change in Mental Status: Pt was transfered to Medicine
around [**11-27**] at which time he was not responding to commands.
The patients Dilantin was titrated down and he was given 1pRBC
for persistent anemia. Hypernatremia (hypovolemic in nature)
was corrected by increasing his free water boluses and IVF. Pt
was found to have a UTI that was treated with Ceftriaxone.
Encephalopathy improved after these interventions. Given the
persistent transaminitis on dilantin, pt was transitioned to
Keppra 500mg [**Hospital1 **] for seizure prophylaxis. Pt was also started
on seroquel qhs for intermittent agitation and by the time of
discharge, he was responded to questions with one word answers,
naming common objects and tolerating some oral diet.
# Chronic renal insufficiency: Stable creatinine of 1.8-2.1
while an inpatient. Urine lytes showed a FeNa of 3.9%, suspected
to be from diabetic nephropathy, apparently diagnosed back in
[**Country 2045**].
# Anemia: Likely secondary to chronic renal insufficiency and
ACD. Iron level was normal, ferritin was high, TIBC was low.
Reticulocyte count was low.
# DMII: Newly diagnosed in [**Month (only) 956**] according to his sister. Hgb
A1c was 6.2. Pt was on lantus and sliding scale insulin at
home. He had hypoglycemia while in house initially and as intake
improved, his blood sugars became more stable.
# Sacral decubitus ulcer stage II: This was noted on admission
and wound care was consulted. Pt was treated with barrier
dressing, regular position changes and nutrition support with
TFs. Ulcer was healing well.
# Iatrogenic hypospadias: Urology was consulted for urethral
erosion [**3-10**] chronic indwelling foley catheter, needed to heal
sacral decub ulcers (stage IV). Family members, were [**Name2 (NI) 87793**]
about the procedure and decision to follow-up in [**Hospital 159**] clinic
to discuss the need for a suprapubic catheter (SPC) was made.
Given improved mental status in [**12-16**] and healing penile ulcer,
a voiding trial was attempted which was successful. However, a
condom catheter was applied for incontinence and risk of
contaminating sacral decub. Urology follow up was scheduled for
ongoing management of this issue.
# UTI: Urine Cx grew Klebsiella resistant to Cipro/Unasy and
pansensitive Proteus mirabilis. Pt. was treated with
ceftriaxone IV starting on [**2105-12-4**] and was written to complete
a 10 day course given the indwelling cath/condom cath.
# Transaminitis. Mild on arrival w/ elevated AP and nl Bili.
RUQ US was negative, Hepatitis serologies were negative,
including Hep BsAb, for which he will require immunization. Hep
C was negative. Hep A Ab was positive. The LFT abnormalities
were thought possibly due to dilantin which was discontinued on
[**12-8**]. LFTs should be followed up on [**2105-12-21**].
# Hypothermia episode. Pt. was triggered for an episode of
hypothermia to [**Age over 90 **]F and infectious w/u revealed an aspiration
PNA. Pt was empirically treated with Ceftriaxone/Flagy (started
on [**2105-12-8**]), IVF and warming blanket. Hemodynamics normalized
after 6 hrs of treatment and there were no further episodes of
hypothermia. He was treated for presumed aspiration PNA x 7
days (last day [**2105-12-15**])
# Loose stools. Onset after TF restarted. C.Diff negative x 2
as were common stool cultures, O/P. Amylase/Lipase were normal.
Atrributed due to osmotic load from TF, may need readjustment
while at [**Hospital1 1501**].
Medications on Admission:
Omeprazole 20mg PO daily
Colace 100mg [**Hospital1 **] via G-tube
Lantus 8 units SC daily
Novolin R insulin sliding scale
Heparin 5000 units SC TID
Remeron 15mg PO QHS
Seroquel 75mg PO QHS
Discharge Medications:
1. Lantus
8 units injected subcutaneously once a day in the morning
2. Novolin R insulin
Please take according to your sliding scale
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) 5000
units Injection TID (3 times a day). 5000 units
4. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. epoetin alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
6. quetiapine 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime): give at 6pm daily please .
7. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID PRN () as
needed for agitation.
8. levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
9. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): Day 1 = [**2105-12-8**], total of 8 days, last day
[**2105-12-15**].
10. ceftriaxone 1 gram Piggyback Sig: One (1) gram Intravenous
once a day for 3 days: Day 1 = [**12-4**]
Duration 10 days
Last day [**12-14**].
11. Outpatient Lab Work
Please perform CBC, Chem 7 and LFTs upon arrival.
Please recheck within one week prior to clinic appointments.
12. appointments
Please ensure patient follows up with appointments as listed
above, changed from discharge summary time of writing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare of [**Location (un) **]
Discharge Diagnosis:
Primary:
Seizure
Intracranial Bleed
Secondary:
Chronic renal insufficiency
Diabetes type 2
Anemia
Pre-existing decubitus and urethral ulcer
Discharge Condition:
Mental Status:
Alert, oriented to hospital and city at best, other times only
to name. Able to perform DOW backwards at best, at other time
unable.
Names high frequency objects at best. Follows 2 step commands
at best. His mental status improves with family presence,
requires a translator for appropriate communication.
CNs: EOMi, PERRL, face symmeetric, tongue midline, palate
elevates symmetrically.
Motor: Increased tone in UEs, mild cogwheeling at b/l wrists and
biceps, mild spasticity as well.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname 87792**], it was a pleasure taking part in your care. You
were admitted to [**Hospital1 18**] because you had a seizure. We did a CT
scan of your head which showed signs of a bleeding. It was not
operable and remained stable throughout your hospital stay.
.
For seizures, you were evaluted by neurology and started on
medications to suppress seizures.
Because of the dilantin use (antiseizure medicine) you developed
abnormal liver enzymes. Your seizure medicine was changed to
Keppra.
We had wound care evaluate your ulcers and they recommended
urology follow-up.
.
We made the following changes to your medications (please refer
to your discharge medication list for details).
You were discharged to a nursing home facility for further
rehabilitation and because you required 24 hr care.
Followup Instructions:
Please follow-up with your Nursing Home Care doctors
Please set-up an appointment with a primary care physician when
you leave your nursing home
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2106-1-27**] at 9:00 AM
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: COGNITIVE NEUROLOGY UNIT
When: WEDNESDAY [**2106-1-13**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8384**], MD [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage Please ensure family
member is present for appointment.
Please follow up with the Liver Clinic on [**2106-1-26**] with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 18**] Liver Center, LMOB [**Location (un) **], Please call
([**Telephone/Fax (1) 1582**] to confirm the appointment. Please ensure family
member is present for appointment.
Department: LIVER CENTER
When: TUESDAY [**2106-1-26**] at 1 PM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2105-12-10**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,904
| 125,092
|
42392
|
Discharge summary
|
report
|
Admission Date: [**2168-5-10**] Discharge Date: [**2168-5-24**]
Date of Birth: [**2091-1-19**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
nauea, vomiting, poor oral intake
Major Surgical or Invasive Procedure:
[**2168-5-11**]: biliary endoscopy with brushings/biopsy obtained
[**2168-5-16**]: exploratory laparotomy, gastrostomy, jejunostomy
History of Present Illness:
Ms. [**Known lastname 91793**] is a 77 year old woman with common hepatic duct
stricture of unclear etiology s/p bilateral PTBD who presents as
a direct admission from clinic because of persistent nausea and
vomiting. She is status post recent discharge from [**Hospital1 18**] on [**4-29**]
following work-up and evaluation of RUQ discomfort and fevers.
Since discharge home, pt has endorsed a "gradual worsening" of
her nausea, and states that she frequently has not felt inclined
to eat because of fear of vomiting. During this time interval,
Ms. [**Known lastname 91793**] has endorsed an unspecified weight loss. Of note, she
has completed her out-pt course of antibiotics (ertapenem and
flagyl) and started once daily dosing of Bactrim [**2168-5-10**]. She
denies fevers, rigors, or worsening abdominal pain.
Past Medical History:
Past Medical History: Ulcerative Colitis, Hypothyroidism, R
posterior portal vein thrombosis
Infection History: Multidrug resistant Ecoli UTI, Enterococcus
bactermia (vanc sensitive), also in bile, Cdiff colitis
Past Surgical History: Breast Cancer with Left modified radical
mastectomy >17 yrs ago, Common hepatic duct stricture s/p
bilateral PTBD (currently capped on admission)
Social History:
Widowed, lives alone with her dog. Has 2 sons. Quit smoking
>50 years ago, occasional alcohol use.
Family History:
Mother: Breast CA
Father: Goiter
Physical Exam:
On Discharge:
VS: 99.0 98.2 59 109/54 18 98RA
Gen: pt appears fatigued, sitting upright in hospital bed, in
NAD
CV: RRR, no m/r/g, nml s1/s2
Resp: diminished breath sounds in lung bases bilaterally, good
air movement in upper lobes, no wheezes or ronchi
Abd: soft, mildly distended (baseline), nontender, R subcostal
incision is healing well with only minimal incisional erythema,
no e/o purulence or discharge. Gastrostomy and jejunostomy are
in place, insertion sites are clean, dry, and intact.
gastrostomy remains to gravity. two PTBDs are in place and are
capped, insertion sites are similarly intact and without
evidence drainage or erythema
Ext: 1+ bilateral nonpitting edema (at baseline)
Pertinent Results:
[**2168-5-10**] 04:50PM BLOOD WBC-8.5 RBC-4.13* Hgb-11.4* Hct-34.4*
MCV-83 MCH-27.6 MCHC-33.1 RDW-15.7* Plt Ct-350
[**2168-5-11**] 05:20AM BLOOD WBC-7.3 RBC-3.96* Hgb-10.4* Hct-33.3*
MCV-84 MCH-26.1* MCHC-31.1 RDW-15.7* Plt Ct-338
[**2168-5-12**] 05:25AM BLOOD WBC-8.9 RBC-3.71* Hgb-9.9* Hct-30.9*
MCV-83 MCH-26.7* MCHC-32.0 RDW-15.4 Plt Ct-311
[**2168-5-16**] 08:20PM BLOOD WBC-13.4*# RBC-3.75* Hgb-9.8* Hct-32.4*
MCV-86 MCH-26.2* MCHC-30.4* RDW-15.7* Plt Ct-197
[**2168-5-17**] 02:24AM BLOOD WBC-11.8* RBC-3.70* Hgb-9.7* Hct-32.4*
MCV-87 MCH-26.1* MCHC-29.9* RDW-15.9* Plt Ct-201
[**2168-5-18**] 02:11AM BLOOD WBC-13.6* RBC-3.57* Hgb-9.7* Hct-31.9*
MCV-90 MCH-27.1 MCHC-30.3* RDW-16.3* Plt Ct-189
[**2168-5-19**] 03:24AM BLOOD WBC-12.1* RBC-3.31* Hgb-8.9* Hct-29.4*
MCV-89 MCH-26.9* MCHC-30.3* RDW-16.4* Plt Ct-188
[**2168-5-20**] 05:31AM BLOOD WBC-9.5 RBC-3.14* Hgb-8.2* Hct-26.5*
MCV-84 MCH-26.1* MCHC-31.0 RDW-16.3* Plt Ct-209
[**2168-5-21**] 05:10AM BLOOD WBC-8.5 RBC-3.27* Hgb-8.7* Hct-28.5*
MCV-87 MCH-26.6* MCHC-30.5* RDW-16.5* Plt Ct-210
[**2168-5-22**] 06:45AM BLOOD WBC-12.1* RBC-3.25* Hgb-8.4* Hct-27.6*
MCV-85 MCH-25.7* MCHC-30.3* RDW-16.1* Plt Ct-223
[**2168-5-10**] 04:50PM BLOOD Glucose-86 UreaN-17 Creat-0.9 Na-138
K-4.1 Cl-97 HCO3-26 AnGap-19
[**2168-5-11**] 05:20AM BLOOD Glucose-113* UreaN-15 Creat-0.9 Na-136
K-4.2 Cl-96 HCO3-29 AnGap-15
[**2168-5-12**] 05:25AM BLOOD Glucose-190* UreaN-15 Creat-1.0 Na-135
K-4.3 Cl-98 HCO3-28 AnGap-13
[**2168-5-13**] 06:39AM BLOOD Glucose-154* UreaN-20 Creat-1.0 Na-138
K-4.2 Cl-102 HCO3-26 AnGap-14
[**2168-5-15**] 05:26AM BLOOD Glucose-151* UreaN-27* Creat-0.9 Na-136
K-4.6 Cl-108 HCO3-21* AnGap-12
[**2168-5-16**] 08:20PM BLOOD Glucose-268* UreaN-28* Creat-1.0 Na-132*
K-5.3* Cl-107 HCO3-19* AnGap-11
[**2168-5-17**] 02:24AM BLOOD Glucose-252* UreaN-29* Creat-1.0 Na-132*
K-5.5* Cl-108 HCO3-21* AnGap-9
[**2168-5-18**] 02:11AM BLOOD Glucose-219* UreaN-29* Creat-0.9 Na-132*
K-4.6 Cl-108 HCO3-17* AnGap-12
[**2168-5-19**] 03:24AM BLOOD Glucose-151* UreaN-34* Creat-1.0 Na-133
K-4.7 Cl-107 HCO3-18* AnGap-13
[**2168-5-20**] 05:31AM BLOOD Glucose-111* UreaN-35* Creat-1.0 Na-133
K-4.7 Cl-105 HCO3-22 AnGap-11
[**2168-5-21**] 05:10AM BLOOD Glucose-138* UreaN-32* Creat-0.7 Na-136
K-4.4 Cl-105 HCO3-22 AnGap-13
[**2168-5-22**] 06:45AM BLOOD Glucose-128* UreaN-36* Creat-0.8 Na-137
K-5.1 Cl-106 HCO3-24 AnGap-12
[**2168-5-10**] 04:50PM BLOOD ALT-11 AST-33 AlkPhos-184* TotBili-0.9
[**2168-5-11**] 05:20AM BLOOD ALT-10 AST-29 AlkPhos-167* TotBili-1.0
[**2168-5-12**] 05:25AM BLOOD ALT-28 AST-93* AlkPhos-284* TotBili-2.6*
[**2168-5-13**] 06:39AM BLOOD ALT-28 AST-72* AlkPhos-236* TotBili-1.7*
[**2168-5-14**] 06:00AM BLOOD ALT-25 AST-54* AlkPhos-226* TotBili-1.1
[**2168-5-16**] 08:20PM BLOOD ALT-44* AST-80* CK(CPK)-69 AlkPhos-299*
TotBili-1.1
[**2168-5-18**] 02:11AM BLOOD ALT-36 AST-50* AlkPhos-197* TotBili-0.6
[**2168-5-19**] 03:24AM BLOOD ALT-31 AST-49* AlkPhos-168* TotBili-0.5
[**2168-5-20**] 05:31AM BLOOD ALT-31 AST-46* AlkPhos-177* TotBili-0.7
[**2168-5-22**] 06:45AM BLOOD ALT-32 AST-38 AlkPhos-247* TotBili-0.5
GALL BLADDER ASPIRATE.
**FINAL REPORT [**2168-5-15**]**
GRAM STAIN (Final [**2168-5-11**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND IN SHORT
CHAINS.
FLUID CULTURE (Final [**2168-5-15**]):
ENTEROCOCCUS SP.. SPARSE GROWTH.
ENTEROCOCCUS SP.. SPARSE GROWTH. SECOND STRAIN.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ =>32 R =>32 R
LINEZOLID------------- 2 S 2 S
PENICILLIN G---------- 32 R =>64 R
VANCOMYCIN------------ =>32 R =>32 R
ANAEROBIC CULTURE (Final [**2168-5-15**]): NO ANAEROBES ISOLATED.
CYTOLOGY:
[**2168-5-11**] common bile duct brushings: Atypical glandular cells
[**2168-5-11**] common hepatic duct brushings: A few groups of highly
atypical glandular cells, see note.
[**2168-5-16**] omental node pathology: -Metastatic, well
differentiated adenocarcinoma consistent with pancreaticobiliary
origin in the appropriate clinical setting.
Brief Hospital Course:
Ms. [**Known lastname 91793**] was admitted to the Hepatobiliary surgical service on
[**2168-5-10**] because of poor oral intake due to nausea and vomiting
in the setting of gastric outlet obstruction of unclear
etiology. On admission, Ms. [**Known lastname 91793**] was noted to be stable and
afebrile with no complaints of abdominal pain. Her laboratory
values were notable only for an elevated INR to 5.5 for which
she received 10mg Vit K in preparation for IR procedures the
ensuing day. She was treated with IVF, and on hospital day 1 a
nasogastric tube was placed for gastric decompression to help
alleviate the patient's discomfort and prevent possible
aspiration. on [**2168-5-11**], Ms. [**Known lastname 91793**] [**Last Name (Titles) 1834**] a pullback
cholangiogram with replacement of her 8Fr biliary catheters.
Common bile duct brushings were obtained and were notable for
atypical glandular cells on cytology.
Given Ms. [**Known lastname 91799**] persistent inability to ingest food, a PICC
line was placed on [**2168-5-11**] and she was started on TPN to
improve her nutritional status. Throughout this time she
remained stable, afebrile, and with no abdominal pain. She was
maintained on bactrim as prophylaxis for cholangitis, a regimen
on which she was initiated prior to admission to the hospital.
On [**2168-5-16**], Ms. [**Known lastname 91793**] was taken to the operating room for
resection of presumed cholangiocarcinoma. However,
intraoperative findings were notable for carcinomatosis. An
omental node was sent for pathology, the results of which were
notable for metastatic, well differentiated adenocarcinoma
consistent with pancreaticobiliary origin. Given this finding, a
gastrostomy was placed in addition to a jejunostomy (reader
referred to operative report from [**2168-5-16**] for further details).
Ms. [**Known lastname 91793**] was successfully extubated in the operating room.
While in the PACU, however, she was noted to have significantly
increased work of breathing and was re-intubated. She was
transferred to the SICU post-operative for continued monitoring.
She remained stable during POD #0 and by POD#1 was successfully
extubated. She was treated with nebulizers and and allowed to
auto-diurese, both of which helped improve her respiratory
status. On POD#3 she was doing well enough to be transitioned to
floor level care and has remained as such for the remainder of
her hospital stay.
Since arriving on the floor, Ms. [**Known lastname 91793**] has been tolerating her
jejunostomy feeds at goal rate of 60cc/hr (replete without
fiber). She has also been ingesting clear liquids for comfort,
with her Gtube left to gravity. Her PTBDs remain in place and
are capped, with no rise in her LFTs noted. Her functional
status remains rather limited post-op, with her activity mostly
consisting of moving with aid from bed to chair. She continues
to work with physical therapy to improve her strength.
At the time of discharge, Ms. [**Known lastname 91793**] remains stable, tolerating
clears w/ her Gtube to gravity, receiving Jfeeds at goal rate of
60cc/hour, and minimally ambulating with aid from bed to chair.
She is mentating at baseline. She voids but is, on occassion,
incontinent of urine. She has normal bowel movements.
She will follow up with Dr. [**Last Name (STitle) **] in clinic for routine
post-operative care. Ms. [**Known lastname 91793**] will be contact[**Name (NI) **] for out-pt
follow up with interventional radiology to have her bilateral
PTBDs internalized. She will also follow up with GI to have a
duodenal stent placed so as to help alleviate her gastric outlet
obstruction and potentially eat regular diet.
Ms. [**Known lastname 91793**] has a history of portal vein thrombosis for which she
was treated with coumadin prior to admission to [**Hospital1 18**]. Given her
elevated INR on admisison as well as her procedures this
hospital stay, her coumadin has been held since admission. It is
to be restarted upon discharge, with dosing at 2mg every day.
Her INR is to be checked on [**2168-5-26**].
Medications on Admission:
Oxycodone 5 mg q3h prn pain, tylenol 650 mg prn pain,
levothyroxine 75 mcg daily, omeprazole 20 mg daily, Vit D 1000U
daily, colace 100mg [**Hospital1 **], asacol 1200 mg daily, ferrous sulfate
325 mg daily, coumadin 3 (held [**3-10**] elevated INR), Bactrim DS 1
tab daily, ursodiol 300mg TID
Discharge Medications:
1. ursodiol 300 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO TID (3 times
a day).
2. camphor-menthol 0.5-0.5 % Lotion [**Month/Day (2) **]: One (1) Appl Topical
QID (4 times a day): pruritus.
3. glucagon (human recombinant) 1 mg Recon Soln [**Month/Day (2) **]: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
4. sulfamethoxazole-trimethoprim 200-40 mg/5 mL Suspension [**Month/Day (2) **]:
Ten (10) ML PO DAILY (Daily): cholangitis prophylaxis.
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (2) **]: One (1) inh Inhalation Q6H (every 6 hours) as
needed for wheeze.
6. ipratropium bromide 0.02 % Solution [**Month/Day (2) **]: One (1) inh
Inhalation Q6H (every 6 hours) as needed for wheezing.
7. famotidine (PF)-NaCl (iso-os) 20 mg/50 mL Piggyback [**Month/Day (2) **]: One
(1) Intravenous Q24H (every 24 hours).
8. insulin regular human 100 unit/mL Solution [**Month/Day (2) **]: follow
sliding scaLE Injection four times a day.
9. 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.
10. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
11. dextrose 50% in water (D50W) Syringe [**Month/Day (2) **]: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
12. ondansetron HCl (PF) 4 mg/2 mL Solution [**Month/Day (2) **]: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
13. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
14. warfarin 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
15. Outpatient [**Name (NI) **] Work
PT/INR Thursday [**5-26**]
then twice weekly
16. oxycodone 5 mg/5 mL Solution [**Month/Year (2) **]: 5-10 mg PO Q4H (every 4
hours) as needed for pain: break thru pain
give via J tube only
monitor for sedation.
17. fentanyl 25 mcg/hr Patch 72 hr [**Month/Year (2) **]: One (1) Transdermal
Q72H (every 72 hours): start [**5-24**].
18. Levothyroxine Sodium 37.5 mcg IV DAILY
19. Colace 60 mg/15 mL Syrup [**Month/Year (2) **]: Twenty (20) ml PO twice a day:
give via j tube.
Discharge Disposition:
Extended Care
Facility:
life care center of [**Location (un) **]
Discharge Diagnosis:
gastric outlet obstruction
carcinomatosis
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 will be transferring back to Lifecare Center of Attelboro
You were admitted to the hospital because of inability to ingest
food/liquids because of gastric outlet obstruction.
You were treated with nasogastric decompression, and received IV
nutrition via a PICC line.
You [**Location (un) 1834**] a repeat biliary biopsy with brushings on [**2168-5-11**],
the results of which were non-diagnostic.
You were taken to the operating room on [**2168-5-16**] for placement
of a gastrostomy and jejunostomy.
You are currently receiving nutrition via your jejunostomy. The
gastrostomy is left to gravity to help alleviate your gastric
outlet obstruction.
You will be contact[**Name (NI) **] following discharge to have your biliary
drains internalized. Following this procedure, you will have
follow-up with gastroenterology to have a duodenal stent placed
to help alleviate your gastric outlet obstruction.
You will be seen by oncology following discharge to discuss
chemotherapy options.
You should take your pain medications as needed. You may
continue your home medications.
You will resume your coumadin following discharge. You will need
frequent blood checks to ensure that your INR is not too high.
You may continue to take in clear liquids as tolerated. Be sure
to have your gastrostomy tube open and draining to gravity.
Your PTBD (biliary drains) should remain capped until you are
seen by the radiologists for further follow-up and
internalization.
You should try to ambulate and sit in the chair as often as you
can to help maintain your strength.
Followup Instructions:
You will be contact[**Name (NI) **] while in rehab by [**Name (NI) 698**] [**Last Name (NamePattern1) 699**], RN
[**Telephone/Fax (1) 17195**] regarding follow up with Dr. [**Last Name (STitle) **]
- interventional radiology for internalization of your biliary
drains
- gastroenterology for placement of a duodenal stent
- oncology for discussion regarding chemotherapy options
[**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**], RN coordinator for Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 673**] will
call with follow up appointment in clinic for routine
post-operative check in next 1-2 weeks
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2168-5-24**]
|
[
"V09.91",
"783.21",
"V15.82",
"V85.25",
"518.52",
"537.0",
"338.3",
"575.4",
"574.21",
"V45.71",
"556.9",
"V13.01",
"V10.3",
"789.59",
"156.0",
"197.6",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.14",
"99.15",
"46.39",
"54.23",
"87.54",
"96.6",
"43.19",
"96.71",
"51.98"
] |
icd9pcs
|
[
[
[]
]
] |
13785, 13852
|
7030, 11108
|
336, 470
|
13938, 13938
|
2623, 7007
|
15713, 16499
|
1856, 1891
|
11454, 13762
|
13873, 13917
|
11134, 11431
|
14121, 15690
|
1573, 1721
|
1906, 1906
|
1920, 2604
|
263, 298
|
498, 1314
|
13953, 14097
|
1358, 1550
|
1737, 1840
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,433
| 150,152
|
53404
|
Discharge summary
|
report
|
Admission Date: [**2177-8-13**] Discharge Date: [**2177-8-15**]
Date of Birth: [**2129-10-5**] Sex: F
Service: MEDICINE
Allergies:
Zosyn / Quinolones / Ceftriaxone / Flagyl / Keppra / Lisinopril
/ Naprosyn / Bactrim Ds
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
rash
Major Surgical or Invasive Procedure:
skin biopsy
Intubation
Left subclavian venous line placement
Right arterial line placement
History of Present Illness:
Hx obtained from OMR records and staff as patient is somnolent
and encephalopathic, presumably from a 10 minute episode of a
generalized tonic clonic seizure. Attempted to contact family
(son) and home number w/o ability to reach anyone.
.
47 year old woman with w/spina bifida, MR, paraperesis, recent
TEN ([**3-4**] Bactrim, ~ 20-30% of BSA) and seizure disorder
(non-epileptic and/or epileptic) who initially presented to the
ED with RLE pain and swelling. Reportedly she first noted the
pain and swelling when she awoke on day of admission [**2177-8-13**].
Apparently the pain was greatest in ankle and calf, was
described as sharp, up to [**10-10**], and worse with weight bearing.
No recent trauma, fevers, chills or night sweats. ROS otherwise
negative. It is unknown if she had taken any new or
non-prescribed medications.
.
In ED initial VS were 98 87 128/70 18 98. LENI was negative.
XRays showed DJD and soft tissue swelling but no fracture. ED
and later orthopedics both tried to tap her ankle but were
unable to obtain any fluid. Significant pain was encountered on
attempt to aspirate R ankle joint. She was started on
vancomycin for suspected cellulitis and sent to floor.
.
On the floor, she was normotensive and not tachycardic
overnight. At 1400 was note dto have a "seizure" by RN, lasting
10 minutes, which resolved after administration of 4mg IV
ativan. Later in afternoon, developed a fever to 102.3F, HR to
120s, SBP to 90s and confused. Lost IV access. It was noted
that erythema on her leg had progressed to her hip, became
indurated. There was concern for nec. fasc. thus surgery and
MICU were consulted.
.
Review of systems: Unable to obtain.
Past Medical History:
1. Asthma/COPD
2. Hypertension
3. GERD
4. Urostomy
5. h/o VRE pyelonephritis
6. Spina bifida (myelomengiocele)
7. Paraplegia (documented, though patient can walk)
8. Depression
9. Mild mental retardation
10. Psychogenic dysarthria and tremor
11. [**Month/Year (2) **] vs. pseudoseizures
- EEG work-up at [**Hospital3 **] in [**2165**] frequent runs of regular
bifrontal sharp delta activity although the clinical events
which occurred during the record were not associated with EEG
change
12. Atopic dermatitis
13. Back pain
14. Genital herpes
15. Uterine fibroid
16. Uterine prolapse
17. Diverticulosis
18. External hemorrhoids
Social History:
Social Hx: Lives alone in an apartment in [**Location (un) 86**]. She is able to
transfer independently with walker. No assistance at home
currently, noting that she does everything on her own. She
reports compliance with her meds.
Family History:
Per previous report: 3 healthy children. Mother - died of lung
cancer. Father - killed by his girlfriend. Not in contact with
her brother and sister.
Physical Exam:
Gen: ill-appearing lady on supplemental O2, not oriented, groans
to
pain
Vitals: 102.3F 115/58 99 14 99% on vent
General: Somnolent, responds to vocal stimuli.
HEENT: normal skin, no meningismus, obese.
Neck: flat JVD no LAD
Lungs: CTA bilaterally
CV: Regular rate and rhythm, tachycardic, normal S1 + S2
Abdomen: soft, TTP on RLQ, erythematous, indurated skin surface.
No desquamation. normal BS. Urostomy in place, clear urine.
Ext: Bilateral erythema in LEs, R >> L, TTP and indurated, with
erythema spreading to RLQ and flank. She is very TTP and
winces/screams. There is mild edema in R ankle. There are no
mucosal ulcers or loss of epithelium orally or vaginally.
Exam per dermatology resident at 2 am:
ill-appearing lady on supplemental O2, not oriented, groans to
pain
Skin Type V
A complete cutaneous examination of the scalp, face, neck,
eyelids, mouth, conjunctiva, chest, abdomen, back, bilateral
arms, bilateral legs, buttocks, digits and nails reveals the
following significant findings:
-RLE edema w/ overlying deep erythema which extends up RLE and
is
more pronounced on R lateral thigh/buttock
-similar erythematous rash extends up R lateral trunk, axilla
and
skin folds of neck--> becomes papillomatous-like plaques from
excessive soft tissue and skin swelling, there is more
violaceous
skin changes along R axilla; pt groans to pain when lesions
pressed firmly
-L antecubital fossa w/ violaceous patch w/ appears c/w
impending
necrosis
-sclera icteric
-no palmar/plantar involvement
-there are no bullae or vesicles, no desquamtion
-lips and genitals wnls
Repeat dermatological exam:
Pt re-examined 2 hours later. Rash now appears more
violaceous/dusky on b/l axilla and forearms and more concerning
for an early evolving TEN-picutre. There is a + Nikolsky sign
which was absent earlier. In addition, she has what appears to
be impending desquamation on trunk and b/l axilla and forearms.
Still w/ no mucosal lesions. While no clear inciting [**Doctor Last Name 360**] for
TEN, pt does have [**Last Name (un) **] to PCN and meropenem can have some cross
reactivity. We will bx and send specimens for tissue cx and
path. Attempts to call pt's son for consent went unanswered.
Will proceed w/ bx at this time given that pt acutely ill and
information gleaned from bx critical to her management. 2 3mm
punch bxs obtained from R abd. + lido/epi, 4.0 Ethilon,
vaseline, bandaid placed. No complications.
Pertinent Results:
[**2177-8-14**] 07:26PM BLOOD WBC-11.0# RBC-4.53 Hgb-14.3 Hct-45.0
MCV-99* MCH-31.5 MCHC-31.8 RDW-15.3 Plt Ct-202
[**2177-8-14**] 07:26PM BLOOD Neuts-91.7* Lymphs-4.3* Monos-1.7*
Eos-2.0 Baso-0.3
[**2177-8-14**] 08:41PM BLOOD PT-12.2 PTT-28.2 INR(PT)-1.0
[**2177-8-15**] 12:30AM BLOOD Glucose-122* UreaN-13 Creat-1.0 Na-139
K-4.0 Cl-111* HCO3-19* AnGap-13
[**2177-8-14**] 07:26PM BLOOD ALT-28 AST-85* LD(LDH)-1307* CK(CPK)-199
AlkPhos-206* Amylase-65 TotBili-0.6
[**2177-8-15**] 12:30AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.7
[**2177-8-15**] 03:05AM BLOOD Type-ART Temp-40.0 pO2-225* pCO2-45
pH-7.21* calTCO2-19* Base XS--9 Intubat-INTUBATED
[**2177-8-15**] 03:05AM BLOOD freeCa-0.97*
.
Imaging:
CT torso [**8-14**]:
1. No evidence of subcutaneous air to suggest nec fasc. please
note that
subcutaneous fat of lateral aspects of the buttocks bilaterally
are excluded
from view.
2. edema of the soft tissues, predominantly of the lower
extremities.
bilateral inguinal lymphadenopathy
3. Pelvic lymphadenopathy, most prominent along the right
external iliac chain
measuring up to 1.1 cm in short axis diameter.
4. bilateral axillary lymphadenopathy, right > left, measuring
up to 1.4 cm
short axis diameter, increased from [**2176-11-8**].
5. status post urostomy with an ileal conduit seen exiting the
right lower
pelvis anteriorly, unchanged.
6. congenital spinal dysraphism in the lower lumbar and upper
sacral regions,
unchanged, with meningocele.
7. stable right upper lobe pulmonary nodule.
XRay ankle, right [**8-14**]:
No definite fracture or dislocation. Demineralization with
degenerative disease. Marked soft tissue swelling. If symptoms
persist,
recommend followup radiographs in 10 days.
LENI [**8-13**]:
IMPRESSION: No definite evidence of DVT in the right lower
extremity.
CXR [**8-13**]:
AP AND LATERAL VIEW, CHEST: The study is limited due to
underpenetration.
Within these limitations, there is no focal consolidation,
pleural effusion,
pulmonary edema, or pneumothorax. Heart size is upper limit of
normal and
hilar contours are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
Labs at time of discharge:
[**2177-8-14**] 07:26PM BLOOD WBC-11.0# RBC-4.53 Hgb-14.3 Hct-45.0
MCV-99* MCH-31.5 MCHC-31.8 RDW-15.3 Plt Ct-202
[**2177-8-14**] 07:26PM BLOOD Neuts-91.7* Lymphs-4.3* Monos-1.7*
Eos-2.0 Baso-0.3
[**2177-8-15**] 12:30AM BLOOD Glucose-122* UreaN-13 Creat-1.0 Na-139
K-4.0 Cl-111* HCO3-19* AnGap-13
[**2177-8-14**] 07:26PM BLOOD ALT-28 AST-85* LD(LDH)-1307* CK(CPK)-199
AlkPhos-206* Amylase-65 TotBili-0.6
[**2177-8-13**] 07:25PM BLOOD CRP-30.0*
[**2177-8-15**] 04:58AM BLOOD Type-ART Rates-/16 Tidal V-500 FiO2-50
pO2-100 pCO2-38 pH-7.26* calTCO2-18* Base XS--9 -ASSIST/CON
[**2177-8-15**] 05:48AM BLOOD Type-MIX Rates-/16 Tidal V-500 FiO2-50
pO2-47* pCO2-44 pH-7.22* calTCO2-19* Base XS--9
[**2177-8-15**] 04:58AM BLOOD Lactate-1.5
[**2177-8-14**] 04:55PM BLOOD Lactate-2.7*
Brief Hospital Course:
On the floor, she was normotensive and not tachycardic
overnight. At 1400 was noted to have a "seizure" by RN, lasting
10 minutes, which resolved after administration of 4mg IV
ativan. Later in afternoon, developed a fever to 102.3F, HR to
120s, SBP to 90s and confused. Lost IV access. It was noted
that erythema on her leg had progressed to her hip, became
indurated. There was concern for nec. fasc. thus surgery and
MICU were consulted. Given hypotension, fever and worsening
mental status she was treated for sepsis. Her ABx coverage was
broadened from Vancomycin to include meropenem and clinda (pt.
w/ multiple cephalosporin allergies) for coverage of necrotizing
fasciitis. BCx were sent prior to broadening of ABx. CT torso
and leg were obtained, no evidence of necrotizing fasciitis was
noted (see results).
In MICU, she was evaluated several times by the surgery team and
dermatology. Erythema, tenderness, and induration spread to
level of axilla bilaterally and to most of trunk. During this
time, patient's blood pressure decreased from 148/98 to 81/49 HR
increased from 110s to 120s.
She was given 2L NS IVF w/o siginficant improvement in BP. Due
to inability to stay still, and incrasing upper airway
obstruction with sedation, she required intubation for line
placement. L subclavian and A-line were placed. She received 3
more L of NS and started on levophed gtt, with SBPs to 100s and
MAPs > 60, SvcO2 was ~ 50, thus dobutatmine was also started as
per sepsis protocol.
Per initial dermatology evaluation, the most concerning process
was nec. fasc., however on reevaluation by derm, rash appeared
more violaceous and dusky and more concerning for evolving TEN,
without mucosal lesions and no clear inciting [**Doctor Last Name 360**] for TEN
(though actual history is unknown). Skin bx as taken for tissue
cx and path.
Per repeat surgical evaluation (Attending Dr. [**Last Name (STitle) **], it was
noted that although TEN was suspected as the primary process, an
underlying nec. fasciitis could not be ruled out, especially in
the indurated area around the right thigh. Given the fact that
patient was being transferred to the trauma/burn unit, a fascial
biopsy was deferred to the treating physician's at [**Hospital1 112**], as an
incision at this time would compromise already impaired skin
barried and would increase risk of further infection given
likely a nonsterile transfer.
Given concern for cross-allergenic reactivity of merepenem and
cephalosporins, the [**8-15**] am dose of meropenem as a possible
inciting [**Doctor Last Name 360**] for TEN, was held. Vancomycin and Clindamycin
were continued. Consider Aztreonam for GN coverage.
Re: [**Doctor Last Name 54422**], given 10 minute event concerning for seizure, pt.
was reloaded with 1g of dilantin completed at 5.30am. She will
need a 2 hr post load level and redosing according to that to a
goal of correlcted dilantin level of 15-20.
Medications on Admission:
Miconazole Powder 2% 1 Appl TP [**Hospital1 **]:PRN skin irritation
Montelukast Sodium 10 mg PO/NG DAILY
Acetaminophen 325-650 mg PO/NG Q6H:PRN pain, fever
Pantoprazole 40 mg PO Q24H
Citalopram Hydrobromide 20 mg PO/NG DAILY
Quetiapine Fumarate 25 mg PO/NG HS
Docusate Sodium 100 mg PO BID
Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
Thiamine 100 mg PO/NG DAILY
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet 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. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
5. Norepinephrine Bitartrate 1 mg/mL Solution Sig: 0.05-0.3
Intravenous TITRATE TO (titrate to desired clinical effect
(please specify)).
6. Dobutamine in D5W 250 mg/250 mL (1 mg/mL) Parenteral Solution
Sig: 2.5-5 mcg Intravenous TITRATE TO (titrate to desired
clinical effect (please specify)): svo2 > 70.
7. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
8. Lorazepam 1 mg IV Q4H:PRN seizure > 5 mins, cluster 3 > 5
mins
page MD [**First Name (Titles) **] [**Last Name (Titles) 109835**].
9. Clindamycin 900 mg IV Q6H Start: 0000
10. Pantoprazole 40 mg IV Q24H
11. Thiamine 100 mg IV DAILY
12. Vancomycin 1000 mg IV Q 24H
13. Morphine Sulfate 2-4 mg IV Q4H:PRN pain
14. Phenytoin Sodium 50 mg/mL Solution Sig: One [**Age over 90 **]y
Five (125) mg Intravenous three times a day: needs trough level
and redosing.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary: Cellulitis vs. necrotizing fasciitis vs. TEN.
Discharge Condition:
intubated, sedated, on pressors.
Discharge Instructions:
Transfer to burn unit at [**Hospital1 112**]
Your were admitted to [**Hospital1 18**] with fever and right leg swelling
concerning for infection. You were felt to have either a severe
cellulitis, necrotizing fasciitis or TEN.
Multiple medications were started (see below)
Followup Instructions:
follow up with PCP after your discharge
Will require infectious disease follow up, to be arranged based
on evaluation at [**Hospital1 112**].
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2177-8-18**]
|
[
"218.9",
"562.10",
"344.1",
"493.20",
"995.92",
"780.39",
"317",
"695.15",
"455.3",
"682.6",
"741.90",
"728.86",
"038.9",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.91",
"81.91",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13263, 13278
|
8641, 11585
|
360, 453
|
13377, 13412
|
5703, 8618
|
13733, 14042
|
3079, 3230
|
12006, 13240
|
13299, 13356
|
11611, 11982
|
13436, 13710
|
3245, 5684
|
2142, 2161
|
316, 322
|
481, 2121
|
2183, 2813
|
2829, 3063
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,875
| 112,781
|
28002
|
Discharge summary
|
report
|
Admission Date: [**2190-9-15**] Discharge Date: [**2190-9-16**]
Date of Birth: [**2165-3-8**] Sex: M
Service: MEDICINE
Allergies:
Prozac / Haldol
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
EtOH withdrawal
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 68181**] is a 25 year-old man with a history of alcoholism and
seizure disorder who presents with alcohol withdrawal and is
admitted to the [**Hospital Unit Name 153**] for management of tachycardia,
hypertension, and significant diazepam requirement.
.
He was last admitted for alcohol withdrawal in [**Month (only) **]/[**2190-7-15**]
and was cocaine positive at that time. He was discharged with a
plan to follow-up at [**Hospital3 **] outpatient substance abuse
program. He continued drinking, however, and notes that he has
been drinking approximately a quart of alcohol daily and two 40
oz beers. He has also not been taking his seizure medications
for several days to weeks. He had his last drink yesterday
morning and states that he had a generalized seizure a few hours
later. It was witnessed by his boyfriend who states that he
lost consciousness for five to ten minutes, with tonic-clonic
motion and loss of bladder continence. He has not had a seizure
since that time. This morning, he presented to the ED for
evaluation, as he felt chest pain, general malaise, was
tremulous, and had visual hallucinations of seeing rats and
bugs.
.
In the ED, initial vs were: 98.6 120 150/100 18 99%ra. He was
given valium 10 mg IV x 9, a banana bag, multivitamin, and
aspirin 325 mg. He was tachy to the 120s and hypertensive to
SBPs of 160, and there was concern for potential hemodynamic
instability, so ICU admission was requested. Serum EtOH 19 and
tox screen otherwise negative.
.
On the floor, he is anxious and tremulous but denies
hallucinations.
.
Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath, or wheezing. Denies chest
pressure, palpitations, or weakness. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
- Alcoholism
- Hx. seizures (GTC) related to hx. of head injury (hit by bat
per
pt.); was on tegretol and neurontin for ppx, as well as
clonazepam for anxiety, but stopped all of these when he began
drinking again
- ?Hepatitis C
Social History:
He drinks approximately a quart of vodka daily and two 40 oz
beers daily and smokes. He reports using cocaine on a single
ocassion (last use [**7-24**]) though some OMR notes report regular
cocaine use. No IVDU. He has no contact with his family and he
works at Subway. He lives with his boyfriend.
Family History:
He has no contact with his family and he works at Subway. He
rents a room with his friend.
Physical Exam:
Vitals: T: 96 BP: 147/100 P: 112 R: 18 O2: 98%RA
General: Alert, oriented, tremulous
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: clear on right, LLL rales
CV: tachy, no murmurs
Abdomen: soft, mildly tender diffusely, non-distended
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: 1-2 cm erythematous blanching papules scattered over
chest, back, arms, and legs
Pertinent Results:
[**2190-9-15**] 06:55AM WBC-6.1 RBC-4.53* HGB-13.9* HCT-42.4 MCV-93
MCH-30.7 MCHC-32.8 RDW-16.4*
[**2190-9-15**] 06:55AM NEUTS-74.0* LYMPHS-19.2 MONOS-5.6 EOS-0.2
BASOS-0.9
[**2190-9-15**] 06:55AM PLT COUNT-200
[**2190-9-15**] 06:55AM ASA-NEG ETHANOL-19* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2190-9-15**] 06:55AM GLUCOSE-128* UREA N-14 CREAT-0.7 SODIUM-139
POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-24 ANION GAP-23*
[**2190-9-15**] 09:45AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2190-9-15**] 09:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2190-9-15**] 09:45AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2190-9-15**] 11:38AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2190-9-15**] 11:38AM URINE HOURS-RANDOM
Hepatitis Panels:
[**2190-9-15**] 06:55AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2190-9-15**] 06:55AM BLOOD HCV Ab-POSITIVE*
Discharge Labs: [**2190-9-16**]
CBC: BLOOD WBC-2.6*# RBC-4.52* Hgb-14.4 Hct-43.0 MCV-95 MCH-31.8
MCHC-33.5 RDW-16.1* Plt Ct-141* Neuts-59 Bands-0 Lymphs-24
Monos-15* Eos-1 Baso-1 Atyps-0 Metas-0 Myelos-0
Blood Smear: Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-1+
Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+
Chem: Glucose-129* UreaN-16 Creat-0.9 Na-139 K-4.3 Cl-101
HCO3-30 AnGap-12
Calcium-9.5 Phos-3.7# Mg-2.2
Brief Hospital Course:
Assessment and Plan:
Mr. [**Known lastname 68181**] is a 25 year-old man with a history of alcoholism and
seizure disorder who presents with alcohol withdrawal and is
admitted to the [**Hospital Unit Name 153**] for management of tachycardia and
significant diazepam requirement.
.
# Alcoholism/withdrawal:
History of alcoholism with multiple admissions for withdrawal.
Has attempted detox in past but unsuccessful. Also has history
of seizures in setting of withdrawal. Pt was put on CIWA scale
w/diazepam 10mg q1hr. Tox screen came back with positive serum
alcohol and urine benzos. Pt unwilling to enter detox program at
this time. However, pt did establish contact with [**Name (NI) 778**] clinic
and set up appointment for clinic intake and physician f/u at
that clinc. Requiring Q3 diazepam into morning of [**9-16**] but none
throughout morning. Pt not significantly symptomatic with
resolution of tachycardia. Somewhat anxious without home
clonazepam which had been held since giving diazepam but eager
to go home and stating ready to go home. Pt d/ced home with
instructions not to drink and f/u with [**Hospital1 778**] as he had
scheduled.
.
# Seizure disorder: No evidence of seizure activity while in
hospital. Was on gabapentin in past but has not been taking
medications for days to weeks. Restart gabapentin in house. At
time of discharge was given 20 day scripts for clonazepam and
gabapentin to get him to his [**Hospital1 778**] appointments.
.
# ?Hepatitis C: No history of documented hepatitis in OMR but
patient states he is hep C positive, contracted from tattoo, no
history of IVDU. Hepatitis serologies showed HCV Ab positing and
HBV ab negative to surface and core. HBV SA also negative.
.
# Rash: unclear etiology - likely tinea corpis although Cculd
represent autoimmune condition. Boyfriend does not have similar
symptoms. Pt given script for ketoconazole cream at time of d/c.
Instructed that if he wanted he could find shampoo with
ketoconazole in it and use this instead of the cream if he
wished.
Medications on Admission:
Acetaminophen 650 mg PO/NG Q6H:PRN pain
Clonazepam 2 mg PO/NG QAM
Clonazepam 1 mg PO/NG QPM
Gabapentin 600 mg PO/NG Q8H
Multivitamins 1 TAB PO/NG DAILY
Nicotine Polacrilex 2 mg PO Q1H:PRN smoking cessation
Thiamine 100 mg PO/NG DAILY
Discharge Medications:
1. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a
day for 20 days.
Disp:*60 Tablet(s)* Refills:*0*
2. Clonazepam 1 mg Tablet Sig: 1-2 Tablets PO 2 tablets in the
AM, 1 tablet in the PM for 20 days: Please take as you were
previously:
-2 tablets in AM
-1 tablet in PM.
Disp:*30 Tablet(s)* Refills:*0*
3. Ketoconazole 2 % Cream Sig: One (1) Topical once a day for 7
days.
Disp:*1 1* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1) Alcohol Withdrawal
Secondary Diagnosis:
1) Seizure disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 68181**], you were admitted to the hospital due to alcohol
withdrawal and were monitored in the ICU with medications to
treat your withdrawal. When you showed improvement, had
scheduled clinic follow-up at [**Hospital 778**] clinic, and felt able to go
home safely, you were discharged to home.
.
You were discharged with prescriptions for 20 days for the
following medications:
-Clonazepam 2mg by mouth every morning and 1mg by mouth every
evening
-Gabapentin 600mg by mouth three times each day
-Ketoconazole Cream 2% apply to your rash once each day for 7
days (as an alternative you can find a shampoo that contains 2%
Ketoconazole and apply this to the rash for 7 days).
.
You should keep your follow-up intake appointments with [**Hospital 778**]
clinic on [**9-22**] and your follow-up with a physician that is
scheduled for 2 weeks afterward.
.
You should refrain from alcohol use upon discharge. Because of
your history of becoming sick from withdrawal, and because you
have a history of seizures that increase your risk for
withdrawal seizures, it would be best for your current and
long-term health to refrain from alcohol use.
Followup Instructions:
Follow up with [**Hospital 778**] clinic as you have already scheduled. It
is very important for your health that you keep these
appointments as the clinic at [**Hospital1 778**] will be able to offer you
resources and care that will greatly improve your long-term
health.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"291.81",
"303.01",
"345.10",
"V15.81",
"782.1",
"785.0",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
7699, 7705
|
4944, 6981
|
298, 304
|
7832, 7832
|
3473, 4506
|
9168, 9580
|
2898, 2990
|
7265, 7676
|
7726, 7726
|
7007, 7242
|
7983, 9145
|
4522, 4921
|
3005, 3454
|
1939, 2310
|
243, 260
|
332, 1920
|
7789, 7811
|
7745, 7768
|
7847, 7959
|
2332, 2563
|
2579, 2882
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,406
| 183,700
|
55039
|
Discharge summary
|
report
|
Admission Date: [**2116-5-12**] Discharge Date: [**2116-5-29**]
Date of Birth: [**2046-5-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
abnormal stress test
Major Surgical or Invasive Procedure:
[**2116-5-15**]
1. Urgent coronary artery bypass graft x4: Left inframammary
artery to left anterior descending artery, and saphenous vein
grafts to diagonal obtuse marginal and posterior left
ventricular branch.
2. Endoscopic harvesting of the long saphenous vein.
3. Aortic valve replacement with size #23-mm [**Last Name (un) 3843**]-[**Doctor Last Name **]
Magna tissue valve.
History of Present Illness:
70 yo man with known coronary artery disease, s/p multiple
PTCA/stents in [**2108**]. He was recently involved in a MVC which
resulted in a subarachnoid hemorrhage and his aspirin and plavix
were stopped. He has been asymptomatic
and underwent a recent stress test which was positive and
underwent cardiac catheritization [**5-12**] which showed aortic
stenosis, left main and severe 3 vessel coronary artery disease.
Past Medical History:
CAD
AS
s/p PTCA/5 stents placed [**2108**]
hyperlipidemia
type 2 diabetes
s/p subarachnoid hemorrhage after MVC [**2-/2116**]
s/p broken shoulder after fall
?previous hyperthyroid-on meds 30 years ago-none since
s/p hemi-colectomy for benign polyp [**12/2115**]
s/p vasectomy
Social History:
Lives with: wife
Occupation: retired wiring inspector
Cigarettes: Smoked no [x]
Other Tobacco use: denies
ETOH:[x]denies < 1 drink/week [] [**12-31**] drinks/week [] >8
drinks/week[]
Illicit drug use:denies
Family History:
non-contributory
Physical Exam:
Admission exam
Pulse:76 SR Resp:14 O2 sat:96%
B/P Right:146/57
General:well appearing in no apparent distress
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 _3/6 systolic
radiating to carotids_____
Abdomen: Soft [x] obese, non-distended [x] non-tender [x] bowel
sounds +[x]
Extremities: Warm [x], well-perfused [x] Edema-none-lower
extremities with chronic venous stasis changes
Varicosities: bilateral R>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 and Left:murmur radiating to carotids
Pertinent Results:
Intra-op TEE [**2116-5-15**]
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-50%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (valve area 1.4-1.5cm2).
Valve area assessed by two different echocardiographers (Drs.
[**Last Name (STitle) 3893**] and [**Name5 (PTitle) 6507**] and [**Name5 (PTitle) 18142**] on the assessment) with VTI,
Velocities and tracing methods. Trace aortic regurgitation is
seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
There is no pericardial effusion.
Dr. [**First Name (STitle) **] was notified in person of the results before surgical
incision.
POST-BYPASS:
LVEF 45 to 50%. Normal RV systolic function.
The aortic bioprosthesis is stable, functioning well, Peak 20
and mean 12 mm of Hg. No perivalvular leaks.
Intact thoracic aorta.
Mild MR. [**First Name (Titles) **] [**Last Name (Titles) **].
Admission labs
[**2116-5-12**] 11:28PM PT-10.0 PTT-29.5 INR(PT)-0.9
[**2116-5-12**] 11:28PM PLT COUNT-225
[**2116-5-12**] 11:28PM WBC-7.7 RBC-4.27* HGB-12.3* HCT-36.7* MCV-86
MCH-28.8 MCHC-33.5 RDW-14.3
[**2116-5-12**] 11:28PM %HbA1c-5.9 eAG-123
[**2116-5-12**] 11:28PM LIPASE-26
[**2116-5-12**] 11:28PM ALT(SGPT)-31 AST(SGOT)-28 ALK PHOS-40
AMYLASE-51 TOT BILI-0.2
[**2116-5-12**] 11:28PM GLUCOSE-159* UREA N-21* CREAT-1.1 SODIUM-140
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-27 ANION GAP-12
Discharge labs:
Brief Hospital Course:
Mr. [**Known lastname 112355**] is 70 year old man with known aortic stenosis and
coronary artery disease. He was transferred to [**Hospital1 18**] from [**Hospital **] after a positive stress test followed by a
cardiac cathetrization which revealed left main and three vessel
coronary artery disease. He underwent the usual pre-operative
workup and was brought to the operating room on [**2116-5-15**] where he
underwent an aortic valve replacement and coronary artery bypass
grafting with Dr. [**First Name (STitle) **]. Please see the operative report for
details, in summary he had:
1. Urgent coronary artery bypass graft x4 with Left inframammary
artery to left anterior descending artery, saphenous vein grafts
to diagonal obtuse marginal and posterior left ventricular
branch. 2. Endoscopic harvesting of the long saphenous vein. 3.
Aortic valve replacement with size #23-mm [**Last Name (un) 3843**]-[**Doctor Last Name **]
Magna tissue valve. His cardiopulmonary bypass time was 179
minutes with an aortic crossclamp time of 160 minutes. He
tolerated the procedure well and post-operatively was
transferred to the cardiac surgery intensive care unit in stable
condition on epinepherine and levophed for invasive monitoring.
He was a difficult intubation, and difficult to mask ventilate
so was weaned causiously. His chest radiograph showed volume
overload and initial attempts to wean the ventilator failed. He
was aggressively diuresed and he did extubate on post-operative
day four only to be re-intubated hours later for failure to
clear secretions. He continued to diurese. On post-operative
day six sputum cultures revealed gram negative rods and he was
started on broad spectrum antibiotic coverage. During this
period the patient weaned off all pressors and inotropes, he was
started on beta blockers once pressors were off and was diuresed
toward his preoperative weight. Chest tubes and epicardial
pacing wires were discontinued per cardiac surgery protocol
without complication. He had several brief episodes of
post-operative atrial fibrillation that were treated with beta
blockers and amiodarone, following which he converted to sinus
rhythm. The patient extubated for a second time on
post-operative day seven, following which he stayed in the
intensive care unit for aggressive pulmonary hygiene. The
patient was transferred to the telemetry floor on post-operative
day thirteen for further recovery. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility. He was found to have increased swelling in his left
upper extremity so an ultrasound was performed of this extremity
and found to be without deep vein thromboses. By the time of
discharge on post-operative day fourteen the patient was
ambulating with assistance, the wound was healing and pain was
controlled with oral analgesics. The patient was discharged to
rehabilitation at [**Hospital1 **] in good condition with appropriate
follow up instructions.
Medications on Admission:
1. Allopurinol 100 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. fenofibrate micronized *NF* 67 mg Oral daily
5. Furosemide 80 mg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
Do Not Crush
8. Clopidogrel 75 mg PO DAILY
9. Simvastatin 40 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Insulin 70/30 18U Breakfast, 70/30 10U Lunch, 70/30 25U
Dinner
Glargine 70 Units Bedtime
12. Fish Oil (Omega 3) 1200 mg PO DAILY
Discharge Medications:
1. Allopurinol 100 mg PO DAILY
2. fenofibrate micronized *NF* 67 mg Oral daily
3. 70/30 18 Units Breakfast
70/30 10 Units Lunch
70/30 25 Units Dinner
Glargine 70 Units Bedtime
4. Aspirin EC 81 mg PO DAILY
5. Lisinopril 5 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Fish Oil (Omega 3) 1200 mg PO DAILY
9. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
Do Not Crush
10. Metoprolol Succinate XL 100 mg PO DAILY
11. Acetaminophen 650 mg PO Q4H:PRN pain/fever
12. Amiodarone 400 mg PO DAILY
take 400mg daily for one week then decrease to 200mg daily
ongoing
13. Docusate Sodium 100 mg PO BID
14. Heparin 5000 UNIT SC TID
15. Milk of Magnesia 30 ml PO HS:PRN constipation
16. Bisacodyl 10 mg PR DAILY:PRN constipation
17. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
18. Furosemide 40 mg IV BID
titrate per labs and phycical exam. patient takes 80mg PO daily
at home ongoing, with an ejection fraction of 45%.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
CAD s/p CABG
AS s/p AVR
s/p PTCA/5 stents placed [**2108**]
hyperlipidemia
type 2 diabetes
s/p subarachnoid hemorrhage after MVC [**2-/2116**]
s/p broken shoulder after fall
?previous hyperthyroid-on meds 30 years ago-none since
Past Surgical History
s/p hemi-colectomy for benign polyp [**12/2115**]
s/p vasectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with tylenol
Sternal Incision - healing well, no erythema or drainage
Edema - 2+ lower extremities bilaterally, 2+ left upper
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 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:
Surgeon Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] [**2116-6-30**] at 1:15PM
Cardiologist Dr. [**Last Name (STitle) 20222**] [**2116-6-19**] at 2PM
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **] in [**2-27**] weeks [**Telephone/Fax (2) 43460**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2116-5-29**]
|
[
"518.0",
"424.1",
"250.00",
"427.31",
"287.5",
"272.4",
"285.9",
"V45.82",
"458.29",
"276.69",
"414.01",
"293.9",
"307.9",
"276.0",
"998.59",
"E878.8",
"426.4",
"518.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.61",
"36.15",
"38.97",
"93.90",
"96.04",
"35.21",
"96.71",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
8983, 9057
|
4483, 7474
|
331, 715
|
9416, 9630
|
2527, 4443
|
10433, 11065
|
1708, 1726
|
8021, 8960
|
9078, 9395
|
7500, 7998
|
9655, 10410
|
4460, 4460
|
1741, 2508
|
270, 293
|
743, 1167
|
1189, 1466
|
1482, 1692
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,329
| 116,559
|
3136
|
Discharge summary
|
report
|
Admission Date: [**2101-10-4**] Discharge Date: [**2101-10-7**]
Date of Birth: [**2043-6-3**] Sex: F
Service: General Surgery
HISTORY OF PRESENT ILLNESS: This is a 58 year-old woman with
chronic pancreatitis, status post multiple abdominal
surgeries who presented disoriented. Her History of Present
Illness is obtained from her son. Apparently the patient was
in her usual state of health until five days prior to
presentation when she started having nausea and vomiting of
unclear frequency. She was also noted to have decreased
appetite and increased weakness to the point where she
couldn't ambulate with assistance. She was found to be short
of breath on the day of admission. Abdominal pain is unknown
and whether se was having gas or not was unknown. The
patient denies diarrhea, fever, chills, cough, urinary
symptoms, headaches, photophobia but due to this weakness is
brought to the operating room. In the Emergency Room she was
confused, was afebrile with a heart rate of 90 and blood
pressure of 110/70 initially. Her blood pressure then
dropped into the 70s and she was noted to have a very tender
abdomen. She was given 2 liters of fluid and started on a
Dopamine drip. She was admitted to the Medical Service in
the Intensive Care Unit.
PAST MEDICAL HISTORY: Includes [**Doctor Last Name 14837**] Roux-en-Y in [**2096**], a
laparoscopic cholecystectomy in [**2097**], a sphincterotomy in
[**2099**], splenectomy in [**2079**] secondary to motor vehicle
accident, an appendectomy, a right carotid endarterectomy in
[**2099**] and an aorto-[**Hospital1 **]-femoral graft placement which was
revised secondary to infection and replacement with an ex
[**Hospital1 **]-femoral. She also had chronic pancreatitis, coronary
artery disease with an ejection fraction of 45 percent, an
AICD placement in [**2100-1-13**], gastroesophageal reflux
disease, history of deep venous thrombosis in [**2096**],
hypercholesterolemia and migraines. Her medications at home
included Coumadin, Prilosec, Creon, Atenolol, Celebrex and
folic acid. She was an active smoker but denies alcohol.
FAMILY HISTORY: Her sister died of liver cancer and her
father died of an myocardial infarction at an unknown age.
On the evening of admission the medical Intensive Care Unit
staff consulted surgery for question of abdominal process.
When she was seen by surgery she was 99.5 with a heart rate
of 100, blood pressure of 70/21 on Dopamine at 10 and she was
markedly acidotic with a bicarbonate of 15 and a base deficit
of 7. She was awake but confused. Her abdomen was soft,
distended and diffusely tender, left greater than right side.
She had perfusion tenderness and guarding and she had gross
blood and stool in the rectal vault. Her white count is
16.6. Her hematocrit had fallen from 30 to 28, platelets
268. Her PT was 22.5, PTT 63 and INR of 3.5. Chem-7
135/4.0, 100/16, 11/1.1 and 58. Her urinalysis was positive
for nitrites, had 11 to 20 white cells and many bacteria.
Her ALT was 21, AST 59, alk phos 291 and total bilirubin .6
and amylase of 11, lipase of 16 and lactate level of 3.2.
Her CK was 966. She underwent an abdominal CT which showed
portal venous air and apparently a right colon that was
thickened mid transverse colon consistent with colonic
ischemia. She also had pneumatosis. She was therefore
diagnosed with likely dead bowel and taken to the operating
room where she underwent exploratory laparotomy and found to
have dense adhesions and a frankly necrotic sigmoid and
proximal rectum. She underwent left sigmoid resection and
transverse colostomy and underwent extensive lysis of
adhesions. She was then admitted to the Surgical Intensive
Care Unit in critical condition.
She was initially maintained on a Levophed drip and received
4 units of packed cells and 4 of fresh frozen plasma over her
first day. She was given Levophed and Flagyl for
antibiotics. She was maintained with extreme acidosis with
base deficit in the 10 - 11 range. On postoperative day one
her platelets fell to 28 and her abdomen was very distended
with drains pouring out serosanguinous fluid. A bladder
pressure was obtained with a question of abdominal
compartment syndrome. This was found to be 19 and at that
time she had systolic blood pressure of 119 so no further
treatment was required for that. By postoperative day two
she had deteriorated and required a change of pressors from
Levophed to dobutamine secondary to a low cardiac index. She
was also placed on Pitressin with these maintaining her blood
pressure in the 80/60 range.
Her next problem area was oxygenation with worsening
oxygenation over the night and a low pO2 of 36 with
improvement of pO2 in the 50's on pressure control once she
was paralyzed and sedated. She received 8 more units of
fresh frozen plasma over the night of postoperative day
number two to treat elevated coags. Discussion was
undertaken on postoperative day number two with her sons
given her worsening clinical status, her worsening acidosis.
At this point her lactate was 17 and her sons made it clear
that they did not want to continue treatment and elected for
comfort measures only status when the pressors were
withdrawn. The patient died quickly.
DISPOSITION: Death.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern1) 7589**]
MEDQUIST36
D: [**2101-10-7**] 12:55
T: [**2101-10-11**] 14:44
JOB#: [**Job Number 14838**]
|
[
"785.51",
"272.0",
"553.21",
"577.1",
"401.9",
"557.0",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.76",
"45.95",
"46.11",
"53.51",
"48.63"
] |
icd9pcs
|
[
[
[]
]
] |
2135, 5531
|
172, 1281
|
1304, 2118
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,742
| 165,199
|
46856
|
Discharge summary
|
report
|
Admission Date: [**2163-9-23**] Discharge Date: [**2163-9-27**]
Date of Birth: [**2085-8-5**] Sex: M
Service: MED
Allergies:
Hydrochlorothiazide
Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
Fevers, Chills
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Pt is a 78 y/o male with metastatic [**First Name3 (LF) **] CA to his bladder
base, kidney pelvic floors, and liver requiring b/l nephrostomy
tubes for urteteral obstruction. He was admitted to the ICU with
fever and hypotension. He was in his usual state of health
until [**2163-9-20**] when his nephrostomy tubes were replaced by IR.
Since that time, the pt developed anorexia, inability to feed
himself, and difficulty swallowing. On the evening of [**9-22**], the
pt vomited after eating dinner and spiked a temp to 101. He
also was having chills at home.
Past Medical History:
1. [**Date Range **] CA metastatic to base of the bladder and pelvic
floor, c/b bilateral ureteral obstruction requiring nephrostomy
tubes. He is s/p XRT and hormonal treatment, currently
palliative care.
2. Bowel/bladder spasms
3. Type 2 DM
4. PVD, s/p L fem-[**Doctor Last Name **] [**2157**]
5. PE s/p bypass surgery in [**2157**]
6. HTN
7. Depression
8. Neuropathy
9. Recent severe sepsis [**2-7**] pna requiring intubation and MICU
stay, c/b ICU psychosis [**5-10**]
Social History:
Lives with his wife. Family is involved in his care. Denies tob
or EtOH use.
Family History:
Father with DM, Mother died from cerebral hemorrhage.
Physical Exam:
T 97.8, 116/57, 77, 16, 100% RA
Gen: alert, NAD, appears very tired
HEENT: PERRL, EOMI, Anicteric, dry MM, poor dentition
CV: II/VI systolic murmer, Nl S1S2
Lungs: CTAB
Back: b/l nephrostomy tubes in place draining clear urine, C/D/I
Abd: soft, mildly distended, NT, pos BS
Ext: 1+ peripheral edema to knees, 2+ DP pulses
Neuro: CN II-XII intact, [**4-11**] musc strenght UE and [**5-11**] musc
strenght LE
Pertinent Results:
[**2163-9-23**] 06:15PM URINE HOURS-RANDOM
[**2163-9-23**] 06:15PM URINE UHOLD-HOLD
[**2163-9-23**] 06:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2163-9-23**] 06:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
[**2163-9-23**] 06:15PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-OCC
EPI-0
[**2163-9-23**] 04:02PM TYPE-[**Last Name (un) **] COMMENTS-NOT SPECIF
[**2163-9-23**] 04:02PM GLUCOSE-167* LACTATE-2.1*
[**2163-9-23**] 04:00PM GLUCOSE-153* UREA N-17 CREAT-0.9 SODIUM-128*
POTASSIUM-4.9 CHLORIDE-90* TOTAL CO2-24 ANION GAP-19
[**2163-9-23**] 04:00PM WBC-13.9*# RBC-3.13* HGB-7.4* HCT-23.6*
MCV-75* MCH-23.8* MCHC-31.5 RDW-18.3*
[**2163-9-23**] 04:00PM NEUTS-89.9* BANDS-0 LYMPHS-5.7* MONOS-4.1
EOS-0.2 BASOS-0.1
[**2163-9-23**] 04:00PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-3+ POLYCHROM-NORMAL
[**2163-9-23**] 04:00PM PLT SMR-VERY HIGH PLT COUNT-714*
Brief Hospital Course:
78 y/o male with metastatic [**Month/Day/Year **] CA admitted with fevers and
chills following nephrostomy tube readjustment.
In the ED, his Vital Signs were reported to be 101.5, 76,
160/80, 18-20, 98% RA. He received Levaquin 500mg IV x1, Vanc 1
gm IV x1, and Flagyl 500 mg IV x1. During his time in the ED,
his SBP decreased to 75-85, but increased with a NS fluid bolus.
He received a total of 2L NS in the ED. In the ICU pt's BP
remained stable w/ NS and he was able to be restarted on his
antihypertensives. He was ketp on Levo/Vanco/Flagyl. His right
nephrostomy tube was repositioned on [**9-24**] by IR.
Pt was then transferred to the floor, where he remained
hemodynamically stable with low grade temps.
1. Fever. The most likely source of his infection is related to
his recent nephrostomy tube replacement given the time course of
his symptoms. He was initially covered for GN, GP, and anaerobic
organisms b/c of a reported h/o abd pain. 1 out of 3 bld cx's
grew staph coag neg and his urine grew VRE. His triple abx
therapy was changed to levo (questionable pna) and liezolid
(vanco was d/c'ed on [**2163-9-26**] when the urine sensitivities
returned). There is no need to check a follow up CBC in this pt.
2. Metastatic [**Date Range **] CA. Right nephrostomy tube adjusted by IR
on [**9-24**]. He was found to have mets to his liver on abd CT, and
possible mets to his lungs on a CXR. These new findings were
discussed with the patient and his family. Tx remained
palliative and the pt was set up with home hospice care to start
the day following his discharge.
3. Diabetes. His oral hyperglycemics were held, FS were checked
QID and he was covered with a RISS. Avandia was restarted prior
to discharge.
4. HTN. He was restarted on metoprolol and hydralazine once his
hypotension resolved. The hydralazine was d/c'ed prior to
discharge.
5. Depression. Pt appeared depressed throughout his stay. His
SSRI was d/c'ed and his remeron was increased to 30 qhs.
6. Anemia. Pt has a baseline microcytic, microchromic anemia. He
had a drop in his Hct from 23 to 17 upon transfer from the ED,
likley related to volume repletion. He was transfused a total of
4 Units of PRBCs during his stay, with a Hct increase to 32 on
day of discharge.
7. Constipation. Pt had not had a BM for 7 days on the day of
discharge. He was given bisacodyl po and pr, senna, and colace
as well as a lactulose emema with no improvement. Manual
disempaction was attempted without results. He was sent home
with a prescription for lactulose enemas for home hospice to
continue to use as needed.
Medications on Admission:
ASA 81, Avandia 8 mg qd, colace, Lasix 20 mg qd, Glyburide 10 mg
qd, hydralazine 50 mg q6h, ketaconazole 400 mg po bid, MVT,
metoprolol 100 mg po bid, omeprazole 20 mg qd, remeron 15 mg
qhs, sertraline 50 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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
Disp:*30 Cap(s)* Refills:*2*
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
7. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Lactulose 10 g/15 mL Syrup Sig: Three Hundred (300) ML PO
once a day as needed for constipation.
Disp:*10 ML(s)* Refills:*0*
10. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 12 days.
Disp:*24 Tablet(s)* Refills:*0*
11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
12. Rosiglitazone Maleate 8 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
13. 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*
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 13054**] Hospice/[**Last Name (un) 2646**] Health Services
Discharge Diagnosis:
Metastatic [**Last Name (un) 9197**] Cancer
Discharge Condition:
Fair
Discharge Instructions:
Hospice home care will be visiting your home on Wed [**2163-9-28**].
Please call Dr. [**Last Name (STitle) 2450**] with any questions.
Followup Instructions:
The following appointment was scheduled for you prior to your
hospitalization:
Provider: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2163-10-13**] 10:00
|
[
"V10.46",
"038.11",
"197.7",
"198.89",
"198.1",
"599.0",
"197.0",
"996.65",
"198.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7550, 7651
|
3006, 5599
|
289, 297
|
7739, 7745
|
1994, 2983
|
7928, 8212
|
1497, 1552
|
5861, 7527
|
7672, 7718
|
5625, 5838
|
7769, 7905
|
1567, 1975
|
235, 251
|
325, 890
|
912, 1387
|
1403, 1481
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,581
| 140,044
|
1126
|
Discharge summary
|
report
|
Admission Date: [**2127-7-27**] Discharge Date: [**2127-7-29**]
Date of Birth: [**2072-2-18**] Sex: F
Service: MED
Allergies:
Codeine / Compazine
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
55 y/o female with hepatitis B and C and NIDDM presents with
nausea and vomiting times three days. Also c/o abdominal pain
(diffusely) Denies focality. Normal bowel movements. States
unable to keep anything down po. Would immediately to 30 minutes
later vomit whatever she took in. Also c/o HA, photophobia and
no PO for two days. While not taking PO, pt off PO meds
including methadone, clonodine, lopressor and norvasc. Denies
diarrhea. + fevers (subjective) and chills. Denies hematemesis.
Denies dysuria, cough, shortness of breath or chest pain.
In ED, tachy and hypertensive with BP 210/115 and HR 140s-150s.
AG19, lactate 2.2. WBC 16 with diff of 89N and no bands. UA
positive for 250 of glucose, 30 protein, 50 ketones. Serum was
positive for acetone. CXR showed atelectasis of RLL. CK49, trop
(-). Abd CT showed fatty liver, atelectasis, small scare of past
pleural effusion@R base. LFTs (-). Albumin nl. BC pending. ECG
sinus tach@108, nl axis, nl intervals, no hypertrophy, slight
anterior ST depression new compared to [**2127-1-29**]. 7L in in ED
Past Medical History:
-Hepatitis B and hepatitis C.
-Nonmalignant thoracic spinal tumor diagnosed in [**2110**] status
post vertebrectomy of five thoracic vertebra.
-Hypertension.
-Coronary artery disease status post PTCA and stent of the
circumflex in [**2123-10-3**], status post CABG x2 (LIMA-->LAD,
SVG-->OM)
-Hyperlipidemia.
-Non-insulin dependent-diabetes mellitus type 2.
-IV drug abuse x14 years currently on methadone.
-Gastroesophageal reflux disease.
-Hiatal hernia.
-Migraine
Social History:
former smoker (30 pack-years); former IV heroin user x 14 years,
now on methadone maintenance
Family History:
CAD (father), HTN (mother, brother, sister), DM
Physical Exam:
PE: 99.3/ 192/96 / 20/ 16/ 97% on RA
gen: tremulous, flushed, NAD
heent: pupils small but reactive
heart: tachycardic, regular no MRG
lungs: clear anteriorly
abdomen: +BS tender diffusely, enlarged liver edge, soft, no
rebound or involuntary guarding.
ext: no c/c/edema
Pertinent Results:
[**2127-7-27**] 10:21AM GLUCOSE-269* UREA N-16 CREAT-0.9 SODIUM-143
POTASSIUM-3.0* CHLORIDE-99 TOTAL CO2-24 ANION GAP-23
[**2127-7-27**] 10:21AM ALT(SGPT)-49* AST(SGOT)-50* ALK PHOS-138*
AMYLASE-59 TOT BILI-1.3
[**2127-7-27**] 10:21AM LIPASE-31
[**2127-7-27**] 10:21AM ALBUMIN-4.6 CALCIUM-10.1 PHOSPHATE-3.1
MAGNESIUM-1.8
[**2127-7-27**] 10:21AM ACETONE-SMALL
[**2127-7-27**] 10:21AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2127-7-27**] 10:21AM WBC-16.0*# RBC-5.69* HGB-14.9 HCT-45.1
MCV-79* MCH-26.2* MCHC-33.1 RDW-15.1
[**2127-7-27**] 10:21AM NEUTS-89.4* LYMPHS-8.1* MONOS-1.9* EOS-0.3
BASOS-0.2
[**2127-7-27**] 10:21AM PLT COUNT-334
[**2127-7-27**] 07:06PM LACTATE-2.2*
[**2127-7-27**] 11:23PM PT-13.2 PTT-21.9* INR(PT)-1.2
[**2127-7-27**] 07:06PM TYPE-ART PO2-87 PCO2-27* PH-7.40 TOTAL
CO2-17* BASE XS--5 INTUBATED-NOT INTUBA
Brief Hospital Course:
1)Cardiovascular instability- HTN likely from not taking home BP
meds (especially catapres) plus withdrawel from methadone.
Tachycardia likely secondary to withdrawal and dehydration. Pt.
was given greater than 7 L of IVF. Once her nausea was under
control, restarted on catapres, lopressor and norvasc at her
home doses.
2)CAD- likely tachy with demand ischemia, ruled out for MI
Pt. continued on asa, plavix, lipitor.
3)DM- Anion gap and ketones were concerning for DKA, however,
gap resolved. Maintained onn ISS, glipizide.
4)FEN/Anion gap- Pt had triple DO--resp alk, anion gap met
acidosis and met alk. Resp alk likely secondary to starvation
ketosis with possible DKA. Anion gap met acidosis likely
secondary to same. Met alkalosis secondary to vomitting plus
contraction. All responded well to agressive fluids.
5)anemia - likely diutional hct drop, got >7L IVF, ? of BRBPR
per pt., but no BM in house. Hct remained stable.
6.)Migraines - 6 times a year. This is not well controlled
given that the incapacitating nausea prevents her from taking
her antihypertensive meds. Pt. was sent on script for prn
phenergen (alerted as allergy, but tolerates per pt. report).
Unfortunately pt. is not a candidate for imitrex given CAD or
TCAs given drug history. Pt. advised to use prn tylenol and
motrin for attacks. Pt. may need a neurology appointment which
should be scheduled by her PCP.
7.)Opiate/benzo addiction - continued on home doses of methadone
and clonopin.
8.)Dispo - cleared by physical therapy.
Medications on Admission:
Metoprolol 125 mg po bid.
Colace 100 mg po bid.
Ranitidine 150 mg po bid.
Aspirin 325 mg po q day.
Insulin on a sliding scale for rehab, regular insulin.
Plavix 75 mg po q day x3 months.
Clonidine 0.1 mg [**Hospital1 **].
Norvasc 10 mg po q day.
Methadone 120 mg po q day.
Glipizide 10 mg po q day.
Amiodarone 200 mg po q day
Discharge Medications:
1. Clonidine HCl 0.1 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
2. Methadone HCl 40 mg Tablet, Soluble Sig: Three (3) Tablet,
Soluble PO QD (once a day).
3. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
5. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
7. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
8. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
11. Promethazine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for nausea for 7 days.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Capital Home Care
Discharge Diagnosis:
Hypertensive urgency
Migraine
Hepatitis B and C
CAD, s/p 2 vessel CABG
Discharge Condition:
good
Discharge Instructions:
Please call your doctor if you have any worsened headache,
nausea/vomiting, or if you unable to take your pills for any
reason.
You should resume your prior medications. We have added
phenergen, to be taken as needed for nausea. Also you may use
tylenol and motrin as needed for your migraines.
Please call your doctor if you have any worsened headache,
nausea/vomiting, or if you unable to take your pills for any
reason.
You should resume your prior medications. We have added
phenergen, to be taken as needed for nausea. Also you may use
tylenol and motrin as needed for your migraines.
Followup Instructions:
Please make an appointment with Dr. [**Last Name (STitle) 3357**] to be seen in [**1-3**]
weeks.
Provider: [**Name10 (NameIs) **] WEST,ROOM ONE GI ROOMS Where: GI ROOMS
Date/Time:[**2127-8-6**] 1:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],[**First Name3 (LF) **] PROCEDURES ENDOSCOPY SUITES Where: [**First Name8 (NamePattern2) **]
[**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) ENDOSCOPY SUITE
Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2127-8-6**] 1:30
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"V45.81",
"401.0",
"070.54",
"070.32",
"276.5",
"346.90",
"304.01",
"292.0",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6196, 6244
|
3274, 4791
|
291, 297
|
6359, 6365
|
2359, 3251
|
7009, 7653
|
2005, 2054
|
5167, 6173
|
6265, 6338
|
4817, 5144
|
6389, 6986
|
2069, 2340
|
235, 253
|
325, 1388
|
1410, 1878
|
1894, 1989
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,451
| 153,403
|
53979
|
Discharge summary
|
report
|
Admission Date: [**2172-4-16**] Discharge Date: [**2172-4-21**]
Date of Birth: [**2094-10-27**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
Melena, Hct drop
Major Surgical or Invasive Procedure:
Endoscopy [**2172-4-19**]
Capsule endoscopy [**2172-4-21**]
History of Present Illness:
77M with history of CAD, s/p CABG in [**2143**], with recent admission
in [**3-/2172**] for NSTEMI s/p DES to the OM1 graft, also found to be
in new a.fib during this admission (not cardioverted) discharged
on aspirin/plavix/rivoroxaban who now presents with
lethargy/fatigue and 15 pt Hct drop over last 2 weeks in setting
of dark stools. He notes that since his discharge he has had
worsening fatigue and increased crampy pain in his legs with
exertion (bilaterally, oppsed to his baseline left leg pain).
He's also had decreased appetite and overall energy. He denies
any abdominal pain, and notes that his stools are well formed
without diarrhea, nausea, or vomiting. He went to his scheduled
vascular appointment today where he was found to be pale, and
noted to have a Hct drop and subsequently referred to the ED.
.
In the ED, VS were 97.9 92 98/51 16 96%ra. Rectal showed dark
G+ stool. Hct 19.7 from 34.8 at last discharge. Retic count is
8.7. Lactate was 1.0. INR 1.3. Electrolytes unremarkable.
EKG showed NSR, no signs of ischemia. 2 PIVs were placed and he
was bolused with protonix and started on ggt. He received 1 L
NS. He was crossed for 2 U PRBC and the first unit was hannging
on transfer. GI was consulted who recommended continuing these
interventions with plan to make NPO after midnight and do EGD in
the AM.
On arrival to the MICU, VS 98.1 72 116/58 13 99% RA. He
feels well and is denying CP, SOB, abd pain, n/v/d.
Past Medical History:
CABG [**2143**]
NSTEMI [**3-/2172**], DES to OM1 graft
Dyslipidemia
hypertension
GERD
PVD
Social History:
Lives alone, previously owns a fabric business, reportedly
maintains an active life style.
Tobacco: >120 pky history, stopped in [**2143**]
Alcohol: occasional.
Illicit drug: denies
Family History:
brother had sudden death at age 36, unknown cause
No other family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
ADMISSION EXAM:
.
Vitals: 98.1 72 116/58 13 99% RA
General: Pale, alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic murmur
throughout precordium
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, trace edema. Well healed
scars on medial right thigh
Discharge:
Vitals- 97.7-98.3, 98-120/49-58, 68-90, 94-96% RA
General- Well appearing elderly male in NAD
HEENT- EOMI, PERRL, MMM, oropharynx clear
Neck- supple, JVP 5cm, no LAD
CV- RRR, normal S1/S2, grade III/VI crescendo murmur heard
throughout precordium, radiating to left axilla.
Lungs- Clear to auscultation bilaterally. No w/c/r
Abdomen- +BS, soft, NT, ND, no hepatosplenomegaly
Ext- warm, well perfused, 2+ DP/PT pulses, no edema
Pertinent Results:
ADMISSION LABS:
[**2172-4-16**] 05:42PM BLOOD WBC-9.4 RBC-2.08*# Hgb-6.0*# Hct-19.7*#
MCV-95 MCH-28.9 MCHC-30.4* RDW-18.9* Plt Ct-628*#
[**2172-4-16**] 05:42PM BLOOD PT-13.8* PTT-34.7 INR(PT)-1.3*
[**2172-4-16**] 05:42PM BLOOD Ret Aut-8.7*
[**2172-4-16**] 05:42PM BLOOD Glucose-123* UreaN-25* Creat-1.0 Na-138
K-4.3 Cl-102 HCO3-24 AnGap-16
[**2172-4-16**] 05:42PM BLOOD LD(LDH)-218 TotBili-0.4 DirBili-0.1
IndBili-0.3
[**2172-4-16**] 05:42PM BLOOD Iron-39*
[**2172-4-17**] 03:53AM BLOOD Calcium-7.9* Phos-3.8 Mg-2.3
[**2172-4-16**] 05:42PM BLOOD calTIBC-345 Hapto-194 Ferritn-27* TRF-265
[**2172-4-16**] 08:11PM BLOOD Lactate-1.0
Discharge labs:
[**2172-4-21**] 07:45AM BLOOD WBC-7.0 RBC-3.25* Hgb-9.9* Hct-32.0*
MCV-98 MCH-30.3 MCHC-30.9* RDW-17.3* Plt Ct-419
[**2172-4-20**] 03:50PM BLOOD Hct-32.6*
[**2172-4-20**] 07:30AM BLOOD WBC-7.4 RBC-3.37* Hgb-10.2* Hct-32.8*
MCV-97 MCH-30.3 MCHC-31.1 RDW-17.6* Plt Ct-444*
[**2172-4-16**] 05:42PM BLOOD Ret Aut-8.7*
[**2172-4-16**] 05:42PM BLOOD calTIBC-345 Hapto-194 Ferritn-27* TRF-265
CXR [**4-17**]: Cardiac size is top normal, accentuated by the
projection. Bibasilar opacities, larger on the right side, are
consistent with likely small pleural effusions and
consolidations. There is mild-to-moderate interstitial edema.
There is no pneumothorax. Sternal wires are aligned. Followup is
recommended to exclude the development of TRALI.
CXR [**4-20**]:
IMPRESSION: Substantial interval improvement of post CABG
pulmonary vascular congestion and left-sided pleural effusion.
EGD [**4-19**]:
Mucosa suggestive of Barrett's esophagus
No blood or bleeding. No abnormality to accound for GI bleeding
Polyp in the second part of the duodenum
Otherwise normal EGD to third part of the duodenum
ECG Study Date of [**2172-4-20**] 5:16:08 PM
Sinus rhythm. Inferior Q waves with T wave inversions. T wave
inversions in
leads V5-V6. Consider inferior myocardial infarction with
lateral involvement. Since the previous tracing of [**2172-4-17**]
minimal change.
Brief Hospital Course:
77 yom with CAD, s/p NSTEMI with DES placed [**3-30**], recent
diagnosis of a. fib, discharged on [**4-1**] on
aspirin/plavix/rivaroxaban now presenting with significant Hct
drop in setting of GI bleed, initially admitted to MICU.
# GI bleed with Hct drop: Hct 19.7 on admission. Given dark
stools without signs of bright red blood, most likely represents
an upper GI bleed in setting of starting aspirin, plavix,
rivaroxaban. He was maintained on protonix ggt and changed to
PO PPI once EGD showed no active bleed. It did however show
barrets esophagus which will need outpt followup. He remained
hemodynamically stable in the MICU s/p 3 U PRBC with Hct
stabilizing in the low 30s. His aspirin/plavix were continued
(though changed to lower dose aspirin) givne recent DES.
Rivaroxaban was held given low daily stroke risk with afib and
discharge plan for this was to continue to hold it. Lisinopril
was held given bleed and was restarted at discharge. Metoprolol
was restarted at a low dose and was restarted on discharge.
# SOB: Pt developed acute SOB on morning of [**4-17**]. CXR showed
concern for volume overload vs. TRALI in setting of blood
transfusion. Received lasix 40mg x1, with significant
improvement in respiratory status .
# Recent NSTEMI: S/p DES in OM1 graft, discharged on
aspirin/plavix. Both were continued given the high risk of
in-stent thrombosis, though aspirin was initially changed to
81mg in-house and changed to 81 mg on discharge. Metoprolol was
continued at lower dose given GI bleed and was changed back to
home dose on discharge. Lisinopril was initially held and
changed back to home dose on discharge. He was continued on
home atorvastatin
# Atrial fibrillation: New onset during recent admission for
NSTEMI. CHADS of 2. No cardioversion performed. He was
maintained on rate control with metoprolol and started
rivaroxaban on that admission. On this admission, he remained
NSR on EKG and tele. Overall has very low daily risk of CVA off
of anticoagulation (~5% yearly risk) so held rivaroxaban with
plan for continued holding on d/c and follow up with PCP/
cardiologist. We also lowered aspirin to 81mg daily per
consultation with cardiology. We continued lower dose
metoprolol given GIB in the MICU and was changed back to home
dose at discharge.
# Thrombocytosis: Pt with Plt of 628 on admission, have been
trending down. Likely represents inflammatory state in setting
of bleed.
# PVD: On cilostazol as outpt for PVD for symptomatic treatment.
This was held while in the MICU and while on the floor. We
continued to hold this at discharge, with consideration of
restarting as an outpatient.
# GERD: Maintained on protonix ggt and then changed to [**Hospital1 **] PPI
# Transitional Issues
-Pt is full code
-Needs outpt follow up for barrett's esophagus
-Restarting cilostazole per PCP.
[**Name10 (NameIs) 27061**] up capsule report per GI
Medications on Admission:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. cilostazol 100 mg Tablet Sig: One (1) Tablet PO bid ().
7. rivaroxaban 15 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
# Acute blood loss anemia
# Gastrointestinal bleed
Secondary diagnosis:
# Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your recent
admission.
You were admitted because of fatigue and dark stools concerning
for a gastrointestinal bleed.
You had an endoscopy, looking at the upper portion of your GI
tract, which did not show any source of a bleed.
You were given blood transfusions, and your blood levels
remained stable prior to discharge.
We did a capsule endoscopy which was pending at the time of your
discharge.
The following changes were made to your medication regimen:
- STOP cilostazol, discuss restarting this medication with your
primary care doctor
- STOP rivaroxaban
- CHANGE Aspirin to 81mg daily asa dosing
Followup Instructions:
Name:[**Name6 (MD) 251**] [**Last Name (NamePattern4) 10729**], MD
Specialty: Primary Care/Cardiology
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
When: Thursday, [**4-23**] at 3:00pm
Please discuss a follow up appointment with a gastroenterologist
and colonoscopy at this visit
|
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icd9cm
|
[
[
[]
]
] |
[
"99.20",
"45.13",
"45.19"
] |
icd9pcs
|
[
[
[]
]
] |
9939, 9945
|
5421, 8335
|
321, 383
|
10107, 10107
|
3392, 3392
|
10932, 11380
|
2203, 2375
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9349, 9916
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9966, 9966
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8361, 9326
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10258, 10909
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4040, 5398
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2390, 3373
|
265, 283
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411, 1873
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10058, 10086
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3409, 4024
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9985, 10037
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10122, 10234
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1895, 1987
|
2003, 2187
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,222
| 127,855
|
19748
|
Discharge summary
|
report
|
Admission Date: [**2110-2-28**] Discharge Date: [**2110-4-8**]
Date of Birth: [**2036-5-26**] Sex: M
Service:HEPATOBILIARY SURGERY SERVICE
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 53382**] is a 73 year old male
with a history of cholangiocarcinoma who is status post left
hepatic lobectomy, cholecystectomy, common duct excision and
pylorosparing Whipple procedure on [**2112-1-11**] who was discharged
on [**2110-2-5**] and was subsequently readmitted on [**2110-2-10**] with a
collection of a subphrenic abscess. He developed at that
time acute renal insufficiency with increased creatinine.
His creatinine stabilized at approximately 2.5 and the
patient had been discharged to home with follow up with the
renal service and the hepatobiliary service. Over the few
days prior to admission he had decreasing urine output. His
PTC drain had had minimal output and his [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drain
had had a large amount of output which was reddish brown in
color.
PAST MEDICAL HISTORY: His past medical history was
significant for cholangiocarcinoma, acute renal
insufficiency, squamous cell carcinoma of the lip,
hypercholesterolemia, question of a prior myocardial
infarction, basal cell carcinoma of the skin, diverticulosis.
PAST SURGICAL HISTORY: Is significant for left hepatic
lobectomy, a pylorosparing Whipple procedure, and multiple
excisions of skin cancer.
FAMILY HISTORY: Is significant for coronary artery disease
and a brother with lung cancer.
SOCIAL HISTORY: Is significant for a 40 pack year smoking
history. He quit 10 years ago. He drinks one to two drinks
a day.
MEDICATIONS UPON ADMISSION: Linezolid, fluconazole,
Protonix, Pancrease, Reglan, ciprofloxacin. He had no known
drug allergies.
PHYSICAL EXAMINATION: On admission patient's vital signs
were 95.0, 76, 122/50, 18, 99 percent on room air. He was in
no apparent distress and was alert and oriented times three.
He was minimally jaundiced without rash. Sclerae were mildly
icteric. He had no jugular venous distension. His lung
sounds were decreased at the bases without crackles. His
heart was regular rate and rhythm with no murmurs. His
abdomen was soft. His [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drain had reddish brown
fluid. His rectal was guaiac positive without masses. He
had 2 to 3 pitting edema of the bilateral lower extremities.
His white count was 8.8, hematocrit 32, platelet 103, total
bilirubin was 19.3. On [**2-24**] his creatinine was 3.3 with a
BUN of 50. His bile grew out VRE on [**2-17**] in addition to 3+
yeast. His prior imaging had been significant for renal
ultrasound which showed no hydronephrosis and left 7 mm renal
stone and good bilateral blood scan. CT scan on [**2110-2-18**] had
revealed stable peripancreatic fluid collection, left renal
stone and diverticulosis. Chest x-ray on [**2110-2-19**] revealed a
right upper lobe opacity and bibasilar atelectasis. The
patient was admitted to the hospital for intravenous fluid
hydration, consultation with the nephrology service,
elevation of his legs, antibiotics, strict I's and O's and
follow up of his liver function tests. On [**2110-3-2**] an
abdominal ultrasound was done to assess for vascular flow in
his liver and kidneys for a complaint of left flank pain.
The ultrasound revealed that patient was status post
hepatectomy and no focal lesions were identified in the rest
of the liver. The right kidney was 10 cm, the left was 11
cm. There was a small nonobstructing stone seen in the left
kidney at the interpolar area. There were no renal masses.
There was normal flow in the portal vein including right and
left branches. The flow in the hepatic artery at that time
could not be demonstrated. There was a normal arterial wave
form in the renal arteries with high resistant indices around
0.8. The patient was continued on antibiotics. On [**2110-3-2**]
he was transfused one unit of packed red blood cells. The
goal for his hematocrit was to keep it above 30. His
hepatitis serologies were checked. His renal function
continued to worsen on [**2110-2-2**]. He was continued on
intravenous fluids and a HIT panel was checked. He was seen
in consultation by the Dermatology Service on [**2110-3-3**]. It
was felt that he had a bullous drug versus scabies rash.
He was seen in consultation by the Plastic Surgical Service.
At that time they thought that there was no consideration for
plastic surgical intervention. They doubt that the lesion on
his anterior temporoparietal area on the right with serous
drainage was suitable for any type of debridement at that
time.
On [**2110-3-4**] the patient had a cholangiogram which was
performed through the patient's current at that time biliary
drainage catheter. This demonstrated a leak similar in size
to the prior study of [**2110-2-14**]. It appeared at the level of
the hepaticojejunal anastomosis. The biliary tree appeared
decompressed and there was rapid flow through the biliary
drainage catheter entering the jejunum. The patient
continued to be stable with adequate urine output on [**2109-3-4**].
His [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drain had approximately 200 cc output a
day. His PTC catheter had about 20 cc drainage per day. His
bilirubin was elevated to 18.2. His creatinine had come down
somewhat. Given his suboptimal fluid status at that time and
his hypovolemia, the patient was transferred to the Surgical
Intensive Care Unit at which time a Swan Ganz catheter was
placed. This was completed without complications.
Dermatology followed up on the biopsy that had been obtained
revealed results consistent with a herpetic disseminated
infection. The physical examination at that time revealed
vesicles with erythematous base.
On [**2110-3-5**] a radial arterial line was also placed. An
Infectious Disease consultation at that time revealed an
assessment of cutaneous disseminated herpetic lesion, likely
varicella zoster. His elevated liver function tests and
right upper lobe infiltrate were suspicious at that time for
visceral involvement. The patient was started on acyclovir.
The infusion was followed with serial chest x-rays. The
patient had a worsening respiratory status. On [**2110-3-6**] his
white count was 5.8. His creatinine was 4.0. His INR was
1.5. He was again transfused a unit of packed cells on
[**2110-3-6**]. His antibiotics at that time consisted of Levaquin,
linezolid and acyclovir. His liver function tests at that
time were significant for an ALT of 206 up from 175, an AST
of 478 up from 301, alkaline phosphatase of 411 up from 410,
amylase of 17, total bilirubin of 18.2 up from 15.4, lipase
of 59 and albumin of 2.5. On [**2110-3-6**] as well as a hepatology
consult was obtained. They thought that a liver biopsy was
not necessary at that time given that it would not affect
management. They did feel that he had possibly metastatic
cholangiocarcinoma with visceral involvement. He
Enterobacter was repeated on [**2110-3-7**]. He also had a worsening
pulmonary status and renal status. He did have some bleeding
from his upper airway. At that time it was felt that he had
disseminated HSV. He was continued on acyclovir. His PT on
[**2110-3-7**] was 16.3, INR of 1.3 and his creatinine was 4.4 up
from 4.2. His albumin was 2.5. His AST was 729 and ALT was
261.
The patient through the next several days demonstrated septic
physiology and required fresh frozen plasma and platelet
products. He also required Levophed drip for blood pressure
support in light of his septic physiology. At this point he
was started on Lasix and which did allow us to diurese him to
some small amount. At this time he was also started on
CCVHD. He demonstrated a metabolic acidosis and
coagulopathy. He also had varicella pneumonia and varicella
hepatitis. On [**2110-3-9**] an arterial line was placed without
complication. At this time he was continued on antibiotics
and CCVHD for his renal failure. He was pancultured. A
family meeting was held on [**2110-3-10**] to discuss the current
status and prognosis with the family. It was agreed at that
point that we would continue aggressive therapy include
CCVHD, high dose acyclovir and intubation if necessary.
However, at that time it was decided that the patient would
not be made Do Not Resuscitate. Also on [**2110-3-10**] a right
internal jugular line was placed without complication. In
the evening of that day the patient was intubated for
respiratory distress. Arterial blood gas was 7.33, 61, 64,
34 and 3. An Intensive Care Unit attending was present for
the intubation. The patient was on Levophed as well as
propofol for sedation and was being ventilated in assist
control mode. He continued to be followed by the Infectious
Disease staff on high dose acyclovir.
He had an episode of rapid atrial fibrillation on [**2110-3-12**]. He
was started on amiodarone. Cardioversion was attempted but
the patient did not convert. A right subclavian line was
placed on the 8th without complication. The patient was
continued on CCVHD throughout this time. On [**3-17**] a chest x-
ray revealed improvement in the patient's pulmonary edema. A
CT scan at that time revealed bilateral peribronchial
opacities and bilateral pleural effusions. There was a
slight interval decrease in the size of the peripancreatic
fluid collection and a nonobstructing left renal stone. A
cholangiogram on [**2110-3-21**] revealed a decompressed intrahepatic
bile duct with a continued anastomotic leak. The distal
aspect of the catheter was clotted off and there was no
passage of contrast at that time into the small bowel. A
successful placement of a new #10 French modified nephrostomy
tube was completed. Side holes were created in addition
above the anastomotic leak. A post placement cholangiogram
demonstrated appropriate positioning of the tube with the
side holes draining into the intrahepatic biliary duct and
distal pigtail within the small bowel. The patient underwent
a bronchoscopy which revealed copious secretions which were
suctioned from the right upper lobe and right lower lobe.
Patient was started on Argatroban at that time as well.
Patient continued to be resuscitated with fresh frozen plasma
and platelets throughout his hospital course. He had
worsening hematologic parameters and continued to require
CCVHD. He was maintained on total parenteral nutrition
throughout his hospitalization. When the patient's
amiodarone was discontinued he did recur into rapid atrial
fibrillation. The patient was at this point unable to wean
from the respiratory support that he had been receiving. He
also continued to require total parenteral nutrition.
On [**2110-3-27**] a repeat ultrasound was done due to his biliary
drainage which had decreased output and continuously rising
bilirubin. This revealed a liver that normal in
echogenicity. There was no ductal dilatation. The portal
vein as well as the hepatic veins were noted to be patent and
with proper directional flow. The inferior vena cava was
patent. The right kidney was 10 cm without hydronephrosis.
There was a small right pleural effusion. The patient
remained on fluconazole, Vancomycin and Zosyn at this time.
His white count on [**2110-3-27**] was 17,000 with a hematocrit of 29
and a platelet count of 55. His INR was 2.7 with a PTT of
71.4. His lactate was 2.1 and albumin of 2.7. His total
bilirubin was 59. His alkaline phosphatase was 893, ALT of
45 and an AST of 112. Throughout this time the patient
remained on Levophed. His antibiotics were on the 24th
Zosyn, Vancomycin and fluconazole. His white count was
20,000. His culture data at that time showed a negative
urine, a negative sputum although a bronchoalveolar lavage
revealed no fungal and no viral cultures. Negative blood
cultures. His swab head confirmed varicella antigen test.
His [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drain had [**Female First Name (un) 564**] albicans. His C.
Difficile was negative and his catheter tips were all
negative multiple times. He was more alert on [**2110-3-30**]. His
bilirubin was 44 and his white count was 20,000 which was
elevated. At that time he was scheduled for tracheostomy.
This was performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2110-3-30**] and was
uncomplicated. For the details of that procedure please see
the dictated operative note.
On [**2110-3-31**] he had a chest x-ray which revealed continued
small bilateral pleural effusions and bilateral patchy
opacities with a residual opacity in the right mid lung. His
varies lines were in the proper position at that time. This
was the last chest x-ray that he had. He was bronchoscoped
on [**2110-3-31**] which revealed a thick blood clot completely
obstructing the left main bronchus. This was suctioned out.
He had persistent acidemia. His gas remained adequate at
that time. However, it was also clear that the patient was
not making progress. He had increased ventilator requirement
and an acidosis on CVH. He had increased coagulopathy and
was requiring fresh frozen plasma. His liver function tests
were elevated and his mental status on [**4-1**] was decreased.
The family at that time was updated by the attending
physician of the patient's status and elected at that time to
continue his current care. However, the patient did continue
to do poorly. He continued with full supportive measures.
He was febrile and continued to require ventilatory support
on these first few days of [**Month (only) 116**]. He was continued on pressors
including Levophed and Pitressin. He was continued on total
parenteral nutrition at that time. He was exhibiting multi
organ failure. His total bilirubin was 37 with a lactate of
2.2. His liver function tests were significant for an ALT of
78 and 252. There was a family meeting on [**4-7**] at which time
the decision was made to make the patient CMO on [**2110-4-8**].
This was done and the patient expired on [**2110-4-8**]. He was
pronounced dead at 1729 P.M. of cardiopulmonary arrest
secondary to multi organ failure originating from
disseminated varicella Zoster infection. The family was
present at the time of the patient's death.
CONDITION ON DISCHARGE: Patient expired.
DISCHARGE STATUS: As above.
DISCHARGE DIAGNOSES:
1. Cholangiocarcinoma.
2. Acute renal insufficiency.
3. Blood loss anemia.
4. Hypovolemia.
5. Atelectasis.
6. Cardiopulmonary arrest.
7. Hypercholesterolemia.
8. History of myocardial infarction.
9. Status post tracheostomy.
10. Disseminated varicella Zoster.
11. Multi organ failure.
12. Anastomotic leak from prior biliary anastomosis.
13. Liver failure.
14. Requirement for parenteral nutrition.
15. Varicella Zoster.
16. Bilateral pneumonia.
17. Bilateral pleural effusions.
18. Rapid atrial fibrillation.
19. Delirium.
20. Respiratory failure requiring intubation.
21. Failure to thrive requiring total parenteral
nutrition.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD,PHD[**Numeric Identifier **]
Dictated By:[**Last Name (NamePattern1) 53385**]
MEDQUIST36
D: [**2110-4-25**] 16:25:42
T: [**2110-4-25**] 18:00:08
Job#: [**Job Number 53386**]
|
[
"052.1",
"196.2",
"518.82",
"287.4",
"286.6",
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"197.7",
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] |
icd9cm
|
[
[
[]
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] |
[
"96.56",
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"38.91",
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"39.95",
"87.54",
"31.29",
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] |
icd9pcs
|
[
[
[]
]
] |
1475, 1551
|
14509, 15480
|
1340, 1458
|
1833, 14415
|
188, 1049
|
1708, 1810
|
1072, 1316
|
1568, 1693
|
14440, 14488
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,966
| 104,373
|
28469
|
Discharge summary
|
report
|
Admission Date: [**2136-9-10**] Discharge Date: [**2136-9-11**]
Date of Birth: [**2059-5-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Cardiac arrest
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
Mr. [**Known lastname **] is a 77 year old male with PMH significant for CAD
with 2 prior bypass surgeries and 2 PCIs, PAD s/p carotid
stenting and per patient b/l LE bypass, hypertension,
hyperlipidemia, chronic stable angina who presented with a VF
arrest.
His wife describes that the patient was awoken by tooth pain
overnight yesterday that did not resolve with Percocet or
Ambien; she adds that he has had difficulty sleeping for the
past 2 weeks due to increasing chest discomfort at rest. The
patient also has had palpitations and SOB with exertion that
seemed to be worsening over the past 4-6 weeks. The patient also
describes occasional L arm pain in shoulder. One month ago he
had a exercise stress test at [**Hospital1 3278**] to evaluate these worsening
symptoms- this showed poor exercise toleranace and so the
patient underwent diagnostic cath showing patent CABG grafts,
patent stents, no new occlusions. Of note, the patient stopped
taking Ranexa two weeks ago because of diarrhea side effects; he
associates his worsening symptoms with this. He has extensive
CAD and vascular history as outlined below but has no history of
arrythmis or syncope.
Today, the patient experienced his chronic anginal chest pain
while walking to the board of directors meeting for the
hospital. During the meeting, the patient became unresponsive
and was found to be pulseless; CPR was initiated and the patient
was intubated. Cardiac monitoring demonstrated VF and a 360J
shock was delivered, and chest compressions were continued. The
patient immediately returned to a normal perfusing rhythm, and
was extubated.
He was transferred to the [**Hospital Unit Name 153**]. While in the [**Hospital Unit Name 153**], the patient
was complaining of [**7-24**] sub-sternal chest pain, EKG showed
depressions in I, II, III, aVF, V4-V6. Patient was given ASA and
a bolus of lidocaine. Underwent catheterization which
demonstrated patent stents and LIMA and prominent severe AR.
ROS negative except as for described above.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes +, Dyslipidemia +,
Hypertension +
2. CARDIAC HISTORY: CAD: CABG x2 [**45**] years; Cath x3 with 2
stents placed, last 2 years ago; Carotid endarterectomy 3 years
ago
3. OTHER PAST MEDICAL HISTORY:
OSA on CPAP
HTN
HL
DM
Osteoporosis
Social History:
Smokes [**12-17**] ppd
EtOH- daily wine. Occasional vodka/irish whiskey.
Family History:
CAD with MI on both mother and fathers side of the family
Physical Exam:
GENERAL: Oriented x3 and in NAD. Mood, affect appropriate.
HEENT: NCAT. Moist mucous membranes.
CARDIAC: RR, normal S1, S2. Harsh systolic murmur loudest at
RUSB with no radiation to carotids or axilla.
LUNGS: No chest wall deformities. Resp unlabored, no accessory
muscle use. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND.
EXTREMITIES: No lower extremity edema. Bandages in bilateral
groins, without oozing or erythema.
PULSES: Pedal pulses detectable on doppler.
Pertinent Results:
[**2136-9-10**] 05:38PM BLOOD WBC-6.7 RBC-3.46* Hgb-12.4* Hct-37.5*
MCV-108* MCH-35.9* MCHC-33.1 RDW-14.2 Plt Ct-157
[**2136-9-10**] 09:35PM BLOOD WBC-7.7 RBC-3.34* Hgb-12.0* Hct-36.8*
MCV-110* MCH-35.9* MCHC-32.6 RDW-15.1 Plt Ct-155
[**2136-9-11**] 05:51AM BLOOD WBC-4.9 RBC-3.04* Hgb-11.2* Hct-32.5*
MCV-107* MCH-36.9* MCHC-34.5 RDW-15.2 Plt Ct-131*
[**2136-9-10**] 05:38PM BLOOD Neuts-55.8 Lymphs-38.4 Monos-4.5 Eos-0.8
Baso-0.5
[**2136-9-10**] 05:38PM BLOOD PT-13.0 PTT-24.1 INR(PT)-1.1
[**2136-9-11**] 05:51AM BLOOD PT-12.5 PTT-24.6 INR(PT)-1.1
[**2136-9-11**] 05:51AM BLOOD Plt Ct-131*
[**2136-9-10**] 05:38PM BLOOD Glucose-145* UreaN-51* Creat-1.8* Na-140
K-4.2 Cl-104 HCO3-19* AnGap-21*
[**2136-9-10**] 09:35PM BLOOD Glucose-112* UreaN-45* Creat-1.4* Na-138
K-4.3 Cl-106 HCO3-21* AnGap-15
[**2136-9-11**] 05:51AM BLOOD Glucose-134* UreaN-33* Creat-1.2 Na-137
K-4.0 Cl-106 HCO3-23 AnGap-12
[**2136-9-10**] 05:38PM BLOOD ALT-123* AST-187* LD(LDH)-354*
CK(CPK)-168 AlkPhos-59 TotBili-0.3
[**2136-9-10**] 09:35PM BLOOD CK(CPK)-1058*
[**2136-9-11**] 05:51AM BLOOD CK(CPK)-1647*
[**2136-9-10**] 05:38PM BLOOD CK-MB-8 cTropnT-<0.01
[**2136-9-10**] 09:35PM BLOOD CK-MB-27* MB Indx-2.6 cTropnT-0.21*
[**2136-9-11**] 05:51AM BLOOD CK-MB-27* MB Indx-1.6 cTropnT-0.12*
[**2136-9-10**] 05:38PM BLOOD Albumin-4.4 Calcium-9.1 Phos-4.9* Mg-1.7
Cholest-129
[**2136-9-11**] 05:51AM BLOOD Calcium-8.3* Phos-2.3* Mg-2.0
[**2136-9-10**] 05:38PM BLOOD Triglyc-158* HDL-49 CHOL/HD-2.6
LDLcalc-48
CT Head ([**2136-9-11**])- IMPRESSION: No acute intracranial hemorrhage.
No evidence of hypoxic
ischemic injury.
Brief Hospital Course:
Patient was admitted to the CCU after going into cardiac arrest.
Prior to arrival to CCU, a code STEMI was called and patient
underwent cardiac catheterization. Prior grafts and stents were
patent and now new coronary lesions were found. Patient
remained hemodynamically stable and was alert and oriented after
the procedure. While in the CCU, he was monitored closely. He
denied any further episodes of angina, shortness of breath, or
palpitations. He was started on metoprolol 12.5mg TID and
continued on his other home medications including aggrenox,
rousvastatin, valsartan and plavix. His chest pain was
attributed to compression and was controlled with percocet and a
lidocaine patch. Follow-up EKG's did not show any new ST
changes. Post-cath check was normal and he did well overnight.
He underwent a head CT which did not show any acute intracranial
pathology or evidence of hypoxic ischemic injury.
He is being transferred to [**Hospital 3278**] Medical Center as his primary
cardiologist, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14714**], is based there. He will need an
EP consult for ICD placement.
Medications on Admission:
Aggrenox (ASA+Dipyrimadole) (25/200) AM, PM
Allopurinol 300 mg AM
Crestor (Rosuvastatin) 40 mg AM
Diovan (Valsartan) 80 mg AM
Folic acid, 5 pills PM
Lasix 20 mg AM
Isosorbide (Imdur) 60 mg AM
Namenda (Memantine) 10 mg [**Hospital1 **] (AM, PM)
Niaspan (Niacin) 750 mg PM
Plavix 75 mg PM
Tricor (Fenofibrate) 145 mg AM
Zetia (Ezetimibe) 10 mg PM
Boniva 150 mg AM (once monthly)
Ipratropium Spray (.06%) as needed
Nitrolingual Spray as needed
Zolpidem Tartrate (Ambien) - as needed
Calcium Citrate +D (600/300)
Mucinex 600 mg [**Hospital1 **] (AM, PM)
ToprolXL 25mg daily
Zyrtec 10 mg PM
Discharge Medications:
1. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
3. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO BID (2 times a day).
4. Niacin 250 mg Capsule, Sustained Release Sig: Three (3)
Capsule, Sustained Release PO DAILY (Daily).
5. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q6H (every 6 hours) as needed for
shortness of breath.
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Folic Acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily).
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every eight (8) hours as needed for pain.
13. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO ONCE (Once)
for 1 doses.
15. Namenda 10 mg Tablet Sig: One (1) Tablet PO once a day.
16. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
17. Boniva 150 mg Tablet Sig: One (1) Tablet PO once a month.
18. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
19. Mucinex 600 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day as needed for cough.
20. Medication
Calcium Citrate +D (600/300) daily
21. Nitromist 0.4 mg/Dose Aerosol Sig: One (1) spray
Translingual once a day as needed for chest pain.
Discharge Disposition:
Extended Care
Facility:
other
Discharge Diagnosis:
Primary: Cardiac Arrest
Secondary: Coronary artery disease, aortic stenosis, aortic
regurgitation, hypertension, hyperlipidemia, diabetes mellitus
Discharge Condition:
Alert and oriented
Vital signs stable.
Discharge Instructions:
You were admitted to the Cardiac Care Unit after going into
cardiac arrest yesterday afternoon. You underwent resuscitation
with return of your heart function. A cardiac catheterization
was performed which did demonstrated that your cardiac anatomy
was stable. There were no new coronary lesions. You remained
hemodynamically stable while here. You are being transferred to
[**Hospital 3278**] Medical Center for further management.
No changes were made to your medications.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 69015**] on discharge from [**Hospital 3278**]
Medical Center
Completed by:[**2136-9-12**]
|
[
"401.9",
"250.00",
"414.00",
"733.00",
"424.1",
"305.1",
"278.00",
"327.23",
"V45.82",
"427.41",
"427.5",
"V45.81",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
8604, 8636
|
4996, 6142
|
329, 355
|
8830, 8871
|
3377, 4973
|
9400, 9541
|
2802, 2861
|
6778, 8581
|
8657, 8809
|
6168, 6755
|
8895, 9377
|
2876, 3358
|
2515, 2628
|
275, 291
|
383, 2404
|
2659, 2695
|
2426, 2494
|
2711, 2786
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,320
| 154,445
|
1056
|
Discharge summary
|
report
|
Admission Date: [**2117-9-12**] Discharge Date: [**2117-9-13**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
coffee ground emesis
Major Surgical or Invasive Procedure:
placement of R femoral Cordis resuscitation line
History of Present Illness:
87 yo F with multiple medical problems who presents with coffee
ground emesis from [**Hospital **] rehab.
.
In the ED the patient had NG lavage that showed 200cc coffee
ground emesis. Additionally the patient received 5 L NS and 2U
of PRBCs. Additionally she was given vancomycin, flagyl, and
levofloxacin for concern of infection. CXR showed possible free
air and surgery was contact[**Name (NI) **]. However, it was confirmed that
the family does not want surgery and thus the patient did not
have a formal [**Doctor First Name **] consult. BPs were briefly low in the ED and
the patient was started on levophed. However after further
discussions with the family it was determined that the family
would like to direct the care more towards comfort and the
levofed was stopped.
.
Upon arrival to the MICU the patient appeared to be in pain.
After extensive family discussion, they decided that the patient
should not be intubated and would not be a candidate for
surgery. Additionally they would like to keep the patient
comfortable.
Past Medical History:
1. Diabetes
2. HTN
3. Hypercholesterolemia
4. Arthritis
5. Hypothyroid
6. S/p nephrectomy for renal cell ca done in 94 at BU
7. MRegurgitation
8. Chronic abdominal pain
9. H/o pancreatitis
10. pancreas divisum
11. hiatal hernia repair
12. left colectomy [**3-12**] [**Location (un) 6553**] b 2 colon cancer with neg nodes
13. ccy
Social History:
No tob, no etoh, no narcotics, lives in [**Hospital1 **] House. Three
daughters, currently seeking healthcare proxy.
Family History:
NC
Physical Exam:
VS: T 96.8 Hr 63 BP 119/93 RR 20 02 93% 3L-->15LNRB
GEN: no acute distress
HEENT: PERRLA, sclera anicteric, thick white paste on sides of
tongue, MMM
CV: Regular, nl s1, s2, no m/r/g.
PULM: coarse breath sounds bilaterally
ABD: Soft, RUQ tenderness to deep palpation, no clear rebounding
or guarding. ND, surgical incision with surgical staples in
place, edges black/dark brown, firm to touch, no exudate, drains
in place draining clear serosanginous fluid at midline, + BS, no
HSM.
EXT: Warm, 1+ dp/radial pulses BL, + 2 edema in lower and upper
extremities.
NEURO: somnolent, moves all extremities
Pertinent Results:
[**2117-9-12**] 02:20PM WBC-17.9*# RBC-3.23* HGB-9.7* HCT-29.8*
MCV-92 MCH-30.0 MCHC-32.5 RDW-17.9*
[**2117-9-12**] 02:20PM NEUTS-83.0* BANDS-0 LYMPHS-15.0* MONOS-1.9*
EOS-0 BASOS-0.1
[**2117-9-12**] 02:20PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2117-9-12**] 02:20PM PLT SMR-NORMAL PLT COUNT-190
[**2117-9-12**] 02:20PM GLUCOSE-170* UREA N-92* CREAT-4.1*#
SODIUM-146* POTASSIUM-4.2 CHLORIDE-123* TOTAL CO2-12* ANION
GAP-15
[**2117-9-12**] 02:34PM LACTATE-4.3*
[**2117-9-12**] 08:23PM FIBRINOGE-374 D-DIMER-1687*
[**2117-9-12**] 08:23PM PT-21.7* PTT-44.3* INR(PT)-2.1*
CXR: Two bedside AP views labeled "supine, left at 15:45" and
"upright at 16:15" are compared with study dated [**2117-9-1**]. The
upright view demonstrates an unusual rounded lucency at the
medial aspect of the lower right hemithorax, which appears
bounded by a thin curvilinear structure, and pneumoperitoneum
cannot be excluded. There is no definite evidence of
subdiaphragmatic air in the left hemithorax. Since that time,
left-sided central venous catheter has been removed, and an NG
tube has been inserted, with its tip roughly at the level of the
GE junction and its side hole at approximately the level of the
carina. There is cardiomegaly with LV enlargement and pulmonary
vascular congestion and blurring, indicative of mild CHF, more
marked since study dated [**2117-9-1**]. There is also dense
retrocardiac opacity, and pneumonic consolidation in this region
cannot be excluded. Again demonstrated are surgical clips in the
upper central and skin staples in the left abdomen.
Brief Hospital Course:
87 yo F with history of HTN, C diff, guaiac pos stools, colon
cancer, renal insufficiency, who presented with coffee ground
emesis and hypotension.
Sepsis, with hypotension, leukocytosis, and peritoneal signs,
also elevated lactate. Also, patient had AXR suspicious for
pneumoperitoneum and heme labs consistent with DIC and coffee
ground emesis concerning for gastritis or other source of upper
GI bleeding. Resuscitated to the extent possible with IV fluids
and started broad spectrum antibiotics; a large-bore femoral
line was placed in the emergency room for this purpose. Family
reiterated that the patient would not want to be kept alive with
invasive measures such as mechanical ventilation or hemodynamic
monitoring, and specifically noted that the patient would not
vasopressors. In keeping with these wishes, patient's family
also declined surgical consultation.
After volume resuscitation with several liters of saline, it
became apparent that she would not survive without invasive
measures such as these, and so the family agreed to focus on
keeping the patient comfortable and her status was changed to
Comfort Measures Only. Antibiotics and fluids were discontinued.
Morphine was administered for comfort and patient subsequently
expired on hospital day 2.
Medications on Admission:
pantoprazole 40 mg [**Hospital1 **]
Iron 325 mg daily
labetolol 100 mg [**Hospital1 **]
Ritalin 5 mg [**Hospital1 **]
Combivent q4 prn
ISS (regular)
NTG transdermal .2mg/hr
Levothyroxine 150mcg
Citalopram 10 mg daily
MVI
Amiodarone 200 mg daily
hep sc
tramadol 50 mg q8h
metronidazole 500 mg q8h
glargine insulin 4 U QHS
NTG prn SBP >150
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Diabetes
2. HTN
3. Hypercholesterolemia
4. Arthritis
5. Hypothyroid
6. S/p nephrectomy for renal cell ca done in 94 at BU
7. MRegurgitation
8. Chronic abdominal pain
9. H/o pancreatitis
10. pancreas divisum
11. hiatal hernia repair
12. left colectomy [**3-12**] [**Location (un) 6553**] b 2 colon cancer with neg nodes
13. cholecystectomy
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"578.9",
"584.9",
"585.9",
"250.00",
"038.9",
"995.92",
"403.90",
"276.51",
"V10.05",
"785.52",
"008.45",
"V10.52",
"244.9",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5908, 5917
|
4215, 5491
|
290, 341
|
6303, 6313
|
2557, 4192
|
6365, 6508
|
1916, 1920
|
5880, 5885
|
5938, 6282
|
5517, 5857
|
6337, 6342
|
1935, 2538
|
230, 252
|
369, 1412
|
1434, 1765
|
1781, 1900
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,743
| 129,308
|
10063
|
Discharge summary
|
report
|
Admission Date: [**2198-10-4**] Discharge Date: [**2198-10-14**]
Date of Birth: [**2124-1-13**] Sex: M
Service: MEDICINE
Allergies:
Hydrochlorothiazide
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
nausea, vomiting
Major Surgical or Invasive Procedure:
upper endoscopy x4 with thermal therapy, endovascular clips
History of Present Illness:
74yo gentleman with h/o CAD s/p CABG 1 month ago, DM, HTN, PVD,
and AFib on amiodarone but not coumadin admitted with 1 day of
nausea, vomiting and diarrhea, found to have a GI bleed.
Mr. [**Known lastname 174**] was in his usual state of health until the afternoon
of presentation, when he could not finish a bowl of soup because
of increasing nausea. He felt his stomach was upset and had
emesis x 6. He is unable to describe whether the emesis was
bloody. He than had about 6 black, loose BMs. He cannot
describe if there was an odor or if they were sticky/tarry. He
was able to keep ice water down but could not tolerate other po.
He was feeling weak, and so he came to the ED. Of note, he was
recently admitted [**Date range (1) 33625**] with some nausea and diarrhea as
well as ARF. His symptoms resolved with IV fluids and he
reports that the nausea did not return until yesterday.
In the ED, initial VS were 97.8 72 162/91 22 98%.
Rectal exam revealed maroon stool and NG lavage produced 150ml
of coffee grounds. He was given flagyl 500mg IV, zofran 4mg IV
and protonix 40mg IV. He also received 1L NS and transfusion of
2 units of PRBCs was started. GI and cardiac surgery were
contact[**Name (NI) **] and will see the patient in the morning.
Upon arrival to the MICU, he denies chest pain, shortness of
breath, abdominal pain, or recent fevers. He is thirsty.
Past Medical History:
CAD s/p CABG on [**9-/2198**]: LIMA to LAD, SVG to DIAG, SVG to OM, SVG
to PDA
DM
HTN
PVD
AFib with RVR 2 weeks after CABG, on amiodarone
CKD baseline Cr 3.0-3.7
Anemia baseline Hct 24-29
Admission [**Date range (1) 33626**]: Right LE cellulitis at vein harvest site,
Cx grew Pseudomonas, on cipro and linezolid until [**10/2198**]
Hyperlipidemia
s/p L CEA [**9-10**]
Gangrene of L foot (tips of 4th and 5th digits)
Gout
Osteoarthritis
Cataracts
PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
All: HCTZ--does not know reaction
Social History:
Quite smoking in [**2182**]. No alcohol in last month but prior to
that was 2 drinks one night per week. Lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **].
Uses a walker. He had a VNA coming every other day.
Family History:
Father died of a stroke, mother died of blood clot.
Physical Exam:
96.5 75 136/46 20 96% RA.
Pale appearing man in no acute distress but keeps his eyes
closed during most of interview.
EOMI, pupils equal b/l
Neck: scar on left neck, no carotid bruits. Supple.
S1, S2, RRR, no murmur but distant heart sounds.
Lungs clear b/l. No wheeze or crackle.
Abd +BS, soft, NT, ND.
Ext: Dopplerable pulses at DP b/l. Right LE is mildly pink and
more swollen as compared to left; there is a bandage over a 3 x
5cm ulcerated area on his inner calf.
Pertinent Results:
Hct has trended downward multiple times during the course of the
admission. The patient CRI was stable with similiar BUN/Cr
throughout the course of the admission with Cr in 3.5 range.
Patient had completed ROMI. In MICU patient developed lactate
levels to 5.6, which resolved with appropriate tranfusion and
fluid resus.
QTc was monitored as there is an interaction between
claritromycin and amiodrone. QTc remainined within consistent
range through the course of the admission.
Esophageal brushings showed Fungal forms, consistent with
[**Female First Name (un) 564**] species.
Thursday, [**2198-10-4**] Endoscopist(s): [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD
[**First Name8 (NamePattern2) **] [**Last Name (Titles) **], MD
Patient: [**Known firstname **] [**Known lastname **]
Ref.Phys.:
Birth Date: [**2124-1-13**] (74 years) Instrument:
ID#: [**Numeric Identifier 33627**] ASA Class: P2
Medications: Versed 2 mg
fentanyl 100mcg
Indications: melena
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
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:
Mucosa: Grade 2 esophagitis with no bleeding was seen in the
lower third of the esophagus.
Stomach:
Excavated Lesions Multiple cratered non-bleeding ulcers ranging
in size from 1cm to 2cm were found in the stomach body.
Duodenum:
Excavated Lesions A single superficial non-bleeding 3cm ulcer
was found in the duodenal bulb.
Other
procedures: Two cold forceps biopsies were performed for
exclusion of H-pylori at the stomach antrum.
Impression: Grade 2 esophagitis in the lower third of the
esophagus
Ulcers in the stomach body
Ulcer in the duodenal bulb
(biopsy)
Otherwise normal EGD to second part of the duodenum
Date: Monday, [**2198-10-8**] Endoscopist(s): [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3708**], MD
[**First Name8 (NamePattern2) **] [**Last Name (Titles) **], MD
Patient: [**Known firstname 12056**] [**Known lastname 174**]
Ref.Phys.:
Assisting Nurse(s)/
Other Personnel: [**Name6 (MD) **] [**Name8 (MD) **], RN
Birth Date: [**2124-1-13**] (74 years) Instrument: GIF H180
ID#: [**Numeric Identifier 33627**]
Medications: Cetacaine topical spray
Fentanyl 100 micrograms
Midazolam 2mg
Indications: Melena
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
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 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 improvement of previously seen esophagitis. White
material seen in esophagus and stomach which is likely the
Carafate. was able to wash off.
Stomach:
Excavated Lesions Multiple cratered ulcers ranging in size from
5mm to 15mm were found in the stomach body, posterior wall and
greater curvature. One of the ulcers showed oozing peripherally.
A gold probe was applied for hemostasis successfully.
Duodenum:
Excavated Lesions A single oozing erosion was seen in the
duodenal bulb.
Other A bulging area was seen in 2nd part of duodenal wall
which can be due to an extrinsic mass.
Impression: Improvement of previously seen esophagitis. White
material seen in esophagus and stomach which is likely the
Carafate. was able to wash off.
Ulcers in the stomach body, posterior wall and greater
curvature. (thermal therapy)
Erosion in the duodenal bulb
A bulging area was seen in 2nd part of duodenal wall which can
be due to an extrinsic mass.
Otherwise normal EGD to third part of the duodenum
Date: Tuesday, [**2198-10-9**] Endoscopist(s): [**Name6 (MD) **] [**Name8 (MD) 33628**], MD
Patient: [**Known firstname 12056**] [**Known lastname 174**]
Ref.Phys.: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Assisting Nurse(s)/
Other Personnel: [**First Name4 (NamePattern1) 2270**] [**Last Name (NamePattern1) 33629**], RN
[**Name6 (MD) 33630**] [**Name8 (MD) 33631**], RN
Birth Date: [**2124-1-13**] (74 years) Instrument: GIF H180
ID#: [**Numeric Identifier 33627**] ASA Class: P2
Medications: Cetacaine topical spray
Midazolam 2.5 mg IV
Fentanyl 100 mcg IV
Indications: melena
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
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 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:
Lumen: A Schatzki's ring was found in the gastroesophageal
junction. A medium size hiatal hernia was seen.
Mucosa: Diffuse erythematous mucosa was noted in the lower
third of the esophagus and middle third of the esophagus.
Other There were multiple whitish-yellow plaques throughout the
esophagus, suggestive of [**Female First Name (un) **]. Samples were obtained for
microbiology using a brush.
Stomach:
Mucosa: Diffuse continuous erythema of the mucosa with no
bleeding was noted in the whole stomach.
Excavated Lesions Multiple superficial non-bleeding ulcers were
found in the stomach body. One had stigmata of recent cautery.
There was no active bleeding from any of these ulcers.
Duodenum: Normal duodenum.
Other
findings: Upon entering the duodenum, there was fresh blood in
the blood. The blood continued to pool. 2 cc.Epinephrine
1/[**Numeric Identifier 961**] was injected into the bleeding area with success. The
bleeding stopped completely with injection of epi. There was an
erythematous fold in the duodenum, in the area of bleeding. This
corresponded to the ulcer seen in the duodenum at the first
endoscopy. It was difficult to actually visualize an ulcer , but
there was a significant amount of erythema and edema. Two
endoclips were successfully applied for the purpose of
hemostasis.
Impression: Erythema in the lower third of the esophagus and
middle third of the esophagus
There were multiple whitish-yellow plaques throughout the
esophagus, suggestive of [**Female First Name (un) **]. (brushing)
Erythema in the whole stomach
Ulcers in the stomach body
Medium hiatal hernia
Schatzki's ring
Upon entering the duodenum, there was fresh blood in the blood.
The blood continued to pool. (injection, endoclip)
Otherwise normal EGD to third part of the duodenum
Date: Friday, [**2198-10-12**] Endoscopist(s): [**Name6 (MD) **] [**Name8 (MD) 33632**], MD
[**First Name8 (NamePattern2) **] [**Last Name (Titles) **], MD
Patient: [**Known firstname 12056**] [**Known lastname 174**]
Ref.Phys.:
Birth Date: [**2124-1-13**] (74 years) Instrument:
ID#: [**Numeric Identifier 33627**] ASA Class: P2
Medications: Versed 2 mg
fentanyl 75 mcg
Glucagon 0.5 mg
Indications: ANEMIA -ACUTE POST-HEMO
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
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 1st 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:
Mucosa: Patchy candidiasis was seen in the middle third of the
esophagus and lower third of the esophagus.
Stomach:
Excavated Lesions Multiple cratered,serpiginous non-bleeding
ulcers ranging in size from 5mm to 10mm were found in the
stomach body .
Duodenum:
Excavated Lesions A single non-bleeding 4mm ulcer was found in
the duodenal bulb.
Other
findings: a previously placed bulbal clip was seen on the top of
the small DU.
Impression: Esophageal candidiasis
Ulcers in the stomach body
Ulcer in the duodenal bulb
A previously placed bulbal clip was seen on the top of the small
DU.
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
74yo gentleman with h/o DM, HTN, CAD s/p recent CABG, and AFib
not on coumadin admitted with upper GI bleed. GI bleed was
clinically concerning and the patient was transferred to the
MICU and was transfused 3 units and given fluid resus with
appropriate resolution of the lactate levels. Despite the
patient having CAD and being s/p CABG, ASA was held because of
the GI bleeding. Patient underwent endoscopy which was
consistent with esophagitis. Patient remained hemodynamically
stable and was transferred to the floor. The patient's Hct
continued to slowly trend downward and the patient was
transfused an additional 7 units through the course of the
admission. Patient was started on PPI [**Hospital1 **] and sulcralfate.
Esophageal brushings showed [**Female First Name (un) **] non-invasive and the patient
was started on Nystatin. Because of the continued GI bleed
manifested by the declining Hcts, the patient was scoped an
additional three times. Patient was found to be H pylori
positive and was started on Flagyl 500mg PO TID and
claritromycin 500mg PO Q12H. Patient underwent thermal therapy
and endovascular clipping with EGD at multiple sites. QTc was
monitored because of concern of QT prolongation as an
interaction between claritromycin and amiordrone. Additionally,
the patient was monitored for rhabdomyalsis as an interaction
between calritromycin and simvastatin. Uremic platelets were
thought to contribute the GI bleeding as the pt has CRI. At the
time of discharge, the patient was tolerating regular PO diet
and the Hct was stable. The patient was discharged with home VNA
for resolving cellulitis, home physical therapy, and to serially
monitor Hcts. Patient was told to have close follow up with PCP
and GI.
# CAD s/p recent CABG:
- metoprolol low dose
- continue simvastatin
.
# Paroxysmal AFib:
Had episode of AFib 2 weeks after CABG in setting of cellulitis.
Has been on amiodarone taper since, but unclear if he is taking
it at home.
- continue amiodarone 400mg daily
.
# DM
- insulin sliding scale (a1c 6.9)
- hold glipizide while inpatient
.
# HTN:
- metoprolol low dose
.
# ARF on CRI: Baseline Cr 3.0-3.7, back to baseline c/w
pre-renal from blood loss.
.
# Right LE cellulitis: appears minimally inflamed at present
- continue cipro until [**10-16**] and linezolid until 10/11 per plan
from DC summaries
.
# Infrarenal AAA:
- monitor BP
.
# OA: tylenol for pain control
.
# Gout: allopurinol
Medications on Admission:
(confirmed with pt):
***Please note that patient cannot confirm that he ever filled
Rx for or is taking Amiodarone, Ciprofloxacin, or Linezolid***
Aspirin 81mg daily
Allopurinol 100mg every other day
Simvastatin 40mg daily
Metoprolol Tartrate 50 mg [**Hospital1 **]
Glipizide 5 mg [**Hospital1 **]
Amiodarone 400 mg [**Hospital1 **], being tapered
Ciprofloxacin 500 mg daily until [**10-16**]
Linezolid 600 mg Q12H until [**10-13**]
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): take two tablets daily until [**10-19**], and then one tablet
daily thereafter.
4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): continue until [**10-16**].
5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain.
6. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily): Please do not take until told safe by your
Gastroenterologist.
9. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
Disp:*60 Tablet(s)* Refills:*0*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days.
Disp:*27 Tablet(s)* Refills:*0*
13. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 9 days.
Disp:*36 Tablet(s)* Refills:*0*
14. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO
twice a day: Swish and swallow.
Disp:*300 ML(s)* Refills:*2*
15. Outpatient Lab Work
Serial Hct Twice weekly for two weeks.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
H pylori, Acute GI bleed [**2-3**] esophagitits, acute renal failure
on chronic renal insuffiency
Secondary:
s/p CABG one month prior, a fib, diabetes, HTN, known AAA
Discharge Condition:
stable
Discharge Instructions:
You were admitted for nausea, vomitting, and loose bloody bowel
movements. Since there was concern with your initial
presentation, you were sent to the MICU for care. In the MICU,
you were transfused 3 units of blood in addition to being given
IV fluids. Additionally, in the MICU, an endoscopy was done
which showed esophagitis.
You were transferred back to the floor where it was noted that
your hematocrits continued to trend downward. You were
transfused an additional 7 units of blood throughout the course
of your admission. You underwent endoscopy three more times and
were found to have ulcers related to H pylori, some of which
were clipped and others that were treated with thermal therapy.
At the time of discharge, it appears that the antibiotic
treatment for H pylori was effective in stopping the GI bleeding
and your hematocrits were stable. You were tolerating a regular
diet at the time of discharge. Since there is concern that there
still may be a slow bleed, your hematocrits will be closely
followed.
There were not any cardiac events and you were placed on a
diabetic sliding scale in the hospital.
You are being discharged on a PPI and sulcrafate to prevent
another GI bleed. You are also being given a 2 week course of
antibiotics to complete your treatment for H pylori (the
treatment was started while you were in the hospital so you have
less than 10 days remaining).
You have close follow up appointments scheulded with GI. Until
your GI bleeding has completely resolved, please do not take
your aspirin.
Please return to the ED or contact your physician if you vomit
blood, pass blood in your stool, feel lightheaded, have chest
pain, or acute shortness of breath.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2198-10-23**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1241**]
Date/Time:[**2198-10-24**] 2:00
Please see your primary within two weeks of discharge and
gastroenterology within one month of discharge. Continue to
follow up with Cardiac surgery as previously scheduled.
Home VNA will monitor your hematocrits.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2198-10-15**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,733
| 151,447
|
1314
|
Discharge summary
|
report
|
Admission Date: [**2132-5-12**] Discharge Date: [**2132-5-23**]
Date of Birth: [**2082-8-23**] Sex: M
Service: MEDICINE
Allergies:
Ampicillin / Penicillins / Dexamethasone
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Right distal femur fracture ORIF
History of Present Illness:
49M hx. if active multiple myeloma (known disease throughout
bilateral femurs, hips, sacrum, cervico-thoraco-lumbar spine,
ribs) who sustained a fall this morning and has a displaced
spiral oblique fracture of his left proximal [**12-17**] femur. No
injuries elsewhere per report.In the emergency room the patient
is hemodynamically stable, alert and oriented, and he has
moderate pain in his left thigh.
Past Medical History:
-Multiple Myeloma IgG
-RSV ([**1-/2128**])
-Hypertension
-Depression/Anxiety
-Chronic back pain
-C1 burst fracture, now in C-collar
-s/p vertebroplasties
-s/p appendectomy
-Hyperthyroid, on Propranolol for symptom control, now resolved
Social History:
[**Male First Name (un) **] is married with two children. He is very involved with his
family and coaches his son's teams. He previously worked as a
sales manager, now disabled. He denies tobacco or illicit drug
use, and only has alcohol very occasionally at social events and
holidays
Family History:
Father: Died in 7/[**2128**]. He had been chronically ill.
Mother: type II diabetes mellitus
[**Name (NI) **]: multiple myeloma
Uncle: [**Name (NI) 4278**] disease
Physical Exam:
Admission physical
AFVSS
NAD
RRR
CTA
S/NT/ND
RLE: SILT, Motor intact. Right thigh compartment is soft, but
moderately swollen. Staples are in place. No bleeding. No
hematoma. No concern for compartment syndrome.
Transfer to BMT physical exam
Vitals - 102.0 PO 120/70 130 18 92/RA
GENERAL: thin, ill-appearing male lying in bed w neck brace,
AOX3
HEENT: PERRL, no pharyngeal erythemia, mucous membs moist, no
lymphadenopathy
CHEST: CTAB over anterior chest no wheezes, no rales, no ronchi
CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or
gallops
ABD: soft, non-tender, non-distended, BS normoactive. no
rebound/guarding, neg HSM. neg [**Doctor Last Name 515**] sign.
EXT: LLE very tense, pulses intact b/l, pressure bandaged from
foot to hip, distal pulses in tact, good distal perfusion
SKIN: no rash
Pertinent Results:
Admission Labs
[**2132-5-12**] 02:15PM BLOOD WBC-6.3# RBC-1.47*# Hgb-5.7*# Hct-16.7*#
MCV-114* MCH-38.6* MCHC-33.9 RDW-20.3* Plt Ct-48*
[**2132-5-12**] 02:15PM BLOOD Neuts-85* Bands-6* Lymphs-5* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2132-5-12**] 02:47PM BLOOD PT-15.3* PTT-29.4 INR(PT)-1.3*
[**2132-5-12**] 02:15PM BLOOD Glucose-140* UreaN-16 Creat-0.9 Na-136
K-4.1 Cl-106 HCO3-26 AnGap-8
[**2132-5-12**] 02:15PM BLOOD Calcium-7.5* Phos-3.8 Mg-1.6
Discharge labs
[**2132-5-22**] 12:36AM BLOOD WBC-2.7* RBC-2.69* Hgb-8.6* Hct-24.6*
MCV-92 MCH-31.8 MCHC-34.7 RDW-16.7* Plt Ct-38*
[**2132-5-22**] 12:36AM BLOOD Neuts-78* Bands-0 Lymphs-8* Monos-9 Eos-1
Baso-3* Atyps-1* Metas-0 Myelos-0
[**2132-5-22**] 12:36AM BLOOD PT-14.6* PTT-34.0 INR(PT)-1.3*
[**2132-5-16**] 12:00AM BLOOD Gran Ct-4480
[**2132-5-22**] 12:36AM BLOOD Gran Ct-2106*
[**2132-5-22**] 12:36AM BLOOD Glucose-98 UreaN-16 Creat-0.8 Na-134
K-3.8 Cl-99 HCO3-30 AnGap-9
[**2132-5-14**] 05:04AM BLOOD ALT-12 AST-27 LD(LDH)-285* AlkPhos-41
TotBili-0.7
[**2132-5-22**] 12:36AM BLOOD ALT-23 AST-27 AlkPhos-106 TotBili-0.9
[**2132-5-22**] 12:36AM BLOOD Albumin-2.4* Calcium-7.9* Phos-3.8 Mg-1.9
[**2132-5-19**] 12:00AM BLOOD Osmolal-273*
[**2132-5-17**] 12:00AM BLOOD PEP-ABNORMAL B IgG-2904* IgA-25* IgM-16*
[**2132-5-17**] 06:19AM BLOOD Vanco-11.2
[**2132-5-20**] 02:19PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.012
[**2132-5-20**] 02:19PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2132-5-20**] 02:19PM URINE RBC-1 WBC-<1 Bacteri-FEW Yeast-NONE
Epi-<1
[**2132-5-19**] 10:52AM URINE Hours-RANDOM UreaN-430 Creat-31 Na-126
K-34 Cl-150
[**2132-5-19**] 10:52AM URINE Osmolal-482
[**2132-5-17**] 04:30PM URINE U-PEP-TRACE ABNO
MICRO
[**2132-5-15**] 6:50 pm BLOOD CULTURE 2 OF 2 LEFT.
**FINAL REPORT [**2132-5-21**]**
Blood Culture, Routine (Final [**2132-5-21**]): NO GROWTH.
[**2132-5-20**] 2:19 pm URINE Source: CVS.
**FINAL REPORT [**2132-5-21**]**
URINE CULTURE (Final [**2132-5-21**]): NO GROWTH.
[**2132-5-15**] 6:50 pm BLOOD CULTURE 2 OF 2 LEFT.
**FINAL REPORT [**2132-5-21**]**
Blood Culture, Routine (Final [**2132-5-21**]): NO GROWTH.
Radiology
L ext fluoro
FINDINGS: Multiple fluoroscopic images of the left femur
demonstrate interval placement of an intramedullary rod with
distal interlocking screw and a proximal pin fixating a fracture
involving the proximal shaft of the left femur. There is
improved anatomic alignment. The lytic lesions seen
throughout the pelvis and femur is less well seen due to the
technique.
Please refer to the operative note for additional details.
Chest xray
No pneumonia, no pulmonary edema or appreciable pleural
effusion. There is
hazy opacification over both lateral chest walls, is probably
due to soft
tissue involvement of the pleural space in region of multiple
myelomatous
ribs. Heart size is normal. Dual-channel right central venous
line, is
longstanding, ending in the mid SVC.
LENI
IMPRESSION: No evidence of DVT in right or left lower extremity.
Repeat chest xray
FINDINGS: In comparison with the study of [**5-15**], there is little
change. No
evidence of acute pneumonia, vascular congestion, or pleural
effusion.
Diffuse myelomatous changes within the ribs and other bony
structures are
again seen. Central venous line remains in place.
IMPRESSION: Little change
Brief Hospital Course:
ORTHO summary
Mr.[**Known lastname 8079**] [**2132-5-12**] after a fall at home. He was evaluated by the
orthopaedic surgery service and found to have a left femur
fracture. He had to be admitted to the ICU for a low hematocrit
(16), where he was transfused and monitored hemodynamically. He
was admitted, consented, and prepped for surgery. On [**2132-5-13**] he
was taken to the operating room and underwent an ORIF of his
right femur fracture. Post operatively he received approximately
7 units of blood because his hematocrit kept trending down (to
the low 20s.) and he was tachycardic. At this point the
hematology service was consulted and they felt this patient's
hematologic management (given complicated history of multiple
myeloma) may be best served on their service. Therefore on
[**2132-5-15**] he is being transferred to the [**Hospital Ward Name **].
BMT course [**Date range (3) 8080**]:
This is a 49y M w h/o recurrent IgG multiple myeloma following
his allogeneic transplant currently on Revlimid and
cyclophosphamide (last dose [**2132-4-2**] w known disease throughout
bilateral femurs, hips, sacrum, cervico-thoraco-lumbar spine,
ribs) presented to an OSH s/p mechanical fall with L femur
fracture. He denies other injury including head strike or loss
of consciousness. Now s/p ORIF on [**5-13**] with persistent anemia
and thrombocytopenia and transferred from Ortho to BMT. He was
started postop on lovenox sq on [**5-14**] w intended 4week course by
ortho but dc'd when Hct nonresponsive to transfusions. Plan per
ortho is TDWB on LLE with transfer to BMT service for management
of hematologic disturbance. Pt febrile since [**5-14**] and started
empirically on vanco, cefepime on transfer to BMT.
# Fever: Ddx includes PE, infectious etiology, post-op
complication, ateletasis, or post-transfusion rxn. Hickman looks
erythematous wo purulence or tenderness and improved appearance
after initiation of abx. Wound intact. Chest xray negative.
Giving incentive spirometer. Vanco trough on [**5-17**] = 11 but team
elected to keep dose same to avoid nephrotoxicity give low
suspicion for infection. He continued on vancomycin and
cefepime. Urine cx negative. LENI negative. Pt continued to have
low grade temps on the abx but was HD stable and appeared to be
clinically improving. Lovenox was re-initiated on [**5-16**]. He
completed a 7 day course of vancomycin and cefepime with
negative cultures. Fever was attributed to resorption of
hematoma. Incentive spirometry was encouraged. His fever curve
improved after abx and was afebrile off antibiotics. He
continued to have low grade temps but never hemodynamically
unstable.
.
# Anemia/thrombocytopenia: Concern is for persistent bleed into
the LLE and possible risk for compartment syndrome however
intact pulses on both sides and per ortho recs, compartment
syndrome is a near impossibility in thigh. Would also consider
other hematologic consumptive processes such as
(DIC/HUS-TTP/ITP), decrease production (baseline MM) and/or
sequestration process but most likely is oozing related to
thrombocytopenia on lovenox. Had been getting pRBCs throughout
stay wo platelets. Restarted lovenox on [**5-16**]. He was monitored w
serial CBCs and transfused w goals for Hct>24, plt>50. Home
aspirin was held during stay and at time of discharge w decision
deferred to outpt evaluation. He was continued on lovenox while
bed bound given high risk for DVT. Anticoagulation should be
continued at rehab until pt is ambulating.
.
# LLE fracture: s/p fall at home w decreased bony integrity [**1-16**]
diffuse multiple myeloma. S/p ORIF on [**5-13**] (L TFN). PT worked
with the pt daily however he was very hesitant to mobilize given
his pain. Pain control with dilaudid pca, fentanyl patches, home
methadone and home gabapentin. He was also written for dilaudid
breakthrough doses prior to PT and bandage changes. Bowel
regimen: senna, colace, start miralax and bisacodyl and pt
stooled daily.
Plan for post-pathologic fracture radiation therapy for standard
2 weeks post-operative. Pt has appointment for mapping at [**Hospital1 18**]
radiation oncology on [**5-25**] with Dr. [**Last Name (STitle) 776**] on [**Hospital Ward Name 23**] 5. He
will require transportation from rehab to radiation
appointments. Also has an appointment with orthopedics for
staple removal and evaluation.
.
# Multiple myeloma: On rivlimid and cytoxan (last dose 4/20). He
was monitored w daily cell counts. Prophylaxis with acyclovir,
bactrim from home regimen. He was unable to tolerate a skeletal
survey in house given his severe leg pain and current
instability. He will be referred for skeletal survey as an
outpatient.
Medications on Admission:
ACYCLOVIR - 400 mg Tablet - 1 (One) Tablet(s) by mouth three
times a day
ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - 1 Solution(s) inhaled every six (6) hours as
needed for cough
AZITHROMYCIN - 250 mg Tablet - 2 Tablet(s) by mouth on Day 1,
then 1(one) tablet on Days 2 - 5.
CLONAZEPAM - 0.5 mg Tablet - 1 (One) Tablet(s) by mouth twice a
day as needed
FENTANYL - 100 mcg/hour Patch 72 hr - 3 Patch(s) Q36H (every 36
hours)
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2
Aerosol(s) inhaled twice a day for 2 weeks Rinse mouth after
inhalation
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day
GABAPENTIN - 400 mg Capsule - 1 Capsule(s) by mouth three times
a
day
GELCLAIR - Gel in Packet - Use one packet for oral swish and
spit once to twice per day as needed for as needed for mouth
sores
HEPARIN (PORCINE) IN NS [HEPARIN FLUSH] - (discharge med) - 10
unit/mL Kit - 3 Kit(s) once a day Flush each lumen with 10 cc of
normal saline then follow with heparin flush.
LENALIDOMIDE [REVLIMID] - (Prescribed by Other Provider) - 25
mg
Capsule - 1 (One) Capsule(s) by mouth once a day and increase to
50 mg daily as directed.
LIDOCAINE [LIDODERM] - 5 % (700 mg/patch) Adhesive Patch,
Medicated - Two adhesive patches once a day as needed for pain.
Apply patches to left upper back on 12 hours, then off 12 hours
LORAZEPAM - 0.5 mg Tablet - [**12-16**] Tablet(s) by mouth every eight
(8) hours as needed for nausea
METHADONE - 10 mg Tablet - 1 Tablet(s) by mouth four times a day
as needed for pain
NYSTATIN - 100,000 unit/mL Suspension - 5 mls by mouth four
times
a day, swish and spit
ONDANSETRON - 4 mg Tablet, Rapid Dissolve - 1 Tablet(s) by mouth
q 8h as needed for nausea
OXYCODONE - 30 mg Tablet - 1 (One) to 1.5 (One and a half)
Tablet(s) by mouth every four (4) hours as needed for
breakthrough pain.
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s)
by mouth once a day
PROPRANOLOL - 10 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
SALIVA SUBSTITUTION COMBO NO.2 [CAPHOSOL] - Solution - Rinse
with 30 mls three times a day as needed for dry mouth
SODIUM CHLORIDE 0.9 % [NORMAL SALINE FLUSH] - (discharge med) -
0.9 % Syringe - 3 Syringe(s) once a day Flush each lumen with 10
cc of normal saline daily followed by heparin.
SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1
Tablet(s)
by mouth once a day
TACROLIMUS [PROTOPIC] - (Dose adjustment - no new Rx) - 0.03 %
Ointment - Apply to lips once a day as needed
TIZANIDINE - 4 mg Tablet - 0.5 (One half) to 1(one) Tablet(s) by
mouth HS (at bedtime)
VENLAFAXINE [EFFEXOR XR] - 37.5 mg Capsule, Ext Release 24 hr -
1
(One) Capsule(s) by mouth once a day
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Delayed
Release (E.C.) - 1 (One) Tablet(s) by mouth once a day
BISACODYL - (Prescribed by Other Provider) - 5 mg Tablet,
Delayed Release (E.C.) - 2 Tablet(s) by mouth twice a day as
needed for constipation
CODEINE-GUAIFENESIN [GUAIFENESIN AC] - 100 mg-10 mg/5 mL Liquid
-
5 - 10 mls by mouth every six (6) hours as needed for cough
DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg
Capsule - 2 Capsule(s) by mouth every twelve (12) hours as
needed
for constipation
MULTIVITAMIN WITH MINERALS [MULTI-VITAMIN W/MINERALS] - (OTC) -
Capsule - 1 (One) Capsule(s) by mouth once a day
POLYETHYLENE GLYCOL 3350 [MIRALAX] - 17 gram Powder in Packet -
17 grams by mouth (about 1 heaping tablespoon/1 packet) per day
dissolved in 4 to 8 ounces of water, juice, soda as needed for
constipation.
Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
2. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
3. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ml
ml Inhalation Q6H (every 6 hours) as needed for wheezing.
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. methadone 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. oral wound care products Gel in Packet Sig: Fifteen (15)
ML Mucous membrane TID (3 times a day) as needed for mouth
sores.
10. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for upper back.
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for nausea.
12. propranolol 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. saliva substitution combo no.2 Solution Sig: Thirty (30)
ML Mucous membrane TID (3 times a day) as needed for dry mouth.
14. venlafaxine 37.5 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
15. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) gram PO DAILY (Daily) as needed for constipation.
16. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
17. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch
Transdermal Q48H (every 48 hours).
18. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
19. methyl salicylate-menthol Ointment Sig: One (1) Appl
Topical PRN (as needed) as needed for to affected area.
20. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
21. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
22. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily) as needed for constipation.
23. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**12-16**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
24. hydromorphone 10 mg/mL Solution Sig: One (1) pca Injection
ASDIR (AS DIRECTED): HYDROmorphone (Dilaudid) 0.25 mg IVPCA
Lockout Interval: 6 minutes Basal Rate: 0.12 mg(s)/hour 1-hr Max
Limit: 2.5 mg(s)
use basal rate from [**2120**]-0600
.
25. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
26. potassium chloride 20 mEq/50 mL Piggyback Sig: One (1)
Sliding scale Intravenous PRN (as needed): per handout included
in dc paperwork.
27. magnesium sulfate 4 % Solution Sig: One (1) sliding scale
Injection PRN (as needed): per sliding scale included in dc
paperwork.
28. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Tunneled Access Line (e.g. Hickman), heparin dependent: Flush
with 10 mL Normal saline followed by Heparin as above daily and
PRN per lumen.
29. HYDROmorphone (Dilaudid) 2 mg IV ONCE:PRN prior to PT
hold for sedation, RR<12
30. Ondansetron 8 mg IV Q8H:PRN nausea
31. tizanidine 4 mg Tablet Sig: 0.5-1 Tablet PO at bedtime.
32. Saline Flush 0.9 % Syringe Sig: One (1) syringe Injection
once a day as needed for prn line flush: once a day Flush each
lumen with 10
cc of normal saline daily followed by heparin.
.
33. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: hold while on
lovenox.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Care- [**Hospital1 8**]
Discharge Diagnosis:
Right distal femur fracture
Acute bleeding requiring ICU admission and transfusion
Presume coagulopathy in the setting of multiple myeloma
Discharge Condition:
AAO X 3
Regular diet
Discharge Instructions:
It was a pleasure caring for you at [**Hospital1 18**]. You were admitted for
a leg fracture related to your multiple myeloma.
ACTIVITY
Continue to be touch down weight bearing in your LLE.
Continue to be weight bearing as tolerated in RLE, and bilateral
upper extremities.
General
If you have any increased pain, swelling, or numbness, not
relieved with rest, elevation, and or pain medication, or if you
have a temperature greater than 101.5, please call the office or
come to the emergency department.
Medications:
1) Lovenox: blood thinner, you should take this for 4 weeks or
until you are out of bed and ambulating.
2) You have been prescribed a narcotic pain medication. Please
take only as directed and do not drive or operate any machinery
while taking this medication. There is a 72 hour (Monday through
Friday, 9am to 4pm) response time for prescription refill
requests. There will be no prescription refills on Saturdays,
Sundays, or holidays. Please plan accordingly.
3) Continue any home medications
Wound Care:
- Keep Incision clean and dry.
- Do not soak the incision in a bath or pool.
- Staples should be taken out in 2 weeks from surgery. This can
be done at your first post-operative visit on [**2132-6-5**].
You will need to follow up with your outpatient oncologist.
Given the nature of your fracture, we recommend a post-operative
course of radiation to strengthen the bone. You have an
appointment to see a radiation doctor listed below.
The following changes were made to your medications:
STARTED dilaudid pca (to be continued and weaned at rehab)
STARTED lovenox, this will need to be continued 4 weeks after
your surgery ([**5-13**]), and ambulating
STARTED dilaudid IV prior to PT sessions
Hold your low dose aspirin while you are on lovenox injections.
Followup Instructions:
Department: BMT CHAIRS & ROOMS
When: TUESDAY [**2132-5-27**] at 10:30 AM
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2132-5-27**] at 10:30 AM
With: [**First Name8 (NamePattern2) 8081**] [**Last Name (NamePattern1) 396**], BSN [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: Radiation Oncology
When: [**5-27**] at 2:00 PM
With: Dr. [**Last Name (STitle) 776**] ([**Telephone/Fax (1) 8082**]
Campus: East
Department: HEMATOLOGY/BMT
When: THURSDAY [**2132-5-29**] at 11:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], RNC [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2132-6-5**] at 9:20 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2132-6-5**] at 9:40 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"821.01",
"382.9",
"287.5",
"E885.9",
"401.9",
"285.1",
"203.02",
"253.6",
"V42.81",
"E878.8",
"286.9",
"998.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.15"
] |
icd9pcs
|
[
[
[]
]
] |
17845, 17935
|
5911, 10584
|
314, 349
|
18118, 18141
|
2388, 5888
|
19981, 21417
|
1363, 1528
|
14193, 17822
|
17956, 18097
|
10610, 14170
|
18165, 19186
|
1543, 2369
|
270, 276
|
19198, 19958
|
377, 784
|
806, 1044
|
1060, 1347
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,589
| 173,309
|
54584
|
Discharge summary
|
report
|
Admission Date: [**2155-11-21**] Discharge Date: [**2155-11-26**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3853**]
Chief Complaint:
Supratherapeutic INR and confusion
Major Surgical or Invasive Procedure:
Blood transfusion
History of Present Illness:
89 yo F w/ dementia, recently diagnosed DVT on warfarin, who
presents from [**Location (un) 583**] House with altered mental status and
hypotension. Pt was recently admitted here from [**Date range (1) 18881**] with
altered mental status and was found to have UTI (cefpodoxime
until [**11-23**]) and DVT in the left common femoral and proximal
superficial femoral veins(started on warfarin on [**11-18**], bridged
with lovenox).
She was also admitted from [**Date range (1) **] with lethargy and failure
to thrive, where she was thought to have acute on chronic
diastolic heart failure (discharged on her home 60mg po daily
lasix). Failure to thrive was thought to be subacute in nature
and per her most recent dc summary, pt has had steady decline
over the past year where now she is no longer able to feed
herself.
Per records, she was on coumadin and had her last dose of
lovenox 70mg subq at 8AM on [**11-21**]. Pt had T 100.2 at the nursing
home. In the ED, initial VS were: 96.4 60 100/30 28 99% 2L. Her
INR was 12.8 and she was subsequently given 10mg IV vitamin K.
Pt was also given Ciprofloxacin 400mg IV, Vancomycin 1gm IV, and
Metronidazole 500mg IV as she was hypotensive and was unclear if
there was infection. Of note, her WBC is 11.5, up from 6.4 on
[**2155-11-19**] her HCT was 25.3, down from 34.3 on [**2155-11-19**]. She was
given 2 units FFP and 1 unit pRBC. Gave 1.5L NS and per report
had loose, guaiac negative stool. FAST exam showed no
intraperitoneal bleed and prelim CT torso showed no hematoma. VS
upon transfer 99.2 55 101/24 16 98%, and BP upon manual recheck
118/30.
On arrival to the MICU, pt is in no acute distress, resting
comfortably in bed. She is accompanied by her daughter. Sounds
like over the past two days she has been back at [**Location (un) 583**] house,
she hasn't been having fevers, cough, pain or any new symptoms,
though the daughter does note that she was receiving tylenol
yesterday at the nursing home, though was unsure why. The
daughter also mentioned the pt's propensity to aspirate often
and reported she was on a special diet at [**Location (un) 583**], which is
documented as 2gm sodium, pureed nectar, prethickened liquids,
fluid restriction 2L.
.
ROS is otherwise negative except per above
.
Past Medical History:
- Hypertrophic obstructive cardiomyopathy, status post alcohol
ablation in [**2145-11-2**]
- Endocarditis in [**2140-4-2**]
- Status post benign inguinal node biopsy
- Hypercholesterolemia
- Hypertension
- Diastolic CHF
- Complete Heart Block s/p DDD pacemaker
- atrial fibrillation
- Urinary incontinence s/p bladder stimulator
- Depression
- diastolic CHF with class III symptoms, recently seen by Dr.
[**First Name (STitle) 437**]
- CKD III, BL Cr 1.4
- blind in L eye
- s/p right clavicular fracture after fall in [**3-/2151**]
Social History:
Widowed, currently living at rehabilitation ([**Location (un) 583**] House), no
tobacco or alcohol use. She has two daughters involved in care,
one is in [**Name (NI) 4565**], the other in the area.
Family History:
Coronary artery disease versus hypertrophic obstructive
cardiomyopathy in father and brother.
Physical Exam:
ADMISSION PHYSICAL EXAM
General: A&Ox1, no acute distress
HEENT: Sclera anicteric, MM dry, EOMI
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally when auscultated
anteriorly, no wheezes, rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley draining minimal urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Bilateral hands contracted.
Neuro: Did not perform
.
Discharge PE
VS not checked-patient is CMO
General: patient is comfortable, speaks in a soft voice but is
able to answer questions and follow simple command
Pertinent Results:
ADMISSION LABS
[**2155-11-21**] 01:45PM BLOOD WBC-11.5*# RBC-2.69*# Hgb-8.4* Hct-25.3*#
MCV-94 MCH-31.4 MCHC-33.3 RDW-15.4 Plt Ct-309
[**2155-11-21**] 01:45PM BLOOD PT-139.8* PTT-52.9* INR(PT)-12.8*
[**2155-11-21**] 01:45PM BLOOD Glucose-145* UreaN-26* Creat-1.6* Na-140
K-4.4 Cl-103 HCO3-27 AnGap-14
[**2155-11-21**] 01:45PM BLOOD ALT-37 AST-64* LD(LDH)-310* AlkPhos-75
TotBili-0.3
[**2155-11-21**] 01:45PM BLOOD Albumin-2.8*
[**2155-11-21**] 02:06PM BLOOD Lactate-2.3*
[**2155-11-21**] 01:45PM BLOOD Hapto-214*
.
[**2155-11-22**] CT AP
IMPRESSION:
1. No CT evidence for large hematoma or site of acute bleeding.
2. Small bilateral pleural effusions measuring simple fluid
density.
.
[**2155-11-22**] H-CT
IMPRESSION: No CT evidence for acute intracranial process.
Progressed
cortical atrophy compared to [**2145**].
.
Brief Hospital Course:
89 yo F w/ dementia, HTN, afib, dCHF presenting with
supratherapeutic INR and AMS with HCT drop of 9 points in two
days and hypotension. On arrival the hospital, family wished to
not pursue aggressive measures. Patient received 3 units of
packed RBCs. Family discussion was held with patient and given
recent hospitalizations and overal health decline, it was the
patient's wish to reorient care around comfort. Good [**Hospital 3952**]
Hospice will follow patient and patients wishes to not be
rehospitalized.
***For patient's comfort, please be sure to have thickened water
at bedside. Family and patient under stand risks of aspiration
and asphyxiation.***
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Bisacodyl 10 mg PR DAILY:PRN constipation
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 500 mg PO BID
5. Cyanocobalamin 250 mcg PO DAILY
6. Furosemide 60 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Sertraline 25 mg PO DAILY
12. Simvastatin 40 mg PO DAILY
13. traZODONE 25 mg PO HS:PRN insomnia
14. Vitamin D 800 UNIT PO DAILY
15. Cefpodoxime Proxetil 100 mg PO Q12H
until [**11-23**]
16. Metoprolol Succinate XL 25 mg PO DAILY
hold for sbp < 100 and hr < 60
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Morphine Sulfate (Concentrated Oral Soln) 2-20 mg PO Q2H:PRN
pain
3. Lorazepam 0.5-2 mg PO Q4H:PRN anxiety/agitation
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 583**] House Rehab & Nursing Center
Discharge Diagnosis:
Anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted because you were found to be more lethargic.
On admission, you were found to have anemia because your
coumadin level was high. You were in the ICU for some time where
you received blood and then you were transferred to floor. While
on the floor, we had a discussion with you and your family about
your goals of care and you decided to focus your care around
comfort. You are being discharged to the [**Location (un) 583**] House with
hospice care.
Followup Instructions:
You will be followed by the Good [**Hospital 3952**] hospice team at the
[**Location (un) 583**] House
Completed by:[**2155-11-26**]
|
[
"783.7",
"790.92",
"584.9",
"403.90",
"933.1",
"427.31",
"453.41",
"V45.01",
"428.0",
"263.9",
"244.9",
"294.21",
"V49.86",
"E915",
"285.9",
"311",
"585.3",
"458.9",
"272.0",
"428.32"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6639, 6718
|
5051, 5713
|
288, 308
|
6768, 6768
|
4200, 5028
|
7396, 7530
|
3382, 3477
|
6454, 6616
|
6739, 6747
|
5739, 6431
|
6906, 7373
|
3492, 4181
|
214, 250
|
336, 2594
|
6783, 6882
|
2616, 3149
|
3165, 3366
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,851
| 159,319
|
21445+21446
|
Discharge summary
|
report+report
|
Admission Date: [**2154-8-23**] Discharge Date: [**2154-9-3**]
Date of Birth: [**2122-2-7**] Sex: M
Service: [**Last Name (un) **]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
32M s/p MVC with immediate loss of sensation & movement of his
arms & legs. CT scan at [**Hospital 8641**] Hospital shows multiple C-spine
fractures, He was started on solumedrol drip & transferred to
[**Hospital1 **] for further management.
Major Surgical or Invasive Procedure:
c spine fusion [**8-26**]
percutaneous endoscopic gastrostomy [**8-27**]
percutaneous tracheostomy [**8-27**]
therapeutic bronchoscopy [**8-31**]
History of Present Illness:
32 yo M who was involved in a motor vehicle crash in which he
was the unrestrained passenger.
Past Medical History:
low back pain
h/o IVDU on methadone
Social History:
+cigs
+etoh
Family History:
noncontributory
Physical Exam:
AVSS
Intubated
PERRLA, EOMI
Trachea midline
RRR, CTA B
Soft, NT, ND
Spine: +cervical/thoracic TTP, no stepoffs
Rectal: guaiac neg, no tone
Extrem: 0/5 strength, no sensation, palpable pulses
Neuro: CN 2-12 grossly intact, no sensation below manubrium
Pertinent Results:
[**2154-9-3**] 02:20AM BLOOD WBC-11.5* RBC-2.44* Hgb-7.7* Hct-22.2*
MCV-91 MCH-31.4 MCHC-34.5 RDW-13.9 Plt Ct-385
[**2154-9-3**] 02:20AM BLOOD Glucose-118* UreaN-26* Creat-0.4* Na-144
K-3.9 Cl-102 HCO3-34* AnGap-12
[**2154-9-2**] 02:51AM BLOOD Type-ART Temp-37.2 Rates-[**7-12**] Tidal V-600
PEEP-10 O2-60 pO2-112* pCO2-56* pH-7.44 calHCO3-39* Base XS-12
-ASSIST/CON Intubat-INTUBATED
[**2154-9-2**] 02:41AM BLOOD calTIBC-207* TRF-159* IRON-11*
[**2154-8-23**] 01:15AM ASA-NEG ETHANOL-277* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2154-8-28**] 11:54 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2154-8-31**]**
GRAM STAIN (Final [**2154-8-29**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2154-8-31**]):
RARE GROWTH OROPHARYNGEAL FLORA.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. SPARSE
GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
[**2154-9-2**] 08:27PM URINE RBC-21-50* WBC-[**2-8**] Bacteri-MOD Yeast-NONE
Epi-0 (culture pending)
Brief Hospital Course:
Admitted to SICU for vent management, hemodynamic monitoring.
Taken to OR by Neurosurgery (Dr. [**Last Name (STitle) 1327**] for C-spine fusion on
[**2154-8-26**], which he tolerated well. On [**8-27**], he underwent a
bedside perc tracheostomy & PEG placement. He was unable to
wean off mechanical ventilation, despite some spontaneous
respirations on SIMV/PSV. Also, he had recurrent low grade
fevers. A sputum culture on 21 grew out H flu, and he was
started on PO augmentin.
Neuro: Taken to OR by Neurosurgery (Dr. [**Last Name (STitle) 1327**] for C-spine
fusion on [**2154-8-26**], which he tolerated well.
CV: stable
Resp: He was unable to wean off mechanical ventilation, despite
some spontaneous respirations on SIMV/PSV. On [**8-27**], he
underwent a bedside perc tracheostomy. A sputum culture on 21
grew out H flu, and he was started on augmentin. He continued
to have thick secretions (as seen on a [**8-31**] bronchoscopy) &
intermittently desaturated, with prompt resolution of symptoms
after suctioning. On some of these occasions, he had episodes
of bradycardia that spontaneously resolved. At the time of
discharge, he is doing well on SIMV (fiO2 0.5 - TV 600 - RR 12 -
PS 5 - PEEP 10).
FEN/GI: He had a PEG placed on [**8-27**]. He has tolerated tube
feeds well (promote w/ fiber at 75 cc/hr). He does require a
bowel regimen of colace, reglan, dulcolax & glycerin
suppositories.
HEME: His postop hematocrit has remained stably low, around 22.
He was not transfused on this admission. Iron studies showed
him to have a iron deficiency & he has been started on iron &
epogen. This should be followed. In terms of DVT prophylaxis,
he receives lovenox & should wear pneumoboots. An IVC filter
could not be placed due to his accessory IVC.
ID: He has positive sputum culture, showing H flu & should be
treated with augmentin x1week following discharge. His [**9-2**]
urinalysis showed signs of a UTI, which will be treated with
levaquin x 3days.
ENDO: insulin sliding scale
Lines: Foley, Trach, PEG
Disp: full code
Medications on Admission:
methadone 10 [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: Forty (40) mg
Subcutaneous QD (once a day).
Disp:*30 doses* Refills:*2*
3. Amoxicillin-Pot Clavulanate 250-62.5 mg/5 mL Suspension for
Reconstitution Sig: Five (5) mL PO Q8H (every 8 hours) for 1
weeks.
Disp:*105 mL* Refills:*0*
4. Acyclovir 5 % Ointment Sig: One (1) Appl Topical 6X/D (6
times a day) for 1 weeks.
Disp:*1 container* Refills:*0*
5. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose
Injection ASDIR (AS DIRECTED): follow attached sliding scale.
Disp:*10 ml* Refills:*2*
6. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) ML PO QD
(once a day).
Disp:*150 ML* Refills:*2*
7. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) ML Injection
QMOWEFR (Monday -Wednesday-Friday).
Disp:*15 ML* Refills:*2*
8. Methadone HCl 10 mg/5 mL Solution Sig: 7.5 ML PO TID (3 times
a day).
Disp:*675 ML* Refills:*2*
9. Clonidine HCl 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QMON (every Monday).
Disp:*4 Patch Weekly(s)* Refills:*2*
10. Lorazepam 1 mg IV QID
11. Metoclopramide 10 mg IV Q6H
12. Lorazepam 0.5-2 mg IV Q4H:PRN
13. Hydromorphone 1 mg IV Q3-4H:PRN pain
14. Ondansetron 4 mg IV Q4-6H:PRN
15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*3*
16. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 3-5 MLs
Miscell. Q6H (every 6 hours): neb treatments for secretions.
Disp:*50 ML(s)* Refills:*2*
17. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) ML PO BID
(2 times a day).
Disp:*200 ML* Refills:*2*
18. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
Disp:*250 ML(s)* Refills:*0*
19. Glycerin (Adult) 3 g Suppository Sig: One (1) Suppository
Rectal [**Hospital1 **] (2 times a day) as needed.
Disp:*15 Suppository(s)* Refills:*2*
20. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
21. Levofloxacin 500 PO/NG q24 x 3 days
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p MVC
multiple C1 to C7 vertebral fractures
s/p c spine fusion [**8-26**]
double barrel IVC
postop atelectasis
postop ileus
haemophilus influenzae vent associated pneumonia
s/p percutaneous endoscopic gastrostomy [**8-27**]
s/p percutaneous tracheostomy [**8-27**]
s/p therapeutic bronchoscopy [**8-31**]
hypokalemia
hypomagnesemia
hypocalcemia
iron deficiency anemia
Discharge Condition:
stable
Discharge Instructions:
Wean vent as tolerated. [**Hospital 56633**] rehab treatment per
protocol. Follow up with Dr. [**Last Name (STitle) 1327**] in [**1-8**] weeks.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 1327**] in [**1-8**] weeks.
Completed by:[**2154-9-3**] Admission Date: [**2154-8-23**] Discharge Date: [**2154-9-3**]
Date of Birth: [**2122-2-7**] Sex: M
Service: TRA
CHIEF COMPLAINT: Quadriplegia.
HISTORY OF PRESENT ILLNESS: This is a 32-year-old man status
post a motor vehicle collision with immediate loss of
sensation and movement in his arms and legs. CT scan showed
multiple C spine fractures. He was started on a Solu-Medrol
drip and transferred to [**Hospital3 **] for further management.
PAST MEDICAL HISTORY: Low back pain.
History of IV drug on methadone.
SOCIAL HISTORY: Significant for cigarettes and ethanol.
FAMILY HISTORY: Noncontributory.
MEDICATIONS: Does not take any medicines.
ALLERGIES: Has no known drug allergies.
PHYSICAL EXAMINATION: He is afebrile. Vital signs are
stable. He is intubated. PERRLA. EOMI. Trachea is midline
with a C collar in place. Regular rate and rhythm. Clear to
auscultation bilaterally. His belly is soft, nontender,
nondistended. Spine has tenderness to palpation of the
cervical and thoracic spine with no step-offs. Rectal is
guaiac negative with no tone whatsoever. Extremities have no
growth and no sensation. Does have palpable pulses.
Neurologic examination: His cranial nerves are grossly
intact, but he has no sensation or movement below the
manubrium. He can shrug his shoulders throughout the
admission.
PERTINENT LAB RESULTS: Given in the typed discharge summary.
Of note, his microbiological results are significant for a
positive sputum culture showing Hemophilus influenza as well
as a positive urinalysis on the day of discharge.
HOSPITAL COURSE: He was admitted to the Trauma SICU for vent
management and hemodynamic monitoring. He was taken to the
operating room by Dr. [**Last Name (STitle) 1327**] of Neurosurgery for C spine
fusion on the 20th. On the 21st, he underwent a bedside perc
tracheostomy and PEG placement. On the 25th, he had a
diagnostic bronchoscopy performed.
He was an organ based system approach. The C spine fusion
was done. He remained quadriplegic throughout the admission
and cardiovascularly he is stable.
Respiratory: He was unable to wean off mechanical
ventilation, although he did show signs of spontaneous
respirations. He underwent beside perc trache as described
above. He had positive sputum culture and he was noted to
have very thick secretions throughout his admission with
intermittent desaturations, which improved after suctioning.
He did incidentally have several episodes of bradycardia
associated with the thick secretions. He is doing well on
SIMV with his settings in the printed version of this
discharge summary.
FEN and GI: He had a percutaneous endoscopic gastrostomy
tube placed on the 21st. He was quickly advanced to goal on
tube feeds ProMod with fiber. He does have a bowel regimen,
which allows him to have bowel movements.
Hematologic: Postoperatively, he had a very low hematocrit
of 22. However, he does not require transfusion as his vital
signs are stable throughout and he had good urine output.
Again, he did not require transfusion. Iron studies showed
him to have an iron deficiency anemia. He was started on
iron and Cogentin.
In terms of DVT prophylaxis, he was not able to receive an
IVC filter per our normal protocol because of an accessory
inferior vena cava. He does receive Lovenox every day and
does have pneumoboots on at all times.
ID: He had the sputum cultures as described above and his
Augmentin for one week following discharge. He also has a
positive urinalysis, which should be treated with Levaquin
for three days.
Endocrine: He is on a regular insulin-sliding scale. The
regular insulin-sliding scale he requires of approximately 4-
6 units of regular insulin a day to maintain his sugars below
120.
Tubes, lines, drains: He has a Foley catheter, a PEG tube
and a tracheostomy.
Code: He is a full code.
DISCHARGE MEDICATIONS:
1. Aspirin 325 once a day.
2. Lovenox 40 mg every day.
3. Augmentin 250 every eight hours.
4. Acyclovir for cold sores on his lips for one week.
5. Regular insulin-sliding scale as attached.
6. Iron 325 once a day.
7. Epogen 4000 units Monday, Wednesday, Friday.
8. Methadone 15 mg by mouth three times a day.
9. Clonidine 0.1 every week.
10. Lorazepam 1 mg every four hours.
11. Reglan 10 mg every six hours.
12. Ativan as needed.
13. Hydromorphone as needed.
14. Zofran as needed.
15. Albuterol inhaler.
16. Mucomyst nebulizer treatments.
17. Colace.
18. Milk of magnesia.
19. Glycerine suppository.
20. Dulcolax suppository.
21. Levofloxacin 500 mg by mouth every day.
DISPOSITION: He is being discharged to [**Hospital6 56634**].
DISCHARGE DIAGNOSES: Status post motor vehicle collision.
Multiple C1-C7 vertebral fractures.
Status post cervical spine fusion.
Double-barrel IVC.
Postoperative atelectasis.
Posterior ileus.
Hemophilus influenzae.
Ventilator-associated pneumonia.
Urinary tract infection.
PEG [**8-27**].
Percutaneous tracheostomy [**8-27**].
Therapeutic bronchoscopy on [**8-31**].
Hyperkalemia.
Hypomagnesemia.
Hypocalcemia.
Iron deficiency anemia.
Herpes simplex virus.
Muco-cutaneous herpes.
Quadriplegia.
FOLLOW-UP INSTRUCTIONS: His followup should be with Dr.
[**Last Name (STitle) 28257**] in [**1-8**] weeks.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 16263**]
Dictated By:[**Last Name (NamePattern1) 22879**]
MEDQUIST36
D: [**2154-9-3**] 10:49:00
T: [**2154-9-3**] 11:18:27
Job#: [**Job Number 56635**]
|
[
"518.0",
"560.1",
"997.3",
"599.0",
"482.2",
"304.01",
"806.01",
"276.8",
"997.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"96.04",
"81.02",
"81.63",
"31.1",
"84.52",
"43.11",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
6847, 6917
|
2534, 4590
|
568, 716
|
7331, 7339
|
1246, 2511
|
7534, 7767
|
8252, 8356
|
12366, 12858
|
11546, 12344
|
6938, 7310
|
4616, 4647
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9249, 11523
|
7363, 7510
|
975, 1227
|
8379, 8822
|
7785, 7800
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7829, 8104
|
12883, 13235
|
8847, 9231
|
8127, 8177
|
8194, 8235
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,045
| 148,967
|
34051
|
Discharge summary
|
report
|
Admission Date: [**2172-7-8**] Discharge Date: [**2172-7-16**]
Date of Birth: [**2129-5-9**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Levaquin / Codeine
Attending:[**First Name3 (LF) 78588**]
Chief Complaint:
Bilateral acetabular dysplasia with proximal femoral CAM
morphology with generalized ligamentous laxity with pain in both
hips, right worse than left. Osteoarthrosis, both hips.
Unimproved post arthroscopic surgery, both hips.
Major Surgical or Invasive Procedure:
Right Periacetabular osteotomy under GA on [**2172-7-8**]
History of Present Illness:
[**Known firstname **] is a 42-year-old female from [**Location (un) 3844**] who has been
referred to Dr. [**Last Name (STitle) **] for expert evaluation by Dr. [**Last Name (STitle) 78589**]
[**Name (STitle) 78590**] of bilateral hip pain persisting despite arthroscopic
surgery on both hips.
[**Known firstname **] started having pain and discomfort in the hips at the
age of 15, but really never sought medical attention at this
point in time. She actually began experiencing a dramatic
deterioration in both her hips in [**2168**], when she began to
experience a constant clicking and popping in her right hip.
She was eventually referred to Dr. [**Last Name (STitle) 78589**], who did a right
hip scope in [**2170-8-17**], at which time, he debrided the
labrum, which was found to be torn. She developed symptoms in
her left hip, following which he did a left hip scope in
[**2171-10-17**].
However some months ago she experienced sharp pain in her right
hip following which she has noted a resurgence of pain, which
she states is even worse than what she had prior to the scopes.
She has pain and discomfort in the groin, the anterior aspect of
her hip, as well as the lateral aspect of her thigh. She has
night pain and a constant burning sensation over the lateral
aspect of her thigh. She has a constant dull ache in her right
hip. She is on a lot of opioid medications, which she states do
not really help her too much.
On the [**University/College 33150**] Activity Score, she rates herself as a 3, which
translates that she sometimes participates in mild activities,
such as slow walking and limited housework. She is able to
climb stairs with the help of a bannister. She is not able to
use public transportation, and she can comfortably sit in a
chair for one-half hour. She has problems putting on her socks
and tying her shoelaces. She uses a single cane for long walks,
and is able to walk a maximum of two to three blocks. She often
hears a grinding and clicking noise in both hips, and has
moderate difficulties spreading her legs wide apart, and severe
difficulties striding out when walking. She is constantly aware
of her hip problem, and has totally modified her lifestyle to
avoid activities that could be potentially damaging to her hips.
She is extremely diffident about her hips. She states that
her most bothersome symptoms are divided equally between pain
and instability in her hips, especially the right hip.
Past Medical History:
She is the firstborn female child of a normal vaginal delivery.
She was the only child in her family. There was no history of
hip dysplasia in her childhood. She has had a slew of
surgeries, namely the right hip scope in [**2170-8-17**], a left
hip scope in [**2171-10-17**], L4-L5 fusion in [**2171-4-16**], which
resulted in complications in the form of a dural tear and a
staphylococcal infection, which necessitated repeated washouts
and a one-month stay in the [**Hospital6 2910**]. At
this point in time, she continues to have a nonunion, and has
been put in a bone stimulator in the hopes that it would produce
L4-L5 fusion. She however states that the silver lining in all
of this has been the improvement of sciatica-like symptoms in
her legs following the spinal surgery, but she continues to have
back pain. She has also had two dilatation and curettages. She
had had a hysterectomy in [**2169**]. She has had multiple sinus
surgeries. She has also had a coccygeal shaving as a young
adult, which she states helped reduce her symptoms.
Social History:
She used to work as a nurse recruiter in the past, but has been
off work since [**2168**].
Family History:
Her parents are orthopaedically okay.
Physical Exam:
She is a conscious, cooperative female in no apparent distress,
who is alert and oriented times three. She has a normal
abdominal and cardiovascular and respiratory examination.
She walks with a bilateral Trendelenburg gait, and has a
strongly positive Trendelenburg test on the right side. Her
flexibility is hampered both by her back, as well as her
hamstrings, and she can only touch up to her mid-shins. She
uses no assistive devices to walk.
Her height is 169 cm. Her weight is 76.7 kg. Her temperature
is normothermic.
On examination of her right hip, which is her more symptomatic
side, she has pain at 85 degrees of flexion but was able to flex
up to 100 degrees. She had external rotation of 45 degrees on
flexion and internal rotation of 20 degrees of flexion. On
extension, she was able to externally rotate 30 degrees, and
internally rotate 15 degrees. She has an abduction of 40
degrees, and a straight leg raise of up to 50 degrees with a
positive Lasegue sign. On [**Doctor Last Name **] test, she was able to abduct
up to 2-1/2 fists. She has a strongly positive impingement, as
well as an apprehension, sign, in the right hip. She also has a
positive bicycle sign. On examination of the left hip, she was
able to flex up to 100 degrees, and had excellent rotation to 45
degrees and internal rotation to 20 degrees on flexion. She had
external rotation of 40 degrees and internal rotation of 40
degrees on extension with abduction to 40 degrees and a straight
leg raise of 60 degrees. [**Doctor Last Name **] was 2-1/2 fists in her left
hip. She had a good abductor strength of 4+ in the left hip.
She has a positive impingement sign and a bicycle sign in her
left hip, but a negative apprehension sign. Her leg lengths are
equal at 88 cm, and thigh circumferences are equal at 51 cm.
She has external tibial torsion around 10 degrees bilaterally
Pertinent Results:
[**2172-7-11**] 10:20AM BLOOD WBC-8.2 RBC-3.49*# Hgb-10.0* Hct-28.9*
MCV-83 MCH-28.7 MCHC-34.7 RDW-14.0 Plt Ct-157
Brief Hospital Course:
Lost almost 4 liters of blood intraoperatively and was given
back almost a litre of blood through the cell [**Doctor Last Name 10105**]. Her prior
use of opioid medication and inability to have an epidural due
to prior spine surgery resulted in poor pain control and
necessitated an ICU admission as she was on extremely high doses
of pain medication (particularly Pressidex) that made it unsafe
for the regular floor to manage her. She was transfused 2 units
of blood for acute blood loss anemia.
Her drain was pulled out on the 2nd post op day and dressing was
changed. She was shifted to the floor on the 2nd post op night.
Poor pain control continued to plague her throughout her stay in
hospital and PT was difficult most of the times. It was decided
to shift her to a acute rehab center where she could continue
with PT and other aspects of her convalescence before discharge
home. She was approved for rehab on [**2172-7-16**].
Medications on Admission:
Oxycontin, Dilaudid, Levothyroxine, Ambien, Trazadone,
Amitryptiline
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed.
3. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
5. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) 40 mg/0.4 mL
Syringe Subcutaneous DAILY (Daily) for 4 weeks.
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
7. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day) as needed for pain.
8. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Hydromorphone 4 mg Tablet Sig: Two (2) Tablet PO Q3-4H () as
needed for pain. Tablet(s)
10. Oxycodone 60 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 8 hr PO Q8H (every 8 hours) as needed
for pain.
11. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for pain, spasm.
12. HYDROmorphone (Dilaudid) 0.5-1 mg IV PRE AND POST PT Q 3-4
HRS PRN pain
Please hold for sedation.
Please use 30 minutes prior to PT and post.
13. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] and Islands
Discharge Diagnosis:
Bilateral Hip Dysplasia
Discharge Condition:
Afebrile, vitals within normal limits, pain relatively under
control, dressing clean and dry and intact
Discharge Instructions:
Absorbable sutures do not need removal
Dressing to be changed only if soiled, use waterproof dressing
material
Can shower on dressing, if incision area gets wet pat dry and
redress
PHYSICAL THERAPY
1/6th weight bearing with crutches for 6 weeks. Avoid hip
flexion beyond 90 degrees until first post-op visit (4-6 weeks).
No antigravity exercises should be started until about 2 months
raises or any exercise which potentially uses a long lever arm
at the hip.
AAROM of the involved hip within the restrictions indicated by
the orthopedic surgeon. (ROM is usually flexion 30-80,
abd/adduction [**9-25**], IR/ER [**9-25**].) ROM restrictions are not
absolute contraindications.
Patients will utilize crutches for an average of 3 months. They
should not wean unless cleared by MD.
Although the patient should try to stay within the stated
precautions, he/she can sit at 90 degrees, and won??????t ??????ruin?????? the
surgery by moving hip outside of specified ROM. Active exercises
also include quad sets, glut sets, and ankle pumps.
Physical Therapy:
PHYSICAL THERAPY
1/6th weight bearing with crutches for 6 weeks. Avoid hip
flexion beyond 90 degrees until first post-op visit (4-6 weeks).
No antigravity exercises should be started until about 2 months
raises or any exercise which potentially uses a long lever arm
at the hip.
AAROM of the involved hip within the restrictions indicated by
the orthopedic surgeon. (ROM is usually flexion 30-80,
abd/adduction [**9-25**], IR/ER [**9-25**].) ROM restrictions are not
absolute contraindications.
Patients will utilize crutches for an average of 3 months. They
should not wean unless cleared by MD.
Although the patient should try to stay within the stated
precautions, he/she can sit at 90 degrees, and won??????t ??????ruin?????? the
surgery by moving hip outside of specified ROM. Active exercises
also include quad sets, glut sets, and ankle pumps.
Treatments Frequency:
Remove outer dressing in 10 days from day of surgery. Absorbable
sutures do not need removal
Dressing to be changed only if soiled, use waterproof dressing
material
Can shower on dressing, if incision area gets wet pat dry and
redress
Followup Instructions:
Please call Dr [**Last Name (STitle) 78591**] office to schedule appointment
Completed by:[**2172-7-16**]
|
[
"285.1",
"276.52",
"E878.8",
"338.18",
"755.63",
"715.35"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"78.59",
"78.09",
"77.39",
"80.15",
"77.79"
] |
icd9pcs
|
[
[
[]
]
] |
8630, 8717
|
6355, 7291
|
509, 569
|
8785, 8891
|
6216, 6332
|
11107, 11215
|
4259, 4298
|
7410, 8607
|
8738, 8764
|
7317, 7387
|
8915, 9952
|
4313, 6197
|
9970, 10825
|
10847, 11084
|
243, 471
|
597, 3057
|
3079, 4135
|
4151, 4243
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,061
| 178,323
|
51546
|
Discharge summary
|
report
|
Admission Date: [**2137-12-29**] Discharge Date: [**2138-1-1**]
Date of Birth: [**2055-9-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 18369**]
Chief Complaint:
GI distress, diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
82 yo female with history of with stage IV NSCLCA (BAC) on
Alimta presents with GI distress. Her daughter called the on
call oncologist today who asked the patient to report to the ED.
Her daughter reported the patient was experiencing diarrhea
which started the evening after her last chemotherapy dose
([**2137-12-24**], cycle 30) with associated incontinence, which resolved
by Wednesday ([**2137-12-25**]). Since that time, she reports her
symptoms have progressed. She reports persistent nausea,
vomiting, diarrhea, fatigue, increased incontinence of bowel and
bladder. She reports for the last three days she has had dark to
black stool. Today, she reports worsening intermittent nausea,
with vomiting at 2 am and inability to tolerate oral
antiemetics. Of note, the patient has not allowed re-imaging of
her disease since [**8-1**]. She also has refused colonoscopies in
the past.
In the emergency department her initial vital signs were T 99.1
HR 78 BP 108/53 RR 20 O2 98% on RA. Her labs were significant
for Hct drop of 25 points in 5 days, from 41 to 16, baseline 40,
hypokalemia and elevated INR of 1.9 (on coumadin). 2 large bore
IVs were place. She was given 10mg of IV vitamin K. She was
transfused 2 units of PRBCs and 2 of FFP. GI was consulted in
the ED and felt she was stable for delayed scope. Oncology was
consulted and recommended transfer to the ICU. After signout was
given, it was noted that the patient has a history of right main
pulmonary artery invasion from the tumor, thus a CXR and CT
torso was done to rule out bleeding into chest.
On arrival to the [**Hospital Unit Name 153**], the patient reports continued fatigue
and weakness. She denies ongoing melena, diarrhea or nausea. She
denies pain currently. She reports she has not had any fevers or
chills. Her husband, four daughters and son accompanied her. Her
daughter who is a nurse reports she evaluated her yesterday. She
reports her blood pressure and HR were normal at that time and
she found her stool to be dark but did not believe it was
melena.
REVIEW OF SYSTEMS:
(+)ve:
(-)ve: fever, chills, night sweats, loss of appetite, fatigue,
chest pain, palpitations, rhinorrhea, nasal congestion, cough,
sputum production, hemoptysis, dyspnea, orthopnea, paroxysmal
nocturnal dyspnea, nausea, vomiting, diarrhea, constipation,
hematochezia, melena, dysuria, urinary frequency, urinary
urgency, focal numbness, focal weakness, myalgias, arthralgias
Past Medical History:
- Bronchoalveolar Carcinoma initially diagnosed [**2112**], initially
treated with RML lobectomy. She had recurrence in [**2129-5-8**]
with a left lung nodule. LUL and LLL wedge resections were
completed in [**2129**]. She was treated with carboplatin and
Navelbine from [**2129-8-24**] through 01/[**2130**]. Because of
progression of disease by CT scan and rising CEA, she agreed to
a trial of Tarceva which she began on [**3-/2134**], however,
developed severe skin and mucosal reactions. In [**1-31**], she was
found to have right upper lobe collapse. She was started on
Alimta [**2136-2-23**] and is currently on her 30th cycle.
- Gastrointestinal Stromal Tumor with partial gastrectomy [**2121**]
w/o recurrence
- breast lumpectomy X2
- thyroid adenoma s/p resection
- Pulmonary Embolisms - in [**1-31**], on coumadin
Social History:
The patient has a remote history of tobacco abuse. Occassionally
uses alcohol. Denies illicit drug use.
Family History:
Not contributory
Physical Exam:
GENERAL: Pleasant, well appearing female in NAD
HEENT: Normocephalic, atraumatic. Significant conjunctival
pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck
Supple, No LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP flat
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**1-25**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
EKG: sinus rhythm at 95bpm with AV conduction delay, no ST
changes.
CXR: Trachea deviation to the right, evidence of right sided
resection, missing right 3rd rib, collapse of right upper lobe,
fluid in the fissure on the right.
CT Torso:
1. No evidence of hemorrhage within the torso, or other
explanation for
hematocrit drop.
2. Grossly stable appearance of multiple pulmonary masses, and
post-surgical changes in the lungs, although limited in the
absence of IV contrast.
3. No acute abnormalities in the torso.
EGD [**2137-12-30**]:
Small hiatal hernia
We did not see sign of post-gastrostomy.
Polyps in the stomach body
Erythema in the antrum compatible with gastritis
There was dark blood clot in her stomach body, which was easily
dislodged by water flash. There was no ulcer or visible vessel
under the blood clot. However, the tissue around the blood clot
appears to be thickening and heaped up. The lesion is more
compatible with a dieulafoy lesion. Biopsy did not performed
because of the recent bleeding. (thermal therapy)
Otherwise normal EGD to third part of the duodenum
Admission labs [**12-29**]:
WBC-7.3# RBC-1.66*# Hgb-5.4*# Hct-16.1*# MCV-97 MCH-32.3*
MCHC-33.3 RDW-16.1* Plt Ct-325
Neuts-87.7* Lymphs-10.5* Monos-0.3* Eos-1.2 Baso-0.2
PT-20.1* PTT-26.9 INR(PT)-1.9*
Glucose-121* UreaN-17 Creat-0.8 Na-137 K-3.5 Cl-102 HCO3-27
AnGap-12
ALT-14 AST-33 LD(LDH)-441* AlkPhos-52 TotBili-0.4
Calcium-8.4 Phos-3.4 Mg-1.9
Discharge labs [**1-1**]:
WBC-3.3* RBC-3.89* Hgb-11.7* Hct-35.1* MCV-90 MCH-30.2 MCHC-33.5
RDW-16.6* Plt Ct-191
Glucose-94 UreaN-10 Creat-0.8 Na-136 K-3.5 Cl-99 HCO3-28
AnGap-13
Calcium-8.6 Phos-4.0 Mg-1.8
Microbiology:
H. pylori negative
MRSA screen negative
Blood cultures pending (negative to date)
Brief Hospital Course:
82 yo female with stage IV bronchoalveolar carcinoma, history of
GIST, PEs on coumadin admitted for severe anemia likely
secondary to GI bleed.
#. GI Bleed: Patient admitted with large Hct drop and history
of melena. She underwent EGD that showed a gastic lesion
consistent with a likely dieulafoy lesion. Additionally, the
stomach mucosa was irregular, but no biopsy was performed at the
time of endoscopy because of recent bleeding. GI recommended
that the patient undergo repeat EGD and biopsy in 6 weeks. The
patient received a total of 4 units PRBCs and 2 units FFP, and
remained hemodynamically stable throughout. She was monitored
in the ICU and transferred to the medical oncology service after
36 hours. She had a couple guaiac positive stools but had a
stable hematocrit.
#. Bronchoalveolar Carcinoma: She is s/p LUL and LLL wedge
resections in [**2129**], prior RML lobectomy, with known RUL collapse
seconday to invasion, s/p multiple rounds of chemotherapy, most
recently 30th cycle of Alimta. The patient underwent CT torso
in the ED given her history of known right main pulmonary artery
invasion from the tumor. However, no gross hemorrhage was seen
in the chest cavity. Additionally, she was continued on folic
acid as an adjuct to her chemotherapy regimen. She is to
follow-up with her oncologist.
#. Pulmonary Embolisms: Last documented in [**1-31**], was on
coumadin on presentation. Given her significant GI bleed,
coumadin was stopped (and its effects reversed with FFP) and a
decision was made to stop anticoagulation henceforth. Per
primary oncology team, the patient's history of PE was related
to tumor compression of the pulmonary vasculature, and therefore
there is no clear indication for anticoagulation in the future.
#. Gastrointestinal Stromal Tumor: S/p resection in [**2121**]
without known recurrence, but suspicious lesion was seen on EGD.
The patient was advised to undergo repeat EGD in 6 weeks for
biopsy of gastric lesion. Also suggested outpatient
colonoscopy.
#. Hypothyroidism: S/p thyroid resection for adenoma.
Continued on home levothyroxine.
#. Hypokalemia: Likely secondary to severe diarrhea. Resolved
with fluid resuscitation.
#. Lower Extremity Edema: Likely secondary to chemotherapy vs.
venous stasis. Intially held home lasix due to risk of
hemodynamic compromise, but restarted after fluid resuscitation.
#. Leukopenia and Thrombocytopenia: Decreased platelets could be
consumptive process in setting of recent bleed but more likely
related to recent chemotherapy administration. Could also be
related to PPI administration.
CODE STATUS: DNR/DNI confirmed with patient
EMERGENCY CONTACT: HCP [**Name (NI) **] [**Name (NI) **] ([**2121**], Husband Mr.
[**Known lastname 74225**] [**Telephone/Fax (1) 106862**], Daughter [**First Name8 (NamePattern2) 4051**] [**Last Name (NamePattern1) 4580**] [**Telephone/Fax (1) 106863**]
Medications on Admission:
WARFARIN 5 mg QD
FUROSEMIDE 20mg QD
FOLIC ACID 1 mg QD
LEVOTHYROXINE 75 mcg QD
LORAZEPAM 0.5 mg [**1-25**] PRN
PROCHLORPERAZINE 10 mg PRN
ACETAMINOPHEN PRN
MULTIVITAMIN WITH IRON-MINERAL QD
VIT C-BIOFLAV-HESP-RUTIN-HB111 QD
VIT E- VIT C-MAGNESIUM-ZINC QD
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Upper gastrointestinal bleed
Secondary:
Non small cell lung cancer
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 because you were having
gastrointestinal bleeding. You were seen by gastroenterology who
performed who determined by a procedure called endoscopy that
the bleeding originated in your stomach. You received blood
transfusions and your blood counts have remained stable. Given
this bleeding episode your team of doctors [**Name5 (PTitle) **] decided to take
you off of coumadin.
You will
MEDICATION CHANGES:
STOP coumadin
START (NEW Med) omeprazole 40mg by mouth twice a day: for the
inflammation in your stomach
Followup Instructions:
WE SCHEDULED THE FOLLOWING:
UPPER ENDOSCOPY: [**2137-2-11**] Arrive at 8:30am at [**Hospital Ward Name 516**],
[**Hospital Ward Name 1950**] [**Location (un) 470**] for your upper endoscopy with Dr. [**Last Name (STitle) 349**].
[**Telephone/Fax (1) 463**]
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**]
Date/Time:[**2138-1-9**] 10:00
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3150**] Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2138-1-9**]
10:00
----
THE FOLLOWING WERE ALREADY SCHEDULED
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**]
Date/Time:[**2138-1-23**] 10:00
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3150**] Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2138-1-23**]
10:00
Provider: [**First Name4 (NamePattern1) 539**] [**Last Name (NamePattern1) 10603**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2138-1-23**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**]
Date/Time:[**2138-1-23**] 10:00
|
[
"787.91",
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"288.50",
"244.0",
"287.5",
"V58.61",
"V12.51",
"782.3",
"537.84",
"276.8",
"162.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
10128, 10186
|
6330, 9251
|
295, 301
|
10307, 10307
|
4563, 6307
|
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|
3754, 3772
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9557, 10105
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9277, 9534
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2392, 2770
|
10924, 11030
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234, 257
|
329, 2373
|
10321, 10461
|
2792, 3617
|
3633, 3738
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,496
| 159,938
|
22297
|
Discharge summary
|
report
|
Admission Date: [**2189-10-13**] Discharge Date: [**2189-10-17**]
Date of Birth: [**2141-8-9**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
Unresponsive
Major Surgical or Invasive Procedure:
endotrachial intubation (at outside hospital)
nasogastric tube placement
History of Present Illness:
48 yo M with h/o hepatitis C, h/o pancreatitis, HIT, HTN, T2DM,
found by his girlfriend at home with possible seizures. He had
also been having visual and auditory hallucinations x 8 hours
per his GF.
No seizure activity was noted per EMS. FSBS 170, HR 80's.
Narcan was given with no effect. He was taken to [**Hospital1 58095**] and inital vitals were HR 63 RR 24 O2Sat 95%RA Wt 102kg
(T and BP deferred due to combativeness). He was reportedly
extremely agitated and he was intubated for airway protection
and started on a propofol drip. Per review of telemetry, he was
tachycardic from 23:00 last night until 03:00 with HR 157-->132.
Had CT head that was negative for acute intracranial
abnormality with left otomastoiditis. He had NG tube placed
which showed coffee ground emesis per ED report although per
notes it was "guaiac positive." Labs were notable for a Hct
22.5, Plts 25, CK 1153, tox positive for TCA and cannabis, Crt
1.4, K 2.8, lactate 5.9. He was given protonix, rocephin 2g x
1, cogentin 2mg x 1, haldol 5mg IV x 2, zyprexa 10mg x 1, ativan
2mg IV x 4, banana bag, 2L IVF.
In our ED, initial vitals were 100.9, 127, 143/107, 100%. Had
negative NG lavage. Repeat head CT was also negative. He was
noted to have ecchymosis on his side and abdomen. BS was
normal. ECG showed sinus tachycardia. Most recent vitals 99.1
102 147/92 20 100. Has 3 PIV.
Past Medical History:
HIT
Hepatitis C
Seizure d/o
Hypertension
T2DM with microalbuminuria
Pyogenic arthritis, ?Charcot joint left ankle, now s/p L BKA
Hypothyroidism
Pancreatitis
H/o multiple closed head injuries
H/o ligament ankle injuries
Social History:
Lives with girlfriend in [**Name (NI) 3494**]. Disabled, lives by himself
on the [**Location (un) 10043**] of an apartment.
Family History:
Unable to obtain.
Physical Exam:
On admission:
VS: 97.7 99 142/82 20 100%
GEN: Intubated, sedated, chronically ill appearing overweight
gentleman
HEENT: Pupil 1cm bilaterally, minimally reactive, anicteric, MM
dry with dried blood coming out of his nose, no supraclavicular
or cervical lymphadenopathy, no evident JVD
RESP: CTA bilaterally
CV: RRR without evident MRG
ABD: Hypoactive BS, not obviously tender, liver not palpable due
to obese abdomen, no obvious ascites on exam but some
hyperresonance to percussion over anterior abdomen and less so
on lateral aspects
EXT: With left BKA, 2+ DP pulse on RLE
SKIN: Multiple ecchymoses on abdomen and excoriations on RLQ of
abdomen. Also with abrasions on RLE shin and foot without
surrounding erythema.
NEURO: Normal tone. Hyperreflexia throughout. Responsive to
pain. Upgoing toes on RLE.
RECTAL: Per GI, guaiac negative
Pertinent Results:
[**2189-10-13**] 04:54AM BLOOD WBC-5.3 RBC-2.55* Hgb-8.2* Hct-22.3*
MCV-87 MCH-32.1* MCHC-36.7* RDW-15.5 Plt Ct-37*
[**2189-10-17**] 06:58AM BLOOD WBC-4.0 RBC-3.39* Hgb-10.5* Hct-29.9*
MCV-88 MCH-31.1 MCHC-35.3* RDW-16.5* Plt Ct-73*
[**2189-10-13**] 10:00AM BLOOD Neuts-79.9* Lymphs-17.7* Monos-1.7*
Eos-0.6 Baso-0.2
[**2189-10-14**] 12:21AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Burr-OCCASIONAL
Ellipto-OCCASIONAL
[**2189-10-13**] 04:54AM BLOOD PT-14.6* PTT-23.3 INR(PT)-1.3*
[**2189-10-15**] 04:56PM BLOOD PT-13.1 PTT-21.1* INR(PT)-1.1
[**2189-10-13**] 04:54AM BLOOD Fibrino-236
[**2189-10-13**] 10:00AM BLOOD Glucose-164* UreaN-16 Creat-1.0 Na-136
K-2.6* Cl-104 HCO3-22 AnGap-13
[**2189-10-17**] 06:58AM BLOOD Glucose-121* UreaN-16 Creat-1.0 Na-138
K-3.8 Cl-106 HCO3-23 AnGap-13
[**2189-10-13**] 04:54AM BLOOD ALT-26 AST-78* AlkPhos-113 TotBili-0.5
[**2189-10-13**] 10:00AM BLOOD LD(LDH)-286* CK(CPK)-2377*
[**2189-10-16**] 10:20AM BLOOD ALT-37 AST-81* LD(LDH)-314* CK(CPK)-961*
AlkPhos-152* TotBili-0.7
[**2189-10-13**] 04:54AM BLOOD Lipase-65*
[**2189-10-13**] 10:00AM BLOOD CK-MB-11* MB Indx-0.5 cTropnT-<0.01
[**2189-10-13**] 10:00AM BLOOD Albumin-3.2* Calcium-7.0* Phos-2.1*
Mg-1.7 Iron-20*
[**2189-10-16**] 06:37AM BLOOD Calcium-8.4 Phos-2.0* Mg-1.5*
[**2189-10-13**] 10:00AM BLOOD calTIBC-235* VitB12-824 Folate-GREATER TH
Hapto-12* Ferritn-587* TRF-181*
[**2189-10-13**] 10:00AM BLOOD %HbA1c-6.0* eAG-126*
[**2189-10-13**] 10:00AM BLOOD Triglyc-227*
[**2189-10-13**] 10:00AM BLOOD TSH-99*
[**2189-10-13**] 07:28PM BLOOD TSH-GREATER TH
[**2189-10-14**] 03:00PM BLOOD TSH-96*
[**2189-10-15**] 02:25AM BLOOD TSH-GREATER TH
[**2189-10-13**] 07:28PM BLOOD Free T4-0.32*
[**2189-10-14**] 03:00PM BLOOD T4-4.2*
[**2189-10-15**] 02:25AM BLOOD Free T4-0.84*
[**2189-10-14**] 12:21AM BLOOD Cortsol-12.7
[**2189-10-13**] 04:54AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-POS
[**2189-10-13**] 04:54AM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2189-10-13**] 01:57PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1005*
Polys-47 Lymphs-31 Monos-0 Macroph-22
[**2189-10-13**] 01:57PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-53* Polys-8
Lymphs-53 Monos-0 Macroph-39
[**2189-10-13**] 01:57PM CEREBROSPINAL FLUID (CSF) TotProt-69*
Glucose-124
[**2189-10-13**] 01:57PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-Test Reque
[**2189-10-13**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2189-10-13**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2189-10-13**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2189-10-13**] CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY INPATIENT
[**2189-10-13**] CSF;SPINAL FLUID CRYPTOCOCCAL ANTIGEN-FINAL
INPATIENT
[**2189-10-13**] URINE URINE CULTURE-FINAL INPATIENT
[**2189-10-13**] Blood (EBV) [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG
AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **]
VIRUS VCA-IgM AB-FINAL INPATIENT
[**2189-10-13**] SEROLOGY/BLOOD RAPID PLASMA REAGIN
TEST-FINAL INPATIENT
[**2189-10-13**] SEROLOGY/BLOOD LYME SEROLOGY-FINAL INPATIENT
[**2189-10-13**] IMMUNOLOGY HCV VIRAL LOAD-FINAL INPATIENT
[**2189-10-13**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
Radiology Report CHEST (PORTABLE AP) Study Date of [**2189-10-13**] 4:40
AM
FINDINGS: Tip of the endotracheal tube is 4.4 cm from the
carina. There is a
nasogastric tube within the stomach, however, the side port is
above the GE
junction and could be advanced further. Lung volumes are low.
The heart
appears top normal in size. There is left paratracheal fullness.
There is no
pneumothorax, or pleural effusion. There are no consolidations.
IMPRESSION:
1. Satisfactory ET tube position.
2. NG tube with side port above the GE junction could be further
advanced.
3. Low lung volumes. No pneumothorax or consolidation.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2189-10-13**]
4:46 AM
FINDINGS: There is no hemorrhage, edema, mass effect, or
evidence for acute
vascular territorial infarction. There is no shift of normally
midline
structures and [**Doctor Last Name 352**]-white matter differentiation is preserved.
There is
minimal prominence of the ventricles and sulci, compatible with
parenchymal
involution. There is complete opacification of the sphenoid
sinus. There is
marked mucosal thickening of the ethmoid air cells. There is
mild mucosal
thickening of the maxillary sinuses. There is fluid within the
left mastoid
air cells. There is a catheter inserted through the patient's
right nostril.
IMPRESSION:
1. No acute intracranial findings.
2. Extensive sinus opacification as described.
Radiology Report ABDOMEN U.S. PORT Study Date of [**2189-10-13**] 10:35
AM
FINDINGS: Liver echotexture is within normal limits, although
the examination
is limited. No gross intrahepatic ductal dilatation. The
proximal common duct
is not dilated and measures 0.5 cm. Gallbladder appears
unremarkable, without
gallstones. The body of the pancreas are within normal limits.
The distal
pancreas is obscured by overlying bowel gas. Main portal vein is
patent with
antegrade flow. Trace ascites is seen adjacent to the liver
margin. The
spleen is markedly enlarged measuring 18 cm.
Limited evaluation of both kidneys. The right kidney measures
approximately
12.1 cm. No gross hydronephrosis bilaterally.
IMPRESSION:
1. Trace ascites adjacent to the posterior and inferior liver
margin.
2. No gross liver masses.
3. Marked splenomegaly measuring 18 cm.
4. Limited evaluation of kidneys bilaterally, without gross
hydronephrosis.
Brief Hospital Course:
48 yo M with h/o hepatitis C, h/o pancreatitis, HIT, HTN, T2DM,
found by his girlfriend at home with possible seizures and
hallucinations. Found to have profound hypothryoidism with TSH
of 100.
#. DELRIUM: Differential diagnosis was initally broad, has
significant EtOH use and per patient started seeing bugs on the
wall and seziure observed by girlfriend. Placed on CIWA. TSH
also returned at 100 however was not clinically hypothryoid and
outisde records with TSH of 89 in [**Female First Name (un) **] [**2189**]. He showed no
evidence of myedema coma. He was seen by endocrinology who
recommended restarting his outpatient levothyroxine (the patient
admitted to noncompliance with this therapy and all medications
prior to admission). LP negative on admission. TCA screen
positive however per toxicology consultation, unlikely to be the
cause but did conclude that the most likely cause of his
presentation was alcoholic withdrawal with delirium and possible
citalopram overdose, although the patient denied this. His
condition greatly improved and he was transferred to the medical
floor from the MICU on HD2. He was continued on a CIWA scale
while on the floor but was requiring less benzodiazepines. On
the day of discharge the patient voiced the desire to be
discharged. A conversation with the medicine attending was held
on the day of discharge and he was deemed competent to make this
decision and understood its consecuences. He was able to
articulately describe his reason for admission, his
understanding of his problems with alcohol abuse, the potential
ramifications of that problem should he continue drinking, and
the potential problems associated with continued medication
noncompliance. He denied suicidality, his affect was normal, and
mood was not depressed. He was walking in the hallways using his
prosthetic device on the day of discharge, well-appearing,
coherent, and non-delusional.
#. ANEMIA: Likely due to blood loss given report of coffee
grounds from NGT at OSH, though NGL was negative here. Unclear
duration but likely not acute as was never hemodynamically
unstable. Probably from gastritis or gastric ulcer. Received
3u RBC with appropriate bump. Received 1u platelets given
thrombocytopenia and active bleeding. His Hct remained stable
after transfusions and he had no evidence of bleeding. Patient
will need out patient GI appointement to evaluate for EGD. He
was instructed to continue pantoprazole twice per day for 2
weeks.
#. RESPIRATORY FAILURE: Was intubated for airway protection in
the setting of acute agitation. He was extubated without
difficulty the day after admission.
#. HYPOTHYROIDISM: TSH found to be 100, however per outside
records, has been persistently high (89 in 7/[**2189**]). Received
levothyroxine IV for 3 days and, per endocrine consult,
transitioned to 150 mg PO daily. He also received hydrocortisone
given the possibiliyt of concurrent adrenal insufficiency but
his cortisol level was later found to be normal and this was
ruled out. He was given an appointment at endo clinic.
#. THROMBOCYTOPENIA: Were 25 on admission. Likely
multifactorial [**2-24**] hep c, possible acute viral illness given
splenomeggaly, unclear EtOH use. EBV was IgG (+) and IgM (-).
His thrombocytopenia improved and his platelet count was 73 at
discharge.
#. HISTORY OF HIT: Unclear history, but heparin products were
avodided.
#. HEPATITIS C: Unclear the severity of his disease and if he
has had appropriate workup and evaluation for varices. Abd u/s
with minimal ascites. Viral load showed 6,000,000 IU/mL. He
was given an appointment to follow up at the liver center.
#. ELEVATED CK: Likely has rhabdo given his elevated CK, mild
renal failure on admission and history of acute agitation and
possible seizure. Most likely related to his acute agitation
event. Resolved with IVF.
#. ACUTE RENAL FAILURE: Creatinine elevated to 1.4 at OSH, but
decreased to 1.1 here. Lisinopril held initially but later
re-started and up titrated to 40 mg daily due to hypertension.
#. HYPERTENSION: Hypertensive on admission. At this time and
some of his HTN and tachycardia may be rebound from holding his
home clonidine. Clonidine restarted and lisinopril up titrated
to 40 mg (as above).
#. TYPE II DIABETES MELLITUS: Has microalbuminuria per history
but appears to have diet-controlled DM. A1c was 6%.
# OTOMASTOIDITIS: Patient complained of L sided ear pain. Found
to have ostomastoiditis as seen on CT. He was started on
amoxicillin 500 mg q12h and his condition improve. He was
discharged with a prescription to finish a 7 day course of this
antibiotic on [**10-21**].
Medications on Admission:
Amitriptyline 50mg po qhs
Citalopram 40mg po daily
Clonidine 0.1mg po qhs
Levothyroxine 250mcg po daily
Lisinopril 5mg po daily
Gabapentin 300mg po tid
Betamethasone 0.05% to rash twice daily
Discharge Medications:
1. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Capsule(s)* Refills:*0*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times
a day.
10. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 58096**] Medical
Discharge Diagnosis:
Primary:
1. visual and auditory hallucinations
2. hypothyroidism
3. respiratory failure
4. gastrointestinal bleeding likely secondary to gastritis
5. otomastoiditis
.
Secondary:
1. hypertension
2. diabetes mellitus, type 2
3. hepatitis C
4. s/p left below the knee amputation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity: Uses wheelchair.
Discharge Instructions:
You came to the hospital due to concern about possible seizures
and hallucinations. You were briefly intubated to protect your
airway. You received blood transfusions for low platelets and
anemia. You anemia was thought to be related to inflammation in
your stomach or to an ulcer.
.
You must stop drinking alcohol. Alcohol damages your liver and
puts you at risks for falls, gastrointestinal bleeding, and
other serious problems.
.
There are some changes your medications:
START pantoprazole
START amoxcillin (antibiotic). Stop this after 4 days.
START thiamine
START folic acid
START multivitamin
CHANGE lisinopril to 40 mg daily
CHANGE levothyroxine to 150 mcg daily
STOP amitryptaline
STOP citalopram
STOP gabapentin
Followup Instructions:
Please call yiour primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 766**] to make an
appointment to be seen this week to follow up on your
hospitalization
.
Department: DIV OF GI AND ENDOCRINE
When: TUESDAY [**2189-11-3**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1803**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Can you please call our Registration Department before this
appointment to make sure we have your right demographics on
file. The number is [**Telephone/Fax (1) 10676**]. Thanks.
.
Department: LIVER CENTER
When: WEDNESDAY [**2189-12-30**] at 11:40 AM
With: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Please make an appointment to be seen in the ENT (ear, nose, and
throat) clinic to follow up on your otomastoiditis. The
telephone number is ([**Telephone/Fax (1) 6213**].
|
[
"584.9",
"382.9",
"572.3",
"287.5",
"V49.75",
"577.1",
"728.88",
"368.16",
"070.54",
"518.81",
"401.9",
"531.40",
"250.00",
"280.0",
"303.91",
"780.1",
"383.9",
"291.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"96.07",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
14769, 14828
|
8841, 13485
|
288, 363
|
15148, 15148
|
3072, 8818
|
16028, 17207
|
2175, 2194
|
13727, 14746
|
14849, 15127
|
13511, 13704
|
15283, 16005
|
2209, 2209
|
236, 250
|
391, 1776
|
2223, 3053
|
15163, 15259
|
1798, 2018
|
2034, 2159
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,213
| 101,128
|
27422
|
Discharge summary
|
report
|
Admission Date: [**2190-6-3**] Discharge Date: [**2190-6-7**]
Date of Birth: [**2126-9-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9180**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catherization with stenting to right coronary artery
History of Present Illness:
This is a 63 year-old male with history of type 2 diabetes
mellitus and ESRD on hemodialysis who was admitted to the CCU
after an NSTEMI. He had intially presented to [**Hospital 1474**] Hospital
emergency department with 4 to 6 hours of crushing chest pain
and shortness of breath that occurred while he was watching
television. He rated the pain [**9-16**] and reports that it did not
radiate. The pain was accompanied by diaphoresis, nausea,
vomiting, and severe shortness of breath. He called EMS for
further assistance. He received 3 sublinqual nitroglycerin and
IV lasix with relief of the pain. On arrival to [**Last Name (LF) 1474**], [**First Name3 (LF) **]
EKG showed ST depressions in the anterolateral leads with
inverted T waves. A chest x-ray was notable for pulmonary
edema. He had elevated cardiac enzymes. He received plavix and
heparin and was transfered to the [**Hospital1 18**]. He underwent cardiac
catherization that reveal 3 vessel disease. A stent was placed
in the right coronary. He was transfered to the CCU. with the
goal of CABG with LIMA-LAD and SVG-diagnol. On arrival to the
CCU, he was chest pain free.
Past Medical History:
1. Type 2 Diabetes
2. End stage renal disease on hemodialysis 3 times per week. He
does make some urine.
3. Chronic obstructive pulmonary disease.
4. Hypertension
5. Status post stroke
Social History:
He is separated from his wife. [**Name (NI) **] has not worked for the past
three years but used to be employed as a salesman. He has an 80
pack year tobacco history and smokes 2.5 packs per day. He had
six bloody [**Doctor First Name **] on the day prior to admission but reports that
he does not normally drink alcohol. He denies IV drug use.
Family History:
He is unsure of what diseases run in his family. He reports
that his parents had "all the big diseases." His brother had an
aneurysm. He reports that his sister has inner ear troubles.
Physical Exam:
Vitals: Temperature:100.3 Pulse:92 Blood Pressure:110/69
Respiratory Rate:17 Oxygen Saturation:95% 2L nasal cannula
General: Tired appearing man resting in bed. Alert and oriented
in no acute distress.
HEENT: Pupils equal and reactive, extraoccular movements intact,
anicteric sclera, mildly dry mucous membranes, poor denition.
Cardiac: Regular rate and rhythm, S1 S2, without murmurs, rubs,
or gallops. Bilateral carotid bruits. No jugular venous
distension.
Pulmonary: Mild expiratory wheezes anteriorly and laterally.
Abdomen: Soft, normoactive bowel sounds, mild right upper
quadrant tenderness without rebound orguarding.
Extremities: No cyanosis or edema, feet cool bilaterally, 1+
dorsalis pedis pulses bilaterally, sheath in place in right
groin.
Neuro: Alert and oriented.
Pertinent Results:
Hematology:
WBC-12.6 Hgb-11.7 Hct-34.2 Plt Ct-196
.
Chemistries:
Na-137 K-4.2 Cl-94* HCO3-28 UreaN-26 Creat-4.5 Glucose-141
.
Coagulation:
PT-26.5 PTT-67.3 INR(PT)-2.7
.
Liver Function:
ALT-23 AST-155 AlkPhos-63 Amylase-96 TotBili-0.5
Albumin-4.0
.
Lipid Panel:
Triglyc-206 HDL-69 CHOL/HD-2.5 LDLcalc-65
.
Diabetes:
%HbA1c-6.1
.
VitB12-312
.
Phenytoin-1.7
.
Urinalysis with 500 protein and 100 glucose otherwise dipstick
negative.
.
EKG:
1. On admission to [**Hospital1 1474**]: sinus tachycardia at 113, STE V1,
STD in I, II, III, aVF, V3-V6, TWI II, III, aVF, V4-V6 (new)
2. At [**Hospital1 18**]: Normal sinus at 94, nl axis, STE in V1, V2, STD I,
II, V3-V6, TWI V3-V6, LVH
3. Post procedure: Normal sinus at 85, nl axis, STE V1, V2, V3,
STD I, V4-V6, TWI V4-V6, LVH
.
Liver Ultrasound: Normal Study.
.
Cardiac Catherization: Right dominant circulation. The LMCA was
short and heavily calcified with a distal taper. The LAD had a
proximal eccentric 80% lesion and the distal vessel had a
tubular 70% lesion. Numerous diagonal arteries were without
critical lesions. The left circumflex was a non-dominant vessel
with heavy calcifications. Only a ramus was seen and it was
occluded proximally. The RCA was a dominant vessel with a
proximal 99% lesion. The abdominal aorta was found to have
moderate diffuse disease with iliac aneurysmal dilation and poor
distal flow to the CFA. The RCA was stented with a 3.0 x 18
Cypher. The final residual was 0% with normal flow.
.
Echocardiogram: EF of 40-45% with moderate global left
ventricular hypokinesis.
Brief Hospital Course:
This is a 63 year-old male admitted with NSTEMI.
.
1) NSTEMI: He was admitted with an NSTEMI. Cardiac
catherization revealed three vessel disease. He had a stent
placed in his right coronary. A post-catherization
echocardiogram showed mildly dilated left atrium, mild global
hypokinesis, and an ejection fraction of 40-45%. The initial
plan was to undergo CABG to address is left circumflex and left
anterior descending disease. During the pre-operative work-up,
he was found to have totally occluded bilateral internal carotid
arteries. Therefore, he was deemed to not be a surgical
candidate. He was medically managed with aspirin, high dose
statin, beta-blocker, ACE-inhibitor, and Plavix. His cardiac
enzymes trended down and he had no further chest pain. He was
discharged with cardiology follow-up.
.
2) End stage renal disease: He was maintained on his regular
Tuesday, Thursday, Saturday dialysis. He received epoetin with
dialysis and was maintained on Nephrocaps and phosphate binders.
His dialysis flow sheets during this admission were faxed to
his outpatient dialysis center. He was discharged to continue
his regular dialysis.
.
3) Status post CVA: The details of his CVA are unknown. He was
supposedly on dilantin, but his level was subtherapeutic. He
was maintained on his outpatient dilantin while in house. He
was maintained on aspirin and Plavix for secondary prophylaxis.
.
4) COPD: He had no active issues. He was maintained on
albuterol and Atrovent inhalers.
.
5) Elevated LFT's: His elevated LFTs were thought to be
secondary to alcohol intake or Statin use. A right upper
quadrant ultrasound was normal, and his LFTs remained stable
throughout the admission. He will need his LFTs followed as an
outpatient.
.
6) Diabetes: He was not taking any medications at home for his
diabetes. His A1c on admission was 6.1. His sugars remained
under good control with minimal coverage with an insulin sliding
scale. His blood sugars and A1c should be monitored as an
outpatient.
.
7) FEN: He was maintained on a renal, cardiac, and diabetic
diet. He was maintained on phosphate binders.
.
8) Code: Full.
.
9) Dispo: On the day after his catherization, he wanted to leave
AMA. At the time, he was delirious and could demonstrate that
he understood the gravity of his medical condition. Psychiatry
evaluated him and felt that he did not have the capacity to
leave AMA. He subsequently cleared his delirium. His son was
involved and wanted to take the patient home with him. The
patient was discharged in the care of his son who would help
monitor his medications and follow-up appointments. Psychiatry
also recommended behavioral neurology follow-up as well and
neuropsychiatry testing.
Medications on Admission:
1. Paxil 20 mg daily
2. Lopressor 50 mg [**Hospital1 **]
3. Plavix 300 mg x1
4. Protonix
5. Dilantin 400 daily
6. Nephrocaps 1 tab daily
7. Prandin 1 mg QAC
8. Lipitor 40 mg daily
9. Gemfibrozil 600 mg [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) dose
Injection ASDIR (AS DIRECTED).
8. Phenytoin 100 mg/4 mL Suspension Sig: One (1) tab PO DAILY
(Daily).
Disp:*30 tab* Refills:*2*
9. 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*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
NSTEMI
DM 2
s/p CVA
Discharge Condition:
Stable. He was chest pain free with stable respiratory status.
Discharge Instructions:
Please seek medical attention immediately if you experience
chest pain, arm pain, jaw pain, shortness of breath, nausea,
vomiting, sweating, dizziness, abdominal pain, or fevers/chills.
Please take all medications as prescribed. You MUST continue to
take aspirin and plavix. If you stop these medications, you are
at very high risk of a serious heart attack or even death.
Please attend all follow-up appointments.
Your dilanytin level was very low at the time of discharge and
it was not clear that you were taking this medication at home.
You need to have a follow up dilantin level when you see your
primary care physician.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 39008**] on [**6-22**] at 1:30PM.
Please follow-up with Dr. [**First Name (STitle) **] (cardiologist) on [**6-21**] at
12:45 PM in [**Hospital Ward Name 23**] 7th.
Please follow-up with behavioral neurology on [**6-10**] at 1:30 PM
located in [**Hospital Ward Name 860**] [**Location (un) **]:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11771**], M.D. Phone:[**Telephone/Fax (1) 26488**]
Date/Time:[**2190-6-10**] 1:30
Completed by:[**2190-6-8**]
|
[
"403.91",
"410.71",
"496",
"250.00",
"414.01",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"00.45",
"99.20",
"39.95",
"36.07",
"88.52",
"88.55",
"00.66",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
9135, 9190
|
4738, 7467
|
323, 385
|
9254, 9319
|
3163, 4715
|
9997, 10527
|
2154, 2343
|
7737, 9112
|
9211, 9233
|
7493, 7714
|
9343, 9974
|
2358, 3144
|
273, 285
|
413, 1563
|
1585, 1772
|
1788, 2138
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,466
| 132,416
|
18088+18089
|
Discharge summary
|
report+report
|
Admission Date: [**2173-10-27**] Discharge Date: [**2173-11-3**]
Date of Birth: [**2113-8-9**] Sex: M
Service: GENERAL SURGERY
HISTORY OF PRESENT ILLNESS: This is a 60 year old male with
a history of hypertension, atrial fibrillation, history of
small bowel obstruction, questionable Crohn's disease with
ETOH history, initially presenting to the hospital on
[**2173-10-27**], with abdominal pain radiating to back and
hypotension with blood pressure 68/30.
The patient was transferred to the [**Hospital1 190**] when he was fluid resuscitated with good
response and given three units of fresh frozen plasma and one
unit of packed red blood cells. The patient had an abdominal
CT scan which revealed a subcapsular liver hematoma. The
patient at that time was also guaiac positive. He was
transferred to the Intensive Care Unit. CT of the abdomen
also revealed the patient had one 8.0 centimeter and one 4.0
centimeter liver lesion as well as multiple small liver
lesions throughout his liver.
Otherwise on his initial transfer to [**Hospital1 190**], his white blood cell count was 21.6,
hematocrit 29.7, INR 1.8, creatinine 1.7 with normal liver
function tests. Initially the CT of the abdomen revealed
that the patient had a cirrhotic liver. The patient received
embolization as well as coiling of two branches of the left
hepatic artery, left subclavian was placed on [**2173-10-27**]. The
patient's hematocrit dropped from 29.7 to 22.8. The patient
received a total of 10 units of packed red blood cells as
well as four bags of platelets and 10 bags of cryoglobulin as
well as 17 units of fresh frozen plasma. The patient also
had blood cultures with coagulase negative Staphylococcus as
well as gram negative rods in his sputum. He was started on
Zosyn and Levofloxacin. The patient had a repeat CT scan
which revealed an interval increase in ascites. Antibiotics
were changed to Vancomycin and Zosyn based on Methicillin
resistant Staphylococcus aureus positive sputum from
[**2173-10-25**], [**2173-10-26**], [**2173-10-27**]. Antibiotics were then changed
to Vancomycin, Ceftriaxone and Flagyl.
The patient upon being transferred to the Medical Intensive
Care Unit was noted to have increased ascites. His ascites
was tapped by paracentesis and approximately 2.1 liters were
withdrawn. The paracentesis fluid did not meet criteria for
spontaneous bacterial peritonitis at that time. Otherwise,
the patient had a repeat paracentesis on [**2173-11-1**], as well as
liver biopsy. The liver biopsy results confirmed that the
patient had primary hepatocellular carcinoma with high grade
necrosis as well as vascular invasion.
At this time, hematology/oncology was consulted and it was
felt that given this [**Hospital 228**] medical history that
chemotherapy would probably not be the best option and that
Hospice would be the best course of action.
The patient's family was contact[**Name (NI) **] and they stated that the
patient's wishes prior to admission were that should he get
ill that he would not want any resuscitative efforts
initiated. Thus, the patient and family decided that the
patient would be better off at inpatient Hospice. Procedures
were initiated to place the patient in inpatient Hospice.
Otherwise from an abdominal perspective, the patient was
maintained on Vancomycin and Ciprofloxacin and was to
complete a ten day course of antibiotics. Otherwise, he did
not meet criteria for spontaneous bacterial peritonitis even
on second tap. Otherwise for the patient's respiratory
compromise, the patient was maintained on intubation. He
was mostly maintained on assist control and did well. He was
extubated on [**2173-11-3**], with good response. He remained
stable in room air.
For fevers and elevated white blood cell count, as mentioned
above, the patient had multiple issues including pneumonia,
malignancy, atelectasis as well as hemoperitoneal irritation.
The patient's urinalysis remained negative. He was continued
on Ciprofloxacin and Vancomycin for a total of ten days.
Cardiovascular - During his hospitalization, the patient had
an echocardiogram which revealed an ejection fraction of
greater than 70%. The patient also had one episode of
nonsustained ventricular tachycardia and otherwise had some
episodes of sinus tachycardia. During these episodes, the
patient remained asymptomatic. His electrolytes were
maintained at normal range. Given his asymptomatic nature as
well as his preserved PF, ICD placement was not pursued.
Acute renal failure - During his hospitalization, the patient
had a bump in his creatinine to 1.7. It was felt that his
renal failure was secondary to hyperperfusion as well as
acute tubular necrosis. The patient on examination of his
urine had no eosinophils and only 0-2 granular casts. The
patient was initially maintained on diuresis but then
diuresis was stopped and the patient maintained good urine
output without complication. Otherwise, initially, there was
concern regarding hepatorenal syndrome and bladder scan was
performed which revealed a bladder pressure of negative 14
which was inconsistent with hepatorenal syndrome. During
hospitalization, the patient's creatinine improved and on the
date of discharge, it was 1.3.
Altered mental status - Initially when the patient presented
to the hospital, he was felt to have altered mental status,
however, during his hospitalization, he did not have any
episodes of encephalopathy. No Lactulose was needed, nor any
Haldol. On extubation, the patient's mental status improved.
He was much more lucid.
The patient has a history of heavy alcohol use. During his
hospitalization, he was written for a CIWA scale as well as
Ativan p.r.n. He had only minimal Ativan requirement and had
no symptoms of ETOH withdrawal.
FEN - The patient was maintained on tube feeds at goal. On
the date of discharge, his tube feeds were discontinued and
the patient was to eat food as tolerated.
Lines - The patient has multiple lines placed including an
arterial line, subclavian line as well as peripheral line.
His lines were removed prior to discharge.
Communication throughout his hospitalization was with his
wife. [**Name (NI) 3003**] to discharge, the patient's family had a meeting
with the Medicine team as well as the Hematology/Oncology
team. It was decided that based on his current prognosis
that inpatient Hospice was the best course of action. The
family ardently agreed with this and work was initiated
towards getting the patient inpatient Hospice. The patient's
code status was changed from full to "Do Not Resuscitate".
The patient's family is advised that they should follow-up
with his primary care physician within one week.
MEDICATIONS ON DISCHARGE:
1. Singulair 10 mg one p.o. once daily.
2. Ipratropium Bromide 0.2 mg/ml solution one nebulizer
q6hours as needed.
3. Miconazole Nitrate 2% cream to be applied topical twice a
day as needed.
4. Albuterol 90 mcg aerosol one to two puffs q4hours as
needed.
5. Ipratropium Bromide 18 mcg aerosol one to two puffs
q4hours.
6. Ciprofloxacin 500 mg p.o. twice a day for four days.
DR.[**First Name (STitle) **],[**First Name3 (LF) 734**] 12-988
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2173-11-3**] 15:35
T: [**2173-11-3**] 17:48
JOB#: [**Job Number 50058**]
Admission Date: [**2173-10-28**] Discharge Date: [**2173-11-4**]
Date of Birth: [**2113-8-9**] Sex: M
Service: MICU
The rest of the discharge summary will be dictated by
Medicine intern taking care of the patient on the medicine
floor.
HISTORY OF PRESENT ILLNESS: The patient is a 60 year-old
male with a history of hypertension, atrial fibrillation,
history of SBL, question of Crohn's disease with an ETOH
history who initially presented from the outside hospital
with jarring and tearing abdominal pain with radiation to the
back and hypotension from 68/30 to 38/palp. He was
transferred to the [**Hospital1 69**] on
[**10-20**] when he was fluid resuscitated with good response, given
3 units of fresh frozen platelets, 1 unit of packed red blood
cells. He had an abdominal CT, which revealed subcapsular
liver hematoma and was guaiac positive. He was transferred
to the Intensive Care Unit. Initially white blood cell count
was 21.6, hematocrit was 29.7, INR 1.8, creatinine 1.7 with
normal liver function tests. The patient was intubated on
[**2173-10-21**] and had a liver angiogram, because the CT with
contrast revealed multiple liver masses and a cirrhotic liver
with the largest mass bleeding. The patient received
chemo embolization of two branches of the left hepatic artery
as well as coiling. A left subclavian was placed on [**10-21**] and
then changed over a wire on [**10-24**]. The patient's hematocrit
post procedure was noted to drop from 29.7 to 22.8. He
received a total of 10 units of packed red blood cells, 4
bags of platelets, 1 cryo, 17 units of fresh frozen platelets
between [**10-20**] and [**10-21**]. The patient's blood cultures were
positive for one out of four bottles of coag negative staph.
The patient began to spike on [**10-22**] to a max of 102.6. He
grew out gram negative rods consistent with E-coli in his
sputum on [**10-22**] and was started on Zosyn and then was changed
to Levo. The patient also had an elevated sodium to a max of
157 on [**10-25**]. A right subclavian was placed on [**10-26**]. Repeat
CT on [**10-27**] revealed no abscess, but revealed an interval
increase in ascites and multiple liver masses. The patient's
antibiotics were then changed to Vancomycin and Zosyn based
on MRSA positive sputum on [**8-16**] and [**10-27**]. Antibiotics
were then changed to Vancomycin, Ceftriaxone and Flagyl on
[**10-26**].
PAST MEDICAL HISTORY:
1. Hypertension.
2. Atrial fibrillation.
3. Asthma.
4. Question of chronic obstructive pulmonary disease.
5. Crohn's.
6. NSBO.
7. Obesity.
PAST SURGICAL HISTORY: The patient had a colon polypectomy.
ALLERGIES: Penicillin causes a rash.
MEDICATIONS ON TRANSFER TO THE MICU:
1. Vancomycin.
2. Lansoprazole.
3. Lopressor.
4. Subq heparin.
5. Insulin sliding scale.
6. Albuterol nebulizer.
7. Atrovent nebulizer.
8. Singulair.
9. Clonidine.
10. Tube feeds.
11. Ceftriaxone.
12. Flagyl.
SOCIAL HISTORY: Prior extensive tobacco use. Currently does
not smoke. ETOH, currently not drinking, however, prior very
heavy history. Lives with wife. Currently not working.
PHYSICAL EXAMINATION: Temperature max was 103.1.
Temperature current 100.8. Pulse 77 current, range was 67 to
113. Blood pressure 101 to 171/54 to 86, current was 119/60.
Respiratory rate 15 to 32. Satting 100% on room air. The
patient was on SIMV vent, tidal volume 600, respiratory rate
14 to 24, FIO2 0.4, FIO2 pressures support 5 of PEEP. CVP 11
to 19, current 11, PIP 26, plateau 24, ins and outs were 23,
20/11, 40. Physical examination, the patient was sedated,
eyes opened, but not responding to commands. Pupils are
equal, round and reactive to light. Sclera anicteric. The
patient was jaundice diffusely including under tongue. He
was intubated. Cardiovascular regular rate and rhythm.
Pulmonary no wheezes, occasional rhonchi heard at bases
bilaterally. Abdomen was distended, difficult to appreciate
hepatosplenomegaly. Positive bowel sounds. The patient had
2+ pitting edema bilaterally to the knees. Pneumoboots in
place. Neurological unable to respond to voice. Skin
modeling bilateral in thighs. 2+ dorsalis pedis pulses and
warm.
DATA: Fibrinogen 378, INR 1.3, PT 14, PTT 28.4, white blood
cell count 14.4, hematocrit 33.2, platelet count 218,
neutrophils 86 bands, 7 lymphocytes, 3 monocytes. Urinalysis
large blood, 30 protein, urobilinogen 1, 11 to 20 red blood
cells, 3 to 5 white blood cells, 0 to 2 epithelials, moderate
bacteria, negative glucose, negative nitrite, negative
leukocyte esterase, negative ketone, negative bilirubin. Tox
screen negative on [**10-20**]. Sodium 148, K 4.3, chloride 112,
bicarbonate 30, BUN 44, creatinine 0.9, glucose 219, phos
1.3, magnesium 2.4, ALT 100, AST 109, alkaline phosphatase
123, amylase 14, T bili 4.1, lipase 30, LDH 641, AFP 3, 59.5.
Troponin 0.03. Hep serologies all pending. C-diff pending.
Blood cultures pending. Other results as stated above.
HOSPITAL COURSE: 1. Cirrhosis: Throughout his
hospitalization the patient had elevated transaminases.
Additionally his liver parenchymal was consistent with
cirrhosis. The patient had continued ascites throughout his
hospitalization. Paracentesis was performed and was
consistent with a transudate. Additionally it was not
significant for an SBP. During his hospitalization there was
concern regarding possible compartment syndrome based on the
fact that the patient's ascites would continue to grow. The
patient had decreased urine output. However, a bladder
pressure was obtained, which ruled out compartment syndrome.
Hepatology was following and felt that repeated paracentesis
was indicated only should the patient have pulmonary
compromise. However, the patient remained stable on room air
and then on oxygen by nasal cannula, hence a repeat
paracentesis was not performed. The patient's cytology and
pathology results was consistent with hepatoma. Given that
his disease was so diffuse with multiple hepatic masses and
most likely seeding in his abdomen the family decided that
they did not want to initiate any chemotherapy at the current
time. Hep serologies remained negative.
2. The patient had persistent fevers initially. The
differential diagnoses include MRSA, pneumonia, E-coli,
necrotizing hepatic masses, ischemic bowel, SBP, diarrhea,
endocarditis, deep venous thrombosis, PE, drug fever given
that the patient was on Zosyn and has a Penicillin allergy,
Atelectasis, endocarditis, DVT and PE were all ruled out.
SBP was ruled out based on peritoneal fluid analysis and the
patient's fever curb trended down. It was felt secondary to
heavy tumor burden and consistent with patient metastatic
cancer. Pan cultures were obtained, however, and remained
negative except for those mentioned above.
3. Cardiovascular: The patient did have episodes of a
supraventricular tachycardia, however, remained asymptomatic
during these episodes. He had multiple rule out protocols
performed and ruled out for myocardial infarction on repeated
occasions.
4. Acute renal failure: The patient had acute on chronic
worsening of his renal failure, but with hydration his
creatinine normalized to the baseline of 1.3. Additionally
his hyponatremia improved with free water boluses.
5. FEN: The patient was maintained on tube feeds.
6. Lines: The patient had a peripheral as well as .......
in his left upper extremity.
7. Communication: With his wife. After having extensive
discussions with the wife it was decided that the patient
should be made DNR/DNI and then later the patient was made
comfort measures only. This was due to the fact that the
patient had widely metastatic carcinoma with mets to the
liver and most likely peritoneal seating with an increase in
his ascites. By the time of transfer to the MICU to the
General Medicine Floor the patient again had elevated sodiums
up to 152. These were managed with free water boluses,
otherwise the patient's ascites continued to increase.
However, he remained stable on 2 liters of oxygen. His
family did not reparacentesis. They felt that the patient
should be transitioned into hospice care. A hospice bed
could not be found given that there was conflict between the
facilities available in the area where the patient lived and
his type of insurance. The patient was eventually
transferred to the Medicine Service and per report the
patient expired a few days thereafter. However, the intern
taking care of him on the medicine floor will dictate that
part of the discharge summary.
DR.[**First Name (STitle) **],[**First Name3 (LF) 734**] 12-944
Dictated By:[**Last Name (NamePattern1) 50059**]
MEDQUIST36
D: [**2173-11-29**] 11:05
T: [**2173-12-1**] 12:49
JOB#: [**Job Number 50060**]
|
[
"584.5",
"198.89",
"482.41",
"285.1",
"570",
"785.59",
"790.7",
"155.0",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"96.72",
"96.04",
"88.42",
"96.6",
"99.29",
"88.47",
"89.64",
"54.91",
"50.11"
] |
icd9pcs
|
[
[
[]
]
] |
6758, 7626
|
12360, 16162
|
9978, 10314
|
10519, 12342
|
7655, 9785
|
9807, 9954
|
10331, 10496
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,384
| 193,644
|
52760
|
Discharge summary
|
report
|
Admission Date: [**2199-8-10**] Discharge Date: [**2199-8-26**]
Date of Birth: [**2161-12-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Cough, night sweats, and fevers
Major Surgical or Invasive Procedure:
1. Intubation and Mechanical Ventilation.
2. Lumbar puncture.
3. Blood transfusions.
History of Present Illness:
37 yo alcoholic, homeless female, with negative HIV test 2 years
ago, no known TB, presented with 3 days of night sweats,
productive/nonbloody cough x 1 week, dyspnea, diarrhea, weight
loss of 60 lb x 1 month, and decreased PO intake due to
abdominal pain. Per history obtained by NF resident, the patient
had been seen 1 week prior to admission at [**Hospital1 2177**] for abdominal
pain with a negative workup, returned 5 days prior to admission
and was given "antibiotics"; it is unclear if she ever filled
this prescription. Over the next few days, she noted progressive
weakness, fatigue, cough productive of "black" sputum, fevers,
chills, night sweats, nausea, vomiting, and diarrhea of 12 loose
stools/day. ROS is also positive for left shoulder pain with
bilateral numbness in her arms/legs, but negative for focal
neurologic deficits.
The pt reports a negative HIV test 2 [**Hospital1 1686**] ago and a negative PPD
8 months ago. She lives under a bridge and denies living in
shelters; she has been monogamous with her boyfriend for 14 [**Name2 (NI) 1686**]
and sometimes uses condoms, but notes he is unfaithful, denies
IVDU, prostitution, and jail.
.
Upon presentation to the ED, patient was afebrile, but
tachycardic and pancytopenic. She was noted to be in acute renal
failure with an elevated lactate. CXR showed likely multifocal
process with clear LLL infiltrate, for which she was given
ceftriaxone and azithro. Levofloxacin was added for a U/A
positive for UTI. An MRI L spine was done to rule out cauda
equina syndrome which showed only degenerative joint disease. An
LP ruled out CNS toxo/crytpto/ HSV. After a brief episode of
hypotension with SBP in the 70s that responded to IVF bolus, the
patient was noted to have a PO2 of 60 on ABG and was admitted to
the hospital.
Past Medical History:
1. Negative HIV 2 [**Name2 (NI) 1686**] ago as per report
2. No TB, states had negative PPD 8 monthe ago
3. Pancreatitis 1 month ago at [**Hospital1 2177**] [**2-20**] EtOH, lost 40 lb
4. ?PNA at [**Hospital1 2177**] 1 week ago, may have taken 4-5 days antibiotics
Social History:
Homeless. Drinks [**1-23**] vodka daily (most recently 2 days ago),
+THC, denies IVDU. 1 PPD tobacco. Monogamous x 15 [**Month/Day (1) 1686**] (states
boyfriend cheats, uses condoms sometimes). She has ~10 lifetime
partners, no prostitution, no jail. Lives under bridge (?shelter
exposure). Per partner, they have 2 children who live with his
parents. He cannot tell me how old they are.
Brother is closest relative: [**First Name8 (NamePattern2) 892**] [**Name (NI) **], ph: [**Telephone/Fax (1) 108817**]
Family History:
Mother with HTN
Physical Exam:
VS: 98.0 95/55 128 24 94% RA,99% 3.5 L NC
Gen: chronically ill-appearing female, cachectic, A x2.
incoherent speech.
HEENT: PERRL, OP clear (poor dentition)
Neck: no LAD, no JVD appreciated; no nuchal rigidity
Lungs: rhonchorous BS diffusely
CV: Tachy 120s normal s1/s2, no m/r/g
Abd: diffusely tender, no rebound/guard, decreased BS, no HSM
appreciated
Extr: no c/c/e, PT 1+ bilat
LN: no cervical, submandibular, axillary LAD
Neuro: unable to evaluate
Skin: no rashes/sores
Rectal: deferred on tx to ICU but guaiac positive by ED report;
pt with brown liquid stool in bed.
Pertinent Results:
[**2199-8-10**] WBC-1.2*# RBC-3.30* Hgb-11.0* Hct-31.7* MCV-96
MCH-33.4* MCHC-34.9 RDW-15.3 Plt Ct-48*# PT-13.7* PTT-27.8
INR(PT)-1.2
[**2199-8-11**] Neuts-72* Bands-6* Lymphs-10* Monos-4 Eos-4 Baso-0
Atyps-0 Metas-4* Myelos-0
[**2199-8-10**] WBC-1.2* Lymph-15 Abs [**Last Name (un) **]-180 CD3%-75 Abs CD3-136*
CD4%-53 Abs CD4-95* CD8%-21 Abs CD8-37* CD4/CD8-2.5 Gran Ct-980*
[**2199-8-10**] Glucose-82 UreaN-39* Creat-1.7*# Na-139 K-3.1* Cl-106
HCO3-15* AnGap-21* ALT-45* AST-105* LD(LDH)-381* AlkPhos-221*
Amylase-22 TotBili-0.4
[**2199-8-11**] Calcium-6.2* Phos-6.1* Mg-1.2* Iron-11*
[**2199-8-13**] Fibrino-675* D-Dimer-2034*
[**2199-8-10**] Lipase-8
[**2199-8-11**] calTIBC-87* Hapto-190 Ferritn-485* TRF-67*
[**2199-8-11**] TSH-2.3
[**2199-8-11**] Cortsol-12.2
[**2199-8-11**] HCG-<5
[**2199-8-10**] HIV Ab-NEGATIVE
[**2199-8-12**] 03:53AM BLOOD HCV Ab-NEGATIVE
[**2199-8-10**] ABG pO2-60* pCO2-32* pH-7.37 calHCO3-19* Base XS--5
-NOT INTUBA
[**2199-8-11**] freeCa-1.05*
.
[**2199-8-26**] WBC-8.7 RBC-2.73* Hgb-8.4* Hct-26.0* MCV-95 MCH-30.7
MCHC-32.2 RDW-17.0* Plt Ct-301
[**2199-8-26**] Glucose-84 UreaN-12 Creat-0.5 Na-139 K-4.2 Cl-106
HCO3-25 AnGap-12
[**2199-8-25**] ALT-21 AST-13 LD(LDH)-188 CK(CPK)-10* AlkPhos-192*
TotBili-0.3
[**2199-8-26**] Amylase-55 Lipase-13 Albumin-2.9* Calcium-8.7 Phos-5.1*
Mg-1.8
.
[**2199-8-11**] CSF TotProt-22 Glucose-25 LD(LDH)-23
[**2199-8-10**] U/A Blood-NEG Nitrite-POS Protein-TR Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
UTOX: + cocaine
S TOX: negative other than ASA of 4
HCG negative
Cardiac enzymes ([**Date range (1) 17807**]) negative x 3
.
MICRO DATA:
Sputum: 4+ GPC; Strep pneumo sensitive to PCN
repeat sputum cx positive for budding yeast only
Blood: [**4-22**] GPC in prs/chains, strep pneumo sensitive to PCN
repeat blood cx negative
CSF: no polys; no orgaqnisms.
Stool Cx: pending
.
EKG: sinus tach 120's, no ST/T-wave changes
.
CXR ([**2199-8-10**]): Diffuse LLL infiltrate. increasing bilateral
haziness and opacities c/w multifocal process/PNA
.
MRI L spine ([**2199-8-11**]): Alignment of the lumbar spine is normal.
No intradural abnormalities are noted. There are degenerative
changes of the intervertebral disks at L4-L5 and L5-S1 with
asymmetric bulges. There is no evidence of thecal sac or nerve
root compression. Vertebral body signal intensity appears
normal. There is no abnormal enhancement after contrast
administration.
.
CT head ([**2199-8-11**]): No acute intracranial hemorrhage or evidence
of mass effect.
.
Renal u/s ([**2199-8-13**]): 1. No evidence of hydronephrosis or renal
mass.
2. Echogenic liver consistent with fatty infiltration. More
advanced forms of liver disease such as advanced
fibrosis/cirrhosis cannot be excluded.
.
TTE ([**2199-8-14**]): Mild to moderate mitral and tricuspid
regurgitation with mild, global biventricular systolic
dysfunction (toxic, metabolic). No valvular vegetations are
seen.
.
CTA ([**2199-8-25**]): 1. No pulmonary embolism.
2. Gradually improving left lower lobe consolidation.
3. Slowly improving pulmonary edema related to ARDS vs diffuse
infection. 4. Multifocal nodular opacities likely related to the
patient's infection.
5. Mediastinal and bilateral hilar lymphadenopathy, likely
related to the patient's infection.
.
Brief Hospital Course:
Assessment: 37 yo homeless female, presenting with cough, night
sweats, weight loss, diarrhea, leukopenia, found to have
multifocal pneumonia by CXR and streptococcal bacteremia.
.
Hospital course is discussed below by problem:
.
1. Sepsis: On admission to the ICU, she was febrile, tachycardic
(120s), hypoxic, pancytopenic (WBC 1.2, Hct 29, plt 47) and had
an elevated lactate of 4.2, which was concerning for sepsis. She
was intubated to attempt to correct acidemia (pH 7.13) and
developed persistent hypotension post intubation requiring
maximum doses of levophed to maintain SBPs in the 90s. Her
sputum cx grew strep pneumo and [**4-22**] of her blood cx grew gram
strep pneumonia which was pan-sensitive. She was treated with a
14day course of Penicillin G. All subsequent cultures remained
negative. Echo was negative for vegetations. Upon discharge, she
was afebrile, normotensive, with normal oxygen saturation on
room air.
.
2. Respiratory Failure: This was due to the strep pneumo
pneumonia. She also required significant diuresis prior to
extubation, which occurred on [**2199-8-21**]. As above, she was treated
with 14d of penicillin. On admission, concern was also raised
for TB given nightsweats, cough, homelessness, but she had 3
negative induced sputums. She found some relief with albuterol
during her hospitalization. She was discharged with stable
oxygen saturations off supplemental oxygen.
.
3. Leukopenia, thrombocytopenia, anemia: This was most likely
due to acute response to infection, given that the counts
responded to treatment of the bacteremia and pneumonia. HIV,
hepatitis serologies were negative. Iron studies were consistent
with anemia of chronic disease. The patient's cell counts were
stable upon discharge.
.
4. Chest pain: The patient was complaining of chest pain in the
several days prior to discharge. She was ruled out with three
sets of negative cardiac enzymes. A CTA was negative for PE. The
most likely cause of her chest pain was thought to be the
resolving pneumonia with decreasing amount of covering pain
medications vs. GERD vs. esophagitis (less likely given pt had
no reason for immunocompromise). She was discharged on an
albuterol inhaler and a proton pump inhibitor.
.
5. UTI: Upon admission, she was noted to have pyruria and
bacteruria. Cultures grew gram positive bacteria. Repeat
cultures were negative.
.
6. Diarrhea: Resolved without specificant therapy. All stool
cultures were negative.
.
7. Back pain/numbness: Her neuro exam remained non-focal during
her hospitalization. The neurology service was consulted in ED;
the recommended LP, CT, and L spine MRI were all negative. Her
symptoms improved throughout her hospitalization.
.
8. ETOH use: In ED, patient reportedly stated that she usually
needs 'detox'. Was maintained on versed/fentanyl drips for
sedation which were weaned appropriately. She had some episodes
of agitation which were treated with ativan per CIWA scale;
these had resolved by discharge. She was maintained and
discharged on thiamine/folate. She refused any counseling or
placement for substance abuse.
.
9. Dispo: The patient's family had inquired about filing for
section 35. After discussions between the primary attending, the
psychiatry service, social work, and case management, it was
thought that this filing would have a very low likelihood of
success in the acute setting. The patient declined any help with
her substance abuse and was discharged to home. She was given a
cab voucher to her sister-in-law's house in [**Location (un) 108818**].
.
Medications on Admission:
None (tylenol/motrin prn)
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours).
Disp:*1 month supply* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Principal:
1. Multifocal Streptococcal Pneumonia c/b ARDS.
2. Streptococcal Bacteremia and Septic Shock.
3. Transient Thrombocytopenia.
4. Acute Renal Failure.
5. Biventricular Systolic Dysfunction, EF ~ 45%
Secondary:
1. Malnutrition.
2. Chronic Alcohol Abuse.
3. Multifactorial Anemia - ETOH/Metabolic/Chronic Disease.
4. Acute Pancreatitis - Managed at [**Hospital6 **].
Discharge Condition:
Stable, no oxygen requirement.
Discharge Instructions:
Take all medicines as prescribed.
Call your doctor if you have any dizziness, chest pain,
difficulty breathing, abdominal pain, nausea, vomiting, or
persistent cough.
Followup Instructions:
You have a follow up appointment with:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2199-9-5**] 1:30
|
[
"291.81",
"785.52",
"428.20",
"305.60",
"584.5",
"038.2",
"284.8",
"518.5",
"261",
"303.90",
"481",
"724.5",
"995.92",
"V60.0",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"96.04",
"99.05",
"96.6",
"03.31",
"96.72",
"00.17",
"99.04",
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11227, 11233
|
7010, 10562
|
345, 432
|
11652, 11684
|
3710, 6987
|
11900, 12128
|
3083, 3100
|
10638, 11204
|
11254, 11631
|
10588, 10615
|
11708, 11877
|
3115, 3691
|
274, 307
|
460, 2254
|
2276, 2542
|
2558, 3067
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,136
| 101,384
|
3751
|
Discharge summary
|
report
|
Admission Date: [**2144-5-5**] Discharge Date: [**2144-5-12**]
Date of Birth: [**2070-6-18**] Sex: F
Service: [**Hospital1 **] Inpatient Medicine
CHIEF COMPLAINT: Hypotension
HISTORY OF PRESENT ILLNESS: Ms [**Known lastname **] is a 73 year old
woman with end stage renal disease secondary to diabetes,
requiring hemodialysis Monday, Wednesday and Friday who
recently had an admission to [**Hospital6 2018**] from [**2144-3-21**] to [**2144-4-20**] after
experiencing a mechanical fall. At that time she was
diagnosed with a left intertrochanteric femur fracture. She
had a left open reduction and internal fixation with a screw
placed on [**4-2**]. Her hospital course was complicated by a
right femoral vein thrombosis with initiation of Coumadin,
with a repeat ultrasound to be performed in six weeks. She
also had rapid atrial fibrillation requiring intravenous
Diltiazem, line infection and bacteremia with Methicillin-
resistant Staphylococcus aureus; Vancomycin-resistant
Enterococcus bacteremia; and UTI with Proteus bacteremia and
sepsis. The patient was treated with multiple antibiotics and
was transferred to rehabilitation at the end of [**2144-3-28**],
to receive continued treatment for end stage renal disease,
anticoagulation for DVT and atrial fibrillation, and for
consideration of a percutaneous endoscopic gastrostomy tube
due to decreased p.o. intake secondary to delirium.
On [**5-5**], the patient returned to the [**Hospital6 649**] for decreased blood pressure into the 80s
persistently, preventing hemodialysis. The patient's code status
was recently changed from full to Do-Not-Resuscitate/Do-Not-
Intubate by the family. The patient, prior to admission, had
experienced increased white blood cell count, hypoxia and
hypotension on [**4-29**], and was taken to [**Hospital 8**] Hospital where
she was diagnosed with urosepsis versus aspiration pneumonia and
stated on Gentamicin and Linezolid. She had an increased
gentamicin level and the gentamicin and Linezolid were held as of
[**5-4**], but her blood pressure continued to be low. Upon
transfer to [**Hospital6 256**] her pressure was
57/45. She was given a 500 cc bolus and started on pressors
and transferred to the Medicine Intensive Care Unit for
further evaluation of her hemodynamic instability.
PAST MEDICAL HISTORY: 1. End stage renal disease, secondary
to diabetes, hemodialysis since [**2141**], now on a Monday,
Wednesday and Friday schedule with an estimated dry weight of
between 64.5 and 68 kg. 2. Diabetes mellitus Type 2,
neuropathy and retinopathy and nephropathy. 3. Hypotension.
4. Peripheral vascular disease. 5. Gastroesophageal reflux
disease. 6. Atrial fibrillation, failed Amiodarone in the
past. 7. Congestive heart failure, apparently diastolic
dysfunction with a normal ejection fraction. 8. Coronary
artery disease. 9. Glaucoma. 10. Hypercholesterolemia.
11. Depression. 12. Vertebral compression fractures. 13.
Ligation of left arteriovenous graft secondary to steal
phenomenon, left ulnar nerve palsy. 14. Breast carcinoma,
status post lumpectomy. 15. Osteoarthritis. 16.
Klebsiella bacteremia [**2142-4-29**], Vancomycin-resistant
Enterococcus, Methicillin-resistant Staphylococcus aureus
bacteremia Proteus urosepsis. 17. Restrictive lung disease.
18. Deep vein thrombosis, right common femoral vein,
anticoagulation until the end of [**2144-4-28**]. 19. Left foot
drop. 20. Dementia. 21. Delirium uncertain etiology. 22.
Mechanical falls with left intertrochanteric hip fracture.
23. History of aspiration pneumonias.
PAST SURGICAL HISTORY: 1. Total abdominal hysterectomy. 2.
Third toe amputation secondary to gangrene and focal chronic
osteomyelitis. 3. Left parietal mastectomy, ductal
carcinoma in situ in [**2139-7-29**]. 4. Retinal detachment,
left eye, status post partial vitrectomy in [**2141-3-29**]. 5.
Right brachiocephalic arteriovenous fistula and right
internal jugular Quinton placement. 6. Left forearm
arteriovenous graft, [**Doctor Last Name 4726**]-Tex [**2143-11-29**] with subsequent
ligation secondary to steal phenomenon in [**2143-12-29**].
MEDICATIONS ON ADMISSION: 1. Lipitor 20 mg p.o. q.h.s.; 2.
Tylenol prn; 3. Miconazole powder b.i.d.; 4. Linezolid; 5.
Ranitidine 115 mg p.o. q.d.; 6. Metoprolol 50 mg p.o.
t.i.d.; 7. Coumadin 2.0 mg p.o. q.h.s. to a target INR of
2.0 to 3.0; 8. Regular insulin sliding scale, NPH 6 units
b.i.d.; 9. Epo 3000 units subcutaneous t.i.d. with dialysis;
10. Aspirin 325 mg p.o. q.d.; 11. Diltiazem 60 mg p.o.
q.i.d.; 12. Gentamicin.
ALLERGIES: 1. Sensitive to narcotics regarding blood pressure
and mental status examination; 2. Penicillin; 3. Sulfa; 4. ?
Verapamil.
SOCIAL HISTORY: The patient lives in an [**Hospital3 **]
facility, her doctor is Dr. [**First Name8 (NamePattern2) **] [**Last Name (STitle) 9006**]. Her family spokesperson is
her daughter [**Name (NI) **], at [**Telephone/Fax (1) 16861**]12, ? Her
home #[**Telephone/Fax (1) 16784**], cellular telephone #[**Telephone/Fax (1) 16785**].
PHYSICAL EXAMINATION: On presentation the patient's vital
signs after 500 cc bolus of normal saline and starting on
Neo-Synephrine were 120/70, heartrate 120 and irregular,
respiratory rate 16, and sating 96% on 2 liters. Physical
examination was notable for the following findings, dry
mucous membranes, irregularly irregular heart rhythm, no
murmurs, rubs or gallops, coarse breathsounds bilaterally in
the lungs with scattered rhonchi. She had 1 to 2+ pitting
edema bilaterally and multipodus boots on. Her mental status
was confused and unresponsive.
LABORATORY DATA: The patient on admission had a white blood
cell count of 10.7, 86% neutrophils, 0% bands. Her
hematocrit was 29.5, platelets 339, her INR on admission was
8.3 with a PTT of 61.6 and PT 35.5. Her chem-7 was sodium
137, potassium 4.6, chloride 105, bicarbonate notable for 13.
Her BUN was 37, creatinine 4.6. Her chest x-ray showed no
infiltrate or overt failure on admission and
electrocardiogram showed atrial fibrillation with a rate of
120, left axis deviation and 2 to [**Street Address(2) 2051**] depression in V2
through V4 unchanged from [**2144-4-4**]. Subsequently the
patient had negative blood cultures times two. She had no
urine cultures as she is anuric. Chest x-ray later on
demonstrated worsening left retrocardiac opacity / consolidation
/ collapse, suspicious for possible infection. Her hematocrit
remained stable between 27 and 30. Her INR had decreased to 1.0.
Two days prior to admission, she was started on her Coumadin and
her INR was 1.2 on the day of discharge. The patient, under
fluoroscopic guidance, had jejunostomy tube placed which showed
pigtail catheter to be in good condition.
HOSPITAL COURSE: 1. Cardiovascular - As previously
mentioned, the patient came in significantly hypotensive.
The etiology was deemed likely secondary to hypovolemia from
decreased p.o. intake with a questionable history of
diarrhea. She was given 500 cc bolus and started on
pressors. She had a good response to the pressors and a
normal saline bolus. Her blood pressure came back up to
systolic/100. During the remainder of her hospital stay her
pressure generally remained over 100 systolic on the floor
with occasional drops into the 90s. However, while at
dialysis the patient's pressure tended to drop into the 80s.
The etiology of her hypertension as previously mentioned was
likely hypovolemia as all the cultures were negative and she
did not appear to have impaired cardiac function. The
hypotension was not rate-related either. She was quickly
weaned off of her pressors in the Intensive Care Unit within
two days and then transferred to the floor with further
management. With regard to the patient's atrial fibrillation
she remained atrially fibrillated throughout the remainder of
her hospital stay with ventricular rate as high as 130 but
generally in 80 to 100 range and for the 24 hours prior to
discharge she remained in the 80s, on 60 mg of Diltiazem p.o.
q.i.d.
2. Hematology - The patient came in with a highly elevated
INR Of greater than 8. She has a history of a right lower
extremity deep vein thrombosis from her prior admission. She
needs to be anticoagulated for this deep vein thrombosis for
six months, that would take her through the end of summer,
however, since she has atrial fibrillation, she needs to be
anticoagulated to a target INR of 2.0 to 3.0 for life. This
anticoagulation for the deep vein thrombosis is not an issue
at this point. Her Coumadin was held and restarted two days
prior to discharge at 5 mg p.o. q.d. with INR to be checked
on Thursday, [**5-14**]. The patient was covered with a
heparin drip because of her history of deep vein thrombosis
and she should continue on the heparin drip with a target PTT
of 50 to 70 until she becomes therapeutic with an INR of 2 to
3.
3. Neurologic - The patient has a history of dementia with
superimposed delirium of uncertain etiology. It is possible
that her hypotension contributes to her delirium as well as
possible underlying lung infection. From a dementia
standpoint, at her best, the patient is able to answer simple
questions in respond to her name, however, her mental status
greatly fluctuates and often she is unresponsive except for
the most simple commands and questions. This has been a
significant decline in her cognitive function. According to
her primary care physician and her daughter, six months ago
the patient completely normal neurologically. The etiology
of the neurological decline during this admission is
uncertain.
Of note - The patient is exquisitely sensitive to narcotics with
regard to her mental status.
4. Renal - The patient has end stage renal disease secondary
to diabetes and she is on dialysis three times a week
schedule, now Monday, Wednesday and Friday. She may have had
difficulty taking any fluid off and have just been
ultra-filtering her because of her hypotension.
5. Gastrointestinal - The patient has poor p.o. intake,
likely secondary to neurological status. She is on Nepro 1/2
strength at a goal of 6 cc/hr which she tolerated generally
well through the hospital stay. She had a gastrojejunostomy
placed the day prior to discharge and was tolerating her tube
feeds. These should be advanced to a goal as mentioned of 60
cc/hr of Nepro 1/2 strength through the gastrojejunostomy
tube.
6. Infectious disease - The patient has questionable left
lower lobe infiltrate. She is being treated with
Levofloxacin for presumed pneumonia and questions whether it
is aspiration versus community acquired, although the patient
has had an excellent response to the Levofloxacin and has
been afebrile with decreased sputum production and no
respiratory distress. It is deemed that she does not need
further anaerobic coverage. She is taking 250 mg q. 48 hours
of Levofloxacin and her last day will be [**2144-5-21**].
7. Endocrinologic - The patient had diabetes mellitus and
came in on a dose of insulin NPH 6 units b.i.d. with a
regular insulin sliding scale q.i.d. Her NPH insulin is said
to be titrated because of variations in her p.o. intake and
that should continue to be the case. She is currently on 3
units q. AM and 1 unit q. PM of the regular insulin sliding
scale q.i.d. The had some blood sugars in the 60s the day of
discharge secondary to being NPO for the jejunostomy tube
placement but these had resolved with resumption of her tube
feeds. The patient was also treated with proton pump
inhibitors for a known history of gastroesophageal reflux
disease, 30 mg of Prevacid b.i.d.
8. Dermatologic - The patient has several healed ulcers in
her lower extremities, there are no active infections there,
however, there is a tinea infection in her buttock area and
this should be treated with Miconazole cream b.i.d.
CONDITION ON DISCHARGE: Fair.
DISCHARGE STATUS: Back to [**Hospital1 **].
DISCHARGE DIAGNOSIS:
1. Hypotension, likely secondary to hypovolemia
2. End stage renal disease on hemodialysis Monday, Wednesday
and Friday with estimated dry weight of 64 to 68 kg
3. Diabetes mellitus Type 2
4. Tinea cruris
5. Left lower lobe pneumonia
6. Dementia
7. Delirium, uncertain etiology
DISCHARGE MEDICATIONS:
1. Miconazole 2% cream to the buttocks rash b.i.d.
2. Tylenol 325 to 650 per jejunostomy tube prn, fever or
pain
3. Colace 100 mg jejunostomy tube b.i.d.
4. Levofloxacin 250 mg jejunostomy tube q. 48 hours, ten
days, the last dose [**2144-5-21**]
5. Prevacid 30 mg jejunostomy tube b.i.d.
6. Heparin, GTT, target PTT 50 to 70 until the INR is 2.0 to
3.0
7. Warfarin 5 mg p.o. q.d. adjust per INR 2.0 to 3.0
8. Diltiazem 60 mg p.o. q.i.d.
9. Insulin NPH 3 units q. AM, one unit q. PM to be adjusted
as the tube feeds are titrated up to goal
10. Regular insulin sliding scale q.i.d.
11. Miconazole powder b.i.d. to buttocks
FOLLOW UP PLANS: The patient is follow up with her primary
care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (STitle) 9006**] for an appointment two weeks from
discharge from [**Hospital1 **].
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 10885**]
Dictated By:[**Last Name (NamePattern1) 11801**]
MEDQUIST36
D: [**2144-5-12**] 11:00
T: [**2144-5-12**] 11:38
JOB#: [**Job Number 16862**]
cc:[**Hospital1 **]
|
[
"790.92",
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"276.5",
"250.40",
"276.2",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.32",
"96.6",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12301, 13455
|
11992, 12278
|
4196, 4748
|
6806, 11893
|
3634, 4169
|
5112, 6788
|
185, 198
|
227, 2322
|
2345, 3610
|
4765, 5089
|
11918, 11971
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,296
| 144,117
|
26510
|
Discharge summary
|
report
|
Admission Date: [**2109-2-13**] Discharge Date: [**2109-3-12**]
Date of Birth: [**2033-2-26**] Sex: F
Service: SURGERY
Allergies:
Celexa / Aspirin / Codeine
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Jaundice, abdomenal pain
Major Surgical or Invasive Procedure:
1. Re-exploration of a recent laparotomy.
2. Adhesiolysis.
3. Small bowel resection with primary anastomosis.
4. Removal of J tube.
History of Present Illness:
This 75-year-old lady has a history of well-differentiated
node-positive gastric cancer with a distal gastrectomy performed
about 2 years ago. This
reconstruction was performed with a Roux-en-Y conduit. She
has a history of gastrojejunal ulcer disease as well, with a
significant ulcer this summer that apparently had cleared on
endoscopy.
She currently comes back with biliary obstruction and at the
request of Dr. [**First Name (STitle) **] [**Name (STitle) **], Dr. [**Last Name (STitle) **] was asked to get
involved with
her care when, after an endoscopy 2 days prior to this
procedure, she developed evidence of free air on a CAT scan.
During that endoscopy, Dr. [**Last Name (STitle) **] was attempting to find
the ampulla to relieve the biliary obstruction
endoscopically. He encountered a necrotic cavity in the
stomach area and took a biopsy and then proceeded through an
obstructed area into a drainage limb, but was unable to
ultimately identify the ampulla of Vater. Therefore the
biliary obstruction remained and a follow-up CAT scan was
performed for some abdominal pain and this revealed isolated
free air in the area of the left upper quadrant with a mass
effect in around the stomach on an noncontrast CT. There was
no evidence of any large masses or distant metastasis. There
was central bile duct obstruction and gallbladder distension
but no evidence of intrahepatic distention of her bile duct.
Past Medical History:
hypertension, depression, GERD
Social History:
lives alone, denies alcohol and tobacco
Pertinent Results:
[**2109-2-13**] 01:45PM BLOOD ALT-48* AST-40 AlkPhos-471* Amylase-60
TotBili-12.1*
[**2109-2-13**] 01:45PM BLOOD Lipase-29
[**2109-2-25**] 06:40AM BLOOD calTIBC-163* TRF-125*
[**2109-2-25**] 06:40AM BLOOD Triglyc-559*
Brief Hospital Course:
Upon presentation, the pt was admitted to the Gold Surgical
Service and surgery was performed the next day [see operative
note for details]. She tolerated the procedure and was admitted
to the intensive care unit for close monitoring while intubated.
She was extubated POD 3 and subsequently transferred to the
floor the following day. She did well until about a week
post-op. A CT was obtained on day 9 which showed high-grade
obstruction. The pt was taken back to the OR [see 2nd op note]
for lysis of adhesion. She tolerated the second procedure well.
She was slow to regain bowel function, but did come around and
is now tolerating a regular diet. She has been working with the
physical therapy team to regain her strength. On day of
discharge, she has been afebrile with normal vitals, ambulating
with help, while producing good urine output. She will be
discharged to a rehab center to continue her therapy.
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): see scale.
2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2
hours) as needed.
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) 8641**], NH
Discharge Diagnosis:
1. Gastric perforation from presumed gastrojejunal ulcer.
2. Bile duct stricture.
Small bowel obstruction secondary
to adhesions
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] return to taking outpatient medications. Please follow
directions as discussed previously with Dr. [**Last Name (STitle) **].
Please take medications as prescribed and read warning labels
carefully. If signs of infections such as purulent discharge
from wound, increased pain and redness around wound, please call
or go to the emergency room. Remember to call for a follow up
appointment (bellow). Light activities until seen in clinic.
[**Month (only) 116**] eat regular food. [**Month (only) 116**] take quick showers but no baths.
Absolutely no smoking.
Followup Instructions:
Please call Dr.[**Name (NI) 2829**] office for an appointment to be seen
in 2 weeks ([**Telephone/Fax (1) 2363**]
Completed by:[**2109-3-11**]
|
[
"584.9",
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"560.81",
"V10.04",
"567.22",
"531.10",
"V45.3",
"V16.49",
"V16.0",
"568.0"
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"54.59",
"45.16",
"99.15",
"46.39",
"45.91",
"99.04",
"43.7",
"51.32",
"96.6",
"87.53",
"45.62"
] |
icd9pcs
|
[
[
[]
]
] |
3681, 3759
|
2264, 3189
|
310, 444
|
3933, 3940
|
2022, 2241
|
4575, 4720
|
3212, 3658
|
3780, 3912
|
3964, 4552
|
246, 272
|
472, 1892
|
1914, 1946
|
1962, 2003
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,299
| 196,002
|
37922
|
Discharge summary
|
report
|
Admission Date: [**2125-9-2**] Discharge Date: [**2125-9-8**]
Date of Birth: [**2042-4-1**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
ORIF ([**2125-9-3**])
History of Present Illness:
82 year old woman COPD and restrictive lung disease on 2-3L home
O2 admitted for right femoral neck fracture repair with
difficulty extubating after surgery. Pt initially presented to
[**Hospital1 **] after a mechanical fall and found to have fracture there.
Also found to be in new onset afib with RVR in 140s. She was
started on a dilt drip and anticoagulated with Lovenox and ASA.
She received 1L NS. She became hypoxic so they obtained a CTA
chest which was negative for PE but did show questionable
pneumonia and mild CHF. She was given 20mg IV lasix and
levofloxacin at [**Hospital1 **], percocet for pain, and transferred to
[**Hospital1 18**] at pt request due to history of care here. Pt was further
diuresed at [**Hospital1 18**] on admission and sats improved. She went to
the OR today for repair where she received 125mcg fentanyl. She
was extubated, but became somnolent s/p extubation and ABG
showed pt to be hypercarbic. She was reintubated and induced
with 30mg propofol. After intubation her pressures dropped to
70s (they also dropped with intubation prior to surgery). She
was given 500mL fluid and started on peripheral neosynephrine.
Pressures improved to 90s. There is no suspicion for bleeding
from ortho's perspective. She was transferred to ICU for
hypotension.
Of note, patient went to [**Hospital 13128**] last week for
evaluation of her chronic vocal cord issues, and as [**Name6 (MD) **] family
MD noted extra fluid around cords. He started the patient on
nortryptiline at that time. She has chronic difficulty with
swallowing and speaking. Also of note, the floor team was
holding levoflox for CAP due to low suspicion for PNA on arrival
to [**Hospital1 18**]. They planned to repeat CXR and get echo to eval
cardiac function in setting of pulm edema but those had not been
done yet.
.
On arrival to the floor, patient reports pain to her right hip,
but otherwise is comfortable. She has had no weakness,
dizziness, or palpitations.
Past Medical History:
Her past medical and surgical history includes scoliosis,
hypercholesterolemia, osteoporosis, and hyperthyroidism. She
has a paralyzed vocal cord that occurred in [**2122-6-5**] and is
thought to be secondary to a viral illness. Her vocalization
has not really improved since [**Month (only) 116**]. Her surgical history
includes tonsillectomy, bladder suspension, left stapedectomy,
and left inguinal hernia repair. She has had three D&Cs. She
has squamous cell cancers on her forehead. She had others skin
lesions biopsied. She is gravida 2, para 2 by standard vaginal
delivery without complication.
Social History:
Her social history is notable for the fact she does not smoke,
does not drink, and lives with one of her daughters.
Family History:
Her family history is notable for paternal grandmother with some
sort of
abdominal cancer. Father with esophageal cancer, but no known
family history of colorectal cancer or inflammatory bowel
disease.
Physical Exam:
Vitals: 101.0, 99/57, 76, 23, 99% vent
General: Alert, intubated, shakes head to questions
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, hip dressing in place on right, TTP, dsg c/d/i
Neuro: alert, CN grossly intact
Pertinent Results:
[**2125-9-2**] 08:48PM BLOOD WBC-11.6*# RBC-3.51* Hgb-11.1* Hct-35.2*
MCV-100* MCH-31.6 MCHC-31.5 RDW-12.7 Plt Ct-134*
[**2125-9-4**] 08:25PM BLOOD WBC-15.4* RBC-3.22* Hgb-10.3* Hct-32.3*
MCV-100* MCH-32.2* MCHC-32.0 RDW-12.6 Plt Ct-159
[**2125-9-8**] 05:21AM BLOOD WBC-13.6* RBC-3.22* Hgb-10.0* Hct-33.4*
MCV-104* MCH-31.2 MCHC-30.0* RDW-13.1 Plt Ct-278
[**2125-9-2**] 08:48PM BLOOD Glucose-106* UreaN-11 Creat-0.3* Na-138
K-4.0 Cl-98 HCO3-35* AnGap-9
[**2125-9-4**] 08:25PM BLOOD Glucose-170* UreaN-23* Creat-0.6 Na-138
K-4.4 Cl-99 HCO3-30 AnGap-13
[**2125-9-6**] 09:10AM BLOOD Glucose-371* UreaN-47* Creat-1.0 Na-137
K-5.1 Cl-101 HCO3-28 AnGap-13
[**2125-9-8**] 05:21AM BLOOD Glucose-133* UreaN-50* Creat-0.5 Na-142
K-4.9 Cl-105 HCO3-29 AnGap-13
[**2125-9-3**] 05:20AM BLOOD Free T4-1.1
[**2125-9-3**] 05:20AM BLOOD TSH-1.6
Brief Hospital Course:
82 year old woman COPD and restrictive lung disease on 2-3L home
O2 admitted for right femoral neck fracture repair with
difficulty extubating after surgery. Her MICU course was
complicated by hypercarbic respiratory failure s/p two
intubation. Family discussion on [**2125-9-8**] with patient and her
daughters moved her care towards comfort measures only as she
was again noted to have hypercarbic respiratory failure and
likely need for intubation with transition to tracheostomy and
PEG tube which patient would want for herself.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 84769**].
1. Lovastatin *NF* 80 mg Oral daily
2. Evista *NF* (raloxifene) 60 mg Oral Daily
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Senior Vitamin *NF* (multivitamin-minerals-lutein) 1 tablet
Oral daily
5. Aspirin 81 mg PO DAILY
6. Vitamin E 100 UNIT PO DAILY
7. Nortriptyline 10 mg PO HS
8. Enoxaparin Sodium 30 mg SC Q12H
Started by Outside Hospital before transfer
9. Nitroglycerin SL 0.4 mg SL PRN Chest Pain
10. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain
11. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral daily
12. budesonide *NF* 0.5 mg/2 mL Inhalation [**Hospital1 **]
13. formoterol fumarate *NF* 20 mcg/2 mL Inhalation [**Hospital1 **]
14. Albuterol-Ipratropium [**2-5**] PUFF IH Q6H:PRN Shortness of
Breath
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Hypercarbic respiratory failure
2. Right femoral neck fracture
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"458.9",
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"244.9",
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"737.30",
"285.9",
"518.89",
"478.30",
"780.09",
"584.9",
"272.0",
"V46.2",
"458.29",
"276.7",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"81.52"
] |
icd9pcs
|
[
[
[]
]
] |
6272, 6281
|
4708, 5245
|
281, 305
|
6391, 6397
|
3857, 4685
|
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|
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|
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|
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|
5271, 6221
|
6421, 6426
|
3302, 3838
|
230, 243
|
333, 2299
|
2321, 2932
|
2948, 3066
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,876
| 150,896
|
43348
|
Discharge summary
|
report
|
Admission Date: [**2191-1-22**] Discharge Date: [**2191-1-23**]
Date of Birth: [**2149-8-30**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 23197**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 41yo gentleman with h/o type 1 DM, hepatitis C
and polysubstance abuse who presented with chest pain and was
found to have hyperglycemia to 600.
.
Three days before admission, he went on a drinking and cocaine
binge. During this time, he stopped taking his lantus. He denies
any other drugs and specifically denies opiates. He states that
he only snorts the cocaine. In addition, he reports successful
sobriety from narcotics ever since being on suboxone. His last
drink was just prior to arrival to the emergency room at 3am
[**1-22**]. He came in to the ED because he developed substernal
heavy chest pressure associated with shortness of breath. No
diaphoresis or palpitations. No pleuritic chest pain.
.
In the emergency department, initial VS were: 98.4 144/58 92 28
98%. He became chest pain free without intervention, and there
was no evidence of alcohol withdrawal. EKG did not show evidence
of ischemia. Labs were notable for glucose of 615, anion gap of
25 (ABG not done). WBC was 7 and CEs were normal x 1. CXR was
felt to be normal. He was given ASA 325mg and started on an
insulin gtt.
.
Upon arrival to the ICU, he was sleepy but comfortable. Over the
next couple of hours, he started to feel shaky and sweaty. He
denied chest pain. He has persistent problems with depression
but specifically denied suicidality.
.
REVIEW OF SYSTEMS:
(+)ve: chest pain as above
(-)ve: fever, chills, night sweats, loss of appetite, fatigue,
palpitations, rhinorrhea, nasal congestion, cough, sputum
production, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal
dyspnea, nausea, vomiting, diarrhea, constipation, hematochezia,
melena, dysuria, urinary frequency, urinary urgency, focal
numbness, focal weakness, myalgias, arthralgias
Past Medical History:
Type 1 DM followed at [**Last Name (un) **]
Chronic Hepatitis C - has been referred to Liver Center
Polysubstance abuse - heroin overdose in 96 and 00, has been on
suboxone from Dr. [**Last Name (STitle) 93335**]
Alcohol abuse - reports gets shaky but no known h/o seizures or
DTs
Bipolar disorder h/o suicide attempts (by cutting himself, by
overdose)
s/p appendectomy
Cardiac cath in [**2189**] with non-obstructive coronary disease
Dyslipidemia
Social History:
Per psych notes, he had brief incarceration in [**Month (only) 116**] for Domestic
Violence. Works as roofer but has had trouble getting work.
Longest period of sobriety was 17 months with help of NA/AA. Has
had frequent lapses and Dr. [**Last Name (STitle) 93335**] (his suboxone provider) notes
that he has presented with sedation and suspects that he
continues to use opiates despite the suboxone. Mr. [**Known lastname **] only
smokes tobacco when he is on a drinking binge. Drug of choice
used to be heroin but now it is cocaine.
.
He states that financial stress due to difficulty finding work
was a major contributor to his lapse. Denies legal trouble. He
has a 9yo daughter with whom he is close. Lives with his
girlfriend, who does not use drugs or drink.
.
Family History:
Both parents were alcoholics.
Physical Exam:
VS: 97.1 112/49 80 13 97% RA
GENERAL: Pleasant gentleman who is sleepy but not otherwise in
distress. Sweaty forehead. Yawning frequently
HEENT: No conjunctival pallor. No scleral icterus. PERRL/EOMI.
MMM. OP clear. Neck Supple, No LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally. No crackles or wheeze
ABDOMEN: NABS. Soft, NT, ND. No HSM. Well healed scar in RLQ
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis pulses
SKIN: Very dirty hands. Mildly diaphoretic.
NEURO: A&Ox3, sleepy but easily rousable. Appropriate. CN 2-12
grossly intact. Preserved sensation throughout. 5/5 strength
throughout. Mild intention tremor of LUE. Finger to nose is
slightly slow b/l but otherwise intact. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately,
pleasant. Reasonable insight into his drug use, reports mild
anxiety.
Pertinent Results:
admission:
7.4>42.8<180
no leukocytosis during admission, there was a drop in all three
cell lines which was likely dilutional
PT 12.9, PTT 26.6, INR 1.1
132/5.4/90/17/21/1.3<615
at discharge: 138/3.7/106/26/15/0.9<87
ALT 29, AST 28, CKs 48-58, AlkPhos 68, TB 0.4
MBs not elevated, Trops 0.01 X3
Ca 8.4, Mg 2.2, Phos 2.3
tox screen serum negative
ABG 7.37/43/91
urine culture [**1-22**]
pending at discharge
UA [**1-22**]: neg UTI, >1000 glu, pos cocaine, oxycodone pnd at
discharge, 40 ketone
CXR [**2191-1-22**]:
FINDINGS: The patient is rotated slightly to the right. No focal
consolidation, pleural effusion, or evidence of pneumothorax is
seen. The
heart is not enlarged. No overt pulmonary edema is seen.
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
41 yo diabetic gentleman with chest pain and hyperglycemia in
the setting of an alcohol and cocaine binge.
.
# Hyperglycemia and concern for DKA: Patient presented with
hyperglycemia and urinary ketones in the setting of missing at
least two days of his lantus. Although he had a low bicarbonate
with an elevated anion gap on presentation, he did not clearly
meet criteria for diabetic ketoacidosis. ABG upon arrival to ICU
was: 7.37/43/91/26. His anion gap in the ED was 25, which could
have been elevated due to early DKA vs alcoholic/starvation
ketosis. He did not have systemic signs or laboratory evidence
of infection. He was initially treated with insulin gtt, but
transitioned to subq insulin after several hours, and able to
tolerate PO nutrition. [**Last Name (un) **] was consulted and agreed with
plan to continue on home regigmen as his fingersticks in the
hospital were well controlled during the course of the day.
.
# Polysubstance abuse: Patient's last drink was around 3am on
[**1-22**]. He was considered to be at risk for alcohol and opiate
withdrawal, and was started on CIWA scale. Per discussion with
his suboxone provider, [**Name10 (NameIs) **] has lied about opiate use in the past
and there is concern that he is using despite being on suboxone.
His urinary tox screen was positive for cocaine only. He was
restarted on his home dose of suboxone on the evening of
admission. He was also treated with thiamine and multivitamin x
3 days. Addictions nursing was consulted however patient
refused. He never required medication on his CIWA scale.
.
# Chest pain: Patient has well-documented history of
presentations with chest pain in the setting of substance abuse;
had non-obstructive coronary disease on his cath from 08. He is
a diabetic and has been using cocaine, and so is at risk for
ischemia. His EKG and biomarkers were within normal limits and
his symptoms resolved. He was monitored on telemetry and had no
signs of an ischemia or arrhythmic process.
.
# Chronic Hepatitis C: LFTs within normal limits.
.
# Bipolar disorder: Continued wellbutrin and abilify, seroquel
initially held.
.
# Dyslipidemia: continued statin.
.
.
# CODE STATUS: Confirmed full
.
# EMERGENCY CONTACT: girlfriend [**Name (NI) 1060**] [**Telephone/Fax (1) 93336**]
.
# Dispo: Patient's PCP and [**Name9 (PRE) **] physicians were notified and
an e-mail was sent to [**Hospital 191**] [**Hospital 1944**] clinic on day of
discharge.
Medications on Admission:
(confirmed with patient and pharmacy):
ASA 81mg daily
Insulin lantus 30 units QHS and lispro sliding scale -- has not
taken lantus for 2 days
Simvastatin 40mg daily
Seroquel 50mg
Wellbutrin SR 150mg daily
Abilify 15mg daily
Multivitamin
Suboxone 24mg daily
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-hyperglycemia secondary to medication noncompliance
-drug and alcohol abuse
Secondary
-T1DM
-bipolar disorder
-HLD
Discharge Condition:
Mental Status improved, alert and oriented X3
Ambulating well
Discharge Instructions:
You were admitted to [**Hospital1 **] because of high blood
sugars. This was likely due to the fact that you were not
taking your insulin as prescribed. Your blood sugars came down
after you were on insulin in the hospital. The [**Last Name (un) **] doctors
saw [**Name5 (PTitle) **] and recommended that you continue on your home insulin
regimen.
You also were admitted with chest pain. While you were here you
had lab tests and an EKG which showed that you were not having a
heart attack. The chest pain may have been due to cocaine use.
You required admission to the intesnive care unit because you
were very sick. We strongly reccommend that you refrain from
using alcohol and drugs in the future, especially because you
are at high risk of a heart attack with diabetes and cocaine
puts you at even higher risk.
Followup Instructions:
You should follow-up with Dr.[**Name (NI) 14065**] office within the next 5
days. If you do not hear from their office you should call on
Monday morning. Their number is [**Telephone/Fax (1) 1300**].
You should also follow-up with Dr.[**Name (NI) **] office.
|
[
"070.54",
"304.71",
"786.59",
"250.13",
"V15.81",
"296.80",
"272.4",
"303.91",
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"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7941, 7947
|
5179, 7633
|
284, 290
|
8117, 8181
|
4386, 4568
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9053, 9318
|
3358, 3390
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234, 246
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318, 1678
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,688
| 185,909
|
50027
|
Discharge summary
|
report
|
Admission Date: [**2188-10-10**] Discharge Date: [**2188-10-18**]
Date of Birth: [**2137-1-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
s/p lumbar puncture
History of Present Illness:
This is a 51yo F w/ PMH of afib on coumadin, HTN, p/w 24 hours
acute onset R hand and ankle pain and HA (pounding/generalized),
+ subjective fever/chills. + photophobia. Also Endorses a cough
yesterday that made her vomit and frequent loose stools over the
past few days. No current N/SOB/CP or cough. + Continued pain
in R thumb. + Exposure to sick children at daycare. Her husband
has also had a cold. No exposures to TB.
.
In the ED: Vitals 103.3 ->105, 98, 149/59, 20, 96% on RA. Found
to have nuccal rigidity. Petechiae on feet. LP w/ no glucose
and high protein concerning for bacterial meningitis. DPH
notified. Given Vanc 1 g, Ceftriaxone 2 g, Ampicillin 2 g,
Decadron 10 mg IV X 1, morphine 4 mg IV X 1 and fentanyl 50 mcg
IV X2. AMS (A/O but drifts off, sometimes inappropriate, but is
arousable).
.
[**Hospital Unit Name 153**] course- on broad spectrum abx. [**10-11**], lab called with gram
stain actually 4+ gram negative dipplococci, likely
meningococcus.
.
ROS:
(+) as per hpi, + runny nose.
(-) Denies recent weight loss or gain. Denied constipation or
abdominal pain.
Past Medical History:
1. Atrial Fibrillation on warfarin s/p DCCV x 2
2. Hypertension since [**2183**] - on Enalapril and Sotalol
3. Hyperlipidemia since [**2185**] - on Lipitor
4. Pulmonary calcified granuloma - Pulmonologist: Dr. [**Last Name (STitle) **]
5. Borderline/mild pulmonary hypertension
6. Gastroesophageal reflux disease
Social History:
Single lives with a significant other she has three
children 27, 14, 11. She owns a daycare which she runs in her
own home. She doesn??????t smoke of drink. She travels to [**Location (un) 4708**]
1X per year but no TB exposures that she is aware of. Last
travel was at the end of the summer when she went to [**State 108**].
Family History:
There is no family history of premature coronary artery disease
or sudden death. There is a history of HTN in her mother, an
uncle with MI, and aunt with DM.
Physical Exam:
Vitals: T: 99 P: 80 BP: 111/66 R: 23 SaO2: 93% on 2L
General: Awake, sleepy but oriented X 3. Occasionally gets
confused when answering questions.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, dry MM, w/ crusting around her mouth
Neck: +nucal rigidity, no adenopathy noted
Pulmonary: + crackles at L base otherwise CTAB
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: obese, soft, NT/ND, normoactive bowel sounds, no masses
or organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l. + petechiate (? palp) on dorsum of bilateral feet
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history w/
some extraneous details.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted. ? some arm rigidity (R>L)
-Plantar response was flexor bilaterally.
Pertinent Results:
[**2188-10-10**] WBC-14.5*# RBC-5.03 Hgb-14.2 Hct-40.8 MCV-81* MCH-28.2
MCHC-34.7 RDW-14.3 Plt Ct-154 Neuts-79* Bands-8* Lymphs-6*
Monos-4 Eos-0 Baso-0 Atyps-3* Metas-0 Myelos-0
[**2188-10-11**] WBC-15.7* RBC-4.33 Hgb-12.6 Hct-37.5 MCV-87 MCH-29.2
MCHC-33.7 RDW-14.6 Plt Ct-122* Neuts-89* Bands-1 Lymphs-5*
Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2188-10-13**] WBC-11.4* RBC-3.95* Hgb-11.5* Hct-33.5* MCV-85
MCH-29.2 MCHC-34.5 RDW-14.6 Plt Ct-159
[**2188-10-10**] 07:50PM BLOOD PT-19.3* PTT-25.7 INR(PT)-1.8*
[**2188-10-13**] 06:00AM BLOOD PT-18.6* PTT-22.2 INR(PT)-1.8*
[**2188-10-10**] Glucose-122* UreaN-12 Creat-0.9 Na-136 K-3.2* Cl-98
HCO3-23
Calcium-10.4* Phos-1.9* Mg-1.6
[**2188-10-13**] Glucose-120* UreaN-16 Creat-0.6 Na-145 K-3.2* Cl-109*
HCO3-26
Calcium-8.9 Phos-3.0 Mg-2.1
[**2188-10-10**] 07:50PM BLOOD ALT-32 AST-27 AlkPhos-63 Amylase-37
Lipase-27
[**2188-10-11**] BLOOD Type-ART pO2-78* pCO2-32* pH-7.47* calTCO2-24
Base XS-0
[**2188-10-11**] 09:02AM BLOOD Glucose-203* Lactate-2.4* Na-141 K-3.6
Cl-108
[**2188-10-11**] 09:02AM BLOOD freeCa-1.32
[**2188-10-12**] 09:15AM BLOOD CH 50-PND
[**2188-10-10**] Head CT noncontrast: There is no evidence of acute
intracranial hemorrhage, shift of normally midline structures,
or hydrocephalus. [**Doctor Last Name **]-white matter differentiation appears
grossly preserved. Visualized paranasal sinuses appear normally
aerated.
IMPRESSION: No evidence of acute intracranial hemorrhage or
shift of normally midline structures.
[**2188-10-10**] CXR: The lungs are well expanded and clear. The
mediastinum is
unremarkable. Mild tortuosity of the thoracic aorta is again
noted. The
cardiac silhouette is borderline enlarged but stable. No
effusion or
pneumothorax is evident. The visualized osseous structures are
unremarkable.
IMPRESSION: No acute pulmonary process.
[**2188-10-12**] CXR PICC placement: Lung volumes are moderate. There
is no acute cardiopulmonary process. The lungs are clear and
pleural surfaces are smooth with no effusion or pneumothorax.
The heart is stable in size with mild enlargement and mild
unfolding of the aorta is noted. Right PICC has been placed with
tip in the right atrium.
IMPRESSION:
Right PICC terminates in the right atrium. Findings were
discussed with
[**Doctor First Name **] from the venous access team at the time of the exam.
[**2188-10-10**] 09:20PM CEREBROSPINAL FLUID (CSF) WBC-312 RBC-91*
Polys-81 Lymphs-10 Monos-4 Eos-5 CEREBROSPINAL FLUID (CSF)
TotProt-570* Glucose-0
[**2188-10-10**] 7:50 pm BLOOD CULTURE LEFT AC VENIPUNCTURE.
AEROBIC BOTTLE (Final [**2188-10-12**]): NEISSERIA MENINGITIDIS.
BETA-LACTAMASE NEGATIVE: PRESUMPTIVELY SENSITIVE TO PENICILLIN.
ANAEROBIC BOTTLE (Pending):
[**2188-10-10**] 8:00 pm BLOOD CULTURE VENIPUNCTURE.
AEROBIC BOTTLE (Final [**2188-10-12**]): NEISSERIA MENINGITIDIS.
BETA-LACTAMASE NEGATIVE: PRESUMPTIVELY SENSITIVE TO
PENICILLIN.
ANAEROBIC BOTTLE (Pending):
[**2188-10-10**] 9:20 pm CSF;SPINAL FLUID #3.
GRAM STAIN (Final [**2188-10-10**]):
THIS IS A CORRECTED REPORT [**2188-10-11**].
REPORTED BY PHONE TO DR [**First Name (STitle) 11170**] [**Name (STitle) **] ([**Numeric Identifier 104456**]) [**2188-10-11**] AT
2:40PM.
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
PREVIOUSLY REPORTED AS.
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN ([**2188-10-10**]).
FLUID CULTURE (Preliminary):
NEISSERIA MENINGITIDIS. MODERATE GROWTH. BETA LACTAMASE
NEGATIVE.
BETA-LACTAMASE NEGATIVE: PRESUMPTIVELY SENSITIVE TO
PENICILLIN.
[**2188-10-11**] 2:37 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2188-10-12**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
VIRAL CULTURE (Pending):
Brief Hospital Course:
51 F w/ PMH of afib, HTN, OSA on CPAP, p/w neisseria menigitis
and bacteremia
.
1) Meningicoccal Meningitis: LP in the ER with glucose of zero
and high total protein consistent with bacterial meningitis.
Ultimately returned Neisseria Meningicoccus. Patient initially
received Vanc, Ceftriaxone 2g IV q12 and Ampicillin 2 g IV q
4hrs + dexamethasone. Tailored to ceftriaxone 2g IV q12. Blood
cultures also positive on [**10-10**]. Patient will need 14 days of
ceftriaxone starting [**10-12**], first set of negative blood cultures.
ID involved throughout, has follow up with Dr. [**First Name8 (NamePattern2) 4035**] [**Last Name (NamePattern1) 976**].
Will need safety labs, CBC, chem-10, lft's week of [**10-20**] on the
ceftriaxone. Clinically patient very well, did have persistent
headache through [**10-17**] but no apparent
CH50 within normal limits, no evidence of terminal complement
deficiency.
Infectious disease contact[**Name (NI) **] department of public health given
multiple exposures as patient has her own daycare.
.
2) Afib: H/o difficult-to control rate s/p multiple
cardioversions. Anticoagulated on coumadin (subtherapeutic).
Coumadin initially held given critical illness. Resumed by
[**10-14**]. INR goal 2-2.5.
Held [**10-17**] givne INR 2.7.
Re started
Will need INR check on
Maintained on quinidine throughout. Heart rate generally high
50's to low 60's.
.
3) HTN: BP well controlled, largely off agents. Had been on
low dose metoprolol which was largely held throughout.
.
4) OSA: on CPAP 11 at home. Patient non compliant at
home,secondary to headached. Attempted in house but patient
refused with headache.
.
5)C. diff colitis: Patient with diarrhea beginning before
admission. Empiric flagyl started, c.diff returned positive.
Will need flagyl course for at least 10 days after the cessation
of ceftriaxone. Diarrhea improving by [**10-16**], no loose stools by
[**10-17**].
.
.
) Communication: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4597**] (partner) [**Telephone/Fax (1) 104457**];
[**Telephone/Fax (1) 104458**]
.
Medications on Admission:
Quinidine 324 mg po q8 hrs
Diltiazem CD 300 mg 1 tab daily
Ranitidine 150 mg 1 tab [**Hospital1 **]
Coumadin 2.5 mg 2 tabs on Mon and Fri and 1 tab remaining days
Zocor 40 mg 1 tab daily
Enalapril 5 mg 1 tab daily
Metoprolol 150 mg daily
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
3. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO Q8H (every 8 hours).
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 17 days.
Disp:*51 Tablet(s)* Refills:*0*
5. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAYS
([**Doctor First Name **],TU,WE,TH,SA).
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAYS (MO,FR).
7. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO once a
day.
8. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
9. Ceftriaxone
Sig: 2 grams IV q 12 hour until [**2188-10-25**]
Dispense: quantity sufficient
10. Line care
Please provice PICC line care per Critical Care System Protocol.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. Meningicoccal Meningitis
2. C. Difficile Colitis
Secondary:
1. Atrial Fibrillation
2. Hypertension
3. Obstructive Sleep Apnea
Discharge Condition:
Stable, afebrile, ambulating, good PO intake.
Discharge Instructions:
Follow up as below.
If you have worsening headache, nausea, vomiting, fevers,
chills, diarrhea, abdominal pain or any other new concering
symptoms, contact your doctor or go to the emergency room
immediately.
All medications as prescribed. You will need to be on the
ceftriaxone through [**10-25**]. Continue Flagyl (aka metronidazole)
the antibiotic pill for diarrhea until [**2188-11-4**].
Have your coumadin level (INR) checked at the [**Hospital Ward Name 23**] Building
as you usually do. Please have this checked within the next
week and contact your nurse at [**Hospital6 733**] who
usually follows this for you.
You must have labs checked as directed below. We have given you
a prescription for this.
Followup Instructions:
Follow up with your primary care doctor this week. Call to make
an appointment for this week. [**Telephone/Fax (1) 1247**]
You must have cbc, chem-10, lft's checked the week of [**10-20**].
Dr. [**First Name8 (NamePattern2) 4035**] [**Last Name (NamePattern1) 976**] will follow these labs up.
You had the previosly scheduled [**Last Name (NamePattern1) **] appointment: Provider:
[**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2188-10-23**] 1:45
Follow up with the infectious disease doctor, Dr. [**Last Name (STitle) 976**] as
scheduled:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7380**],MD MPH[**MD Number(3) 708**]:[**Telephone/Fax (1) 457**]
Date/Time:[**2188-11-11**] 11:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2188-10-23**]
|
[
"272.4",
"008.45",
"530.81",
"V58.61",
"401.9",
"036.0",
"427.31",
"515",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10506, 10564
|
7200, 9292
|
326, 347
|
10737, 10785
|
3241, 5940
|
11549, 12445
|
2173, 2332
|
9580, 10483
|
10585, 10716
|
9318, 9557
|
10809, 11526
|
3057, 3222
|
2347, 2953
|
278, 288
|
6201, 6742
|
375, 1473
|
2968, 3040
|
1495, 1811
|
1827, 2157
|
6775, 7177
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,096
| 117,771
|
45213+58793
|
Discharge summary
|
report+addendum
|
Admission Date: [**2123-10-20**] Discharge Date: [**2123-10-23**]
Date of Birth: [**2065-5-25**] Sex: F
Service: CICU
HISTORY OF PRESENT ILLNESS: Patient is a 58-year-old female
with a past medical history significant for coronary artery
disease, status post multiple interventions, type 2 diabetes
mellitus, and hypercholesterolemia who was transferred from
an outside hospital for management of unstable angina.
Patient presented to the outside hospital with a complaint of
recurrent weakness and dizziness with a three day history of
progressive chest pressure and difficulty breathing.
Patient reports a several week history of intermittent dizzy
spells, often occurring in the afternoon while at rest. The
patient's atenolol dose was decreased from 150 to 100 one
week prior to presentation which, by report, seemed to help
for several days. However, the dizziness returned the day of
presentation.
The patient also reports a three day history of chest
pressure with shortness of breath and generalized fatigue,
which prompted the patient to seek evaluation. At baseline,
the patient experiences angina "at rest". Typical anginal
symptoms include chest tightness without radiation or
associated symptoms, relieved with 1-2 sublingual
nitroglycerin. The patient reports anginal symptoms
reportedly worsening over the course of three days.
On the day of admission, the patient reports [**5-26**] chest
pressure described as "weight on my chest", unrelieved with
two sublingual nitroglycerins. The chest pressure was
accompanied by vomiting, tightening around the lower lip,
shortness of breath, and fatigue. The patient reports two
pillow-stable orthopnea, and medical compliance, and denies
new medications, paroxysmal nocturnal dyspnea, cough, fever,
chills, and increasing edema.
At the outside hospital, the patient was found bradycardic
(heart rate in the 40s) and hypotensive (systolic blood
pressure 60-80) with persistent mild chest pain. The patient
was started on dopamine and nitroglycerin drip, and became
chest pain free with stabilization of her blood pressure.
The patient was transferred chest pain free to [**Hospital1 346**] for further management.
In the [**Hospital1 69**] Emergency
Department, the patient has remained chest pain free on
nitroglycerin drip. The dopamine was weaned from 30
mcg/kg/hour to 5 mcg/kg/hour. The patient's
electrocardiogram on admission to [**Hospital1 190**] demonstrated normal sinus rhythm with no acute
ST-T wave changes, and evidence of prior anterior wall
myocardial infarction.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post multiple interventions
including [**2117-3-17**] percutaneous intervention with stents
placed in the left anterior descending artery and right
coronary artery, [**2117-6-17**], status post PTCA of the left
anterior descending artery instent stenosis, [**2117-7-18**],
status post PTCA of right coronary artery instent stenosis,
[**2117-8-17**] anterior wall myocardial infarction status
post coronary artery bypass graft with each graft from the
left internal mammary artery to the left anterior descending
with inferior epigastric graft (subsequently failed), [**2118-1-15**] redo coronary artery bypass graft with [**Year (4 digits) **] to the left
anterior descending artery and saphenous vein graft to the
right coronary artery, [**2119-6-17**] percutaneous intervention
with status post PTCA of the left anterior descending artery
via the [**Last Name (LF) **], [**2122-2-15**] status post PTCA of the D1
branch, [**2122-6-17**] status post cardiac catheterization
with no intervention, patent [**Year (4 digits) **] to the left anterior
descending artery.
2. Type 2 diabetes mellitus.
3. Hypercholesterolemia.
4. Morbid obesity.
MEDICATIONS ON ADMISSION:
1. Atenolol 100 mg po q day.
2. Enteric coated aspirin 325 mg po q day.
3. Reglan 10 mg po tid.
4. Nitropaste (dose unknown).
5. Zocor 40 mg po q day.
6. Ambien 10 mg po q day.
7. Amaryl 4 units po q day.
8. Glucophage 1,000 mg po bid.
9. Folic acid 1 mg po q day.
10. Tiazac 360 mg po q day.
11. Nexium 20 mg po q day.
12. Neurontin 600 mg po bid.
13. Zoloft 200 mg po q day.
14. Lasix 40 mg po bid.
15. Potassium chloride 20 mEq po q day.
16. Plavix 75 mg po q day.
17. Celebrex 200 mg po q day.
18. Xanax (dose unknown).
ALLERGIES: Dye allergy with a reaction of severe vomiting.
SOCIAL HISTORY: The patient is married and lives with her
husband, patient denies tobacco as well as recreational drug
use, and reports rare alcohol use.
FAMILY HISTORY: Notable for coronary artery disease with
father dying of a myocardial infarction at the age of 49.
PHYSICAL EXAM ON ADMISSION: Temperature of 97.0, blood
pressure 100/60, heart rate 64, oxygen saturation 99% on 2
liters nasal cannula. In general, the patient is alert and
pleasant, morbidly obese female in no acute distress. HEENT
examination: Normocephalic, atraumatic, anicteric sclerae,
clear oropharynx, dry mucous membranes. Neck examination:
Supple, no jugular venous distention, jugular venous pressure
to the angle of the jaw. Pulmonary examination: Clear to
auscultation bilaterally with no wheezes, rales, or rhonchi.
Cardiovascular examination: Regular, rate, and rhythm,
normal S1, S2, no S3, S4 noted. Soft systolic murmur noted
at the right upper sternal border. Abdominal examination is
soft, obese, normoactive bowel sounds, nontender,
nondistended. Extremities: Warm and well perfused, 2+
dorsalis pedis and posterior tibial pulses, no edema noted,
no femoral bruit noted.
LABORATORIES AND STUDIES ON ADMISSION TO [**Hospital1 **]: Complete blood count with a white
blood cell count of 10.9, hematocrit 31.3 and platelets of
246. Chem-7 with a sodium of 136, potassium 5.2, chloride
103, bicarb 20, BUN 34, creatinine 1.8, and glucose of 273.
Coags with a PT of 13.2, INR of 1.2, and PTT of 28.2.
Remainder of the hospital course to be continued.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Name8 (MD) 4935**]
MEDQUIST36
D: [**2123-11-25**] 17:14
T: [**2123-11-26**] 07:53
JOB#: [**Job Number 96620**]
Name: [**Known lastname 15346**], [**Known firstname 194**] Unit No: [**Numeric Identifier 15347**]
Admission Date: [**2123-10-20**] Discharge Date: [**2123-10-23**]
Date of Birth: [**2065-5-25**] Sex: F
Service: CICU
ADDENDUM: This is a continuation of the previous Discharge
Summary. Continuation with laboratories and studies.
RADIOLOGY/IMAGING: Initial electrocardiogram at the outside
hospital demonstrated sinus bradycardia with poor R wave
progression consistent with prior anterior wall myocardial
infarction, and a sinus node exit block/Wenckebach.
Electrocardiogram on admission to [**Hospital1 4242**] demonstrated a normal sinus rhythm with normal
axis and continued poor R wave progression in the
anteroseptal leads with no acute ST-T wave changes.
HOSPITAL COURSE BY SYSTEMS:
1. CARDIOVASCULAR SYSTEM: The patient remained chest pain
free; and after several hours, the nitroglycerin drip was
weaned to off. The patient ruled out for a myocardial
infarction by three sets of cardiac enzymes. The patient
maintained adequate blood pressures off of dopamine with
intravenous fluids and 2 units of packed red blood cells.
The patient remained off antihypertensives until hospital day
two, at which time the patient was restarted on a low dose of
beta blocker without evidence of bradycardia or hypotension.
The patient was felt to have symptomatic bradycardia and
hypotension secondary to atrioventricular nodal blockade with
excessive doses of beta blocker and calcium channel blocker.
The patient underwent a transthoracic echocardiogram which
revealed a preserved systolic function with an ejection
fraction of 60%, mild left atrial dilatation, mild left
ventricular hypertrophy, 1+ mitral regurgitation, borderline
pulmonary artery hypertension, and no wall motion
abnormalities or evidence of pericardial effusion.
The patient remained in a normal sinus rhythm on telemetry
during the hospitalization without evidence of arrhythmia.
2. HEMATOLOGIC SYSTEM: The patient's admission hematocrit
was 26.6. The drop in hematocrit was without an obvious
source; however, likely a chronic gastrointestinal bleed
given prior history of gastrointestinal bleed. The patient's
stools remained guaiac-negative throughout the
hospitalization.
The patient was transfused 2 units of packed red blood cells
with an appropriate increase in her hematocrit from 26.6 to
32.3 where she remained stable for 24 hours. The patient was
recommended to follow up with her primary care physician as
an outpatient.
3. ENDOCRINE SYSTEM: The patient's blood glucose remained
well controlled on sliding-scale insulin while in the
hospital. The patient was restarted on oral
antihyperglycemic medications on discharge.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE DIAGNOSES:
1. Symptomatic bradycardia and hypotension secondary to
excessive atrioventricular nodal blockade.
2. Coronary artery disease; status post multiple
percutaneous interventions and coronary artery bypass graft.
3. Type 2 diabetes mellitus.
4. Hypercholesterolemia.
5. Anemia.
6. History of prior gastrointestinal bleed.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. q.d.
2. Plavix 75 mg p.o. q.d.
3. Zocor 40 mg p.o. q.d.
4. Lopressor 25 mg p.o. b.i.d.
5. Reglan 10 mg p.o. t.i.d.
6. Folic acid 1 mg p.o. q.d.
7. Neurontin 600 mg p.o. t.i.d.
8. Zoloft 200 mg p.o. q.d.
9. Celebrex 200 mg p.o. q.d.
10. Xanax 0.5 mg p.o. t.i.d.
11. Metformin 1000 mg p.o. b.i.d.
12. Amaryl 4 mg p.o. q.d.
13. Sublingual nitroglycerin as needed.
14. Ambien 10 mg p.o. q.h.s.
DISCHARGE STATUS: The patient was discharged to home.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with her cardiologist (Dr.
[**First Name (STitle) **] in one week status post discharge.
2. The patient was also instructed to follow up with her
primary care physician (Dr. [**Last Name (STitle) 15348**] in one week status post
discharge.
3. The patient was instructed to hold her diltiazem, Lasix,
and potassium chloride until further notice. The patient's
Lopressor dose will be titrated as per her primary care
physician.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3518**], M.D. [**MD Number(1) 3519**]
Dictated By:[**Name8 (MD) 2285**]
MEDQUIST36
D: [**2123-11-25**] 15:36
T: [**2123-11-25**] 17:51
JOB#: [**Job Number 15349**]
|
[
"250.00",
"427.89",
"285.9",
"786.59",
"414.01",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4553, 4667
|
9045, 9370
|
9397, 9889
|
3794, 4380
|
9922, 10652
|
7034, 8975
|
8990, 9024
|
164, 2571
|
4682, 7005
|
2593, 3768
|
4397, 4536
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,503
| 152,105
|
34752
|
Discharge summary
|
report
|
Admission Date: [**2181-7-6**] Discharge Date: [**2181-8-9**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
85 year old male admitted with gastric bleeding adenocarcinoma
found during EGD at outside hospital.
Major Surgical or Invasive Procedure:
tbd
History of Present Illness:
Mr. [**Known lastname 79627**] is an 85-year-old
gentleman who underwent a previous gastrectomy with Billroth
II reconstruction as management for bleeding peptic ulcer
disease in the [**2122**]. He did not undergo routine surveillance
endoscopies. He recently presented to his physician with
fatigue and weight loss and was discovered to have a
hemoglobin of approximately 5 gram percent. He was admitted
to the hospital and transfused packed red blood cells. He
underwent an upper endoscopy at an outside facility that
demonstrated a large bleeding mass in the remnant stomach
near the efferent limb of his previous Billroth II
reconstruction. In addition, he had a bleeding arteriovenous
malformation in the afferent limb which was cauterized by the
endoscopist. Apparently during this portion of the procedure,
a small perforation was made in the afferent limb, perhaps as
far proximal as the third portion of the duodenum.
On [**2181-7-16**] he underwent a Diagnostic laparoscopy to look for
metastatic disease. None was found. On [**2181-7-18**] patient's case
was discussed at Oncology conference to discuss options. These
options were presented to the patient and family. It was decided
to proceed with surgery and resection of mass.
Past Medical History:
gastric ulcers s/p subtotal gastrectomy/vagotomy/Billroth II
(age 19), L renal cell CA s/p nephrectomy & en bloc resection
(including 11th rib) in [**2152**], HTN, gout, recent urinary
incontinence & frequency (scheduled to see Urology next week),
white matter disease & small aneurysm on MRI (for memory
problems)
Social History:
Married, sons, has written book recently.
Family History:
NA
Physical Exam:
97.5 58 138/80 16 96%RA
Gen: NAD, A&O, NGT in place, draining bilious material
CVS: RRR
Pulm: CTA b/l
Abd: soft, NT, ND, +BS, no mass or hepatosplenomegaly palpated
Ext: no c/c/e, RUE PICC in place
LN: no cervical, axillary, or groin LAD
Pertinent Results:
[**2181-7-6**] 05:50PM BLOOD WBC-7.1 RBC-4.34* Hgb-10.8* Hct-35.1*
MCV-81* MCH-24.9* MCHC-30.8* RDW-16.3* Plt Ct-478*
[**2181-7-8**] 03:48AM BLOOD WBC-6.5 RBC-3.95* Hgb-9.8* Hct-31.9*
MCV-81* MCH-24.8* MCHC-30.6* RDW-16.3* Plt Ct-435
[**2181-7-17**] 05:45AM BLOOD WBC-7.5 RBC-4.30* Hgb-10.8* Hct-35.2*
MCV-82 MCH-25.1* MCHC-30.7* RDW-16.6* Plt Ct-386
[**2181-7-8**] 03:48AM BLOOD Plt Ct-435
[**2181-7-17**] 05:45AM BLOOD Plt Ct-386
[**2181-7-6**] 05:50PM BLOOD Glucose-87 UreaN-24* Creat-0.9 Na-139
K-4.1 Cl-106 HCO3-26 AnGap-11
[**2181-7-12**] 05:00AM BLOOD Glucose-133* UreaN-23* Creat-0.9 Na-139
K-3.7 Cl-109* HCO3-27 AnGap-7*
[**2181-7-18**] 05:20AM BLOOD Glucose-115* UreaN-25* Creat-1.0 Na-138
K-4.4 Cl-109* HCO3-23 AnGap-10
[**2181-7-6**] 05:50PM BLOOD Calcium-8.9 Phos-3.5 Mg-2.2
[**2181-7-20**] 05:03AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.1
[**2181-7-7**] 06:05AM BLOOD calTIBC-229* Ferritn-80 TRF-176*
[**2181-7-17**] 05:45AM BLOOD calTIBC-230* Ferritn-29* TRF-177*
Brief Hospital Course:
Patient presented to primary care provider [**Last Name (NamePattern4) **] [**2181-6-28**] with
fatigue, decreased
appetite/early satiety, paleness, weight loss (11 lbs), all over
1 month.At [**Hospital3 79628**] in [**Hospital1 1474**].
Patient underwent EGD on [**2181-6-30**]. An angiodysplasia was found
and cauterized in the efferent limb. A large,
friable,ulcerated, oozing mass was noted at the efferent limb
entrance.
Biopsies were positive for gastric adenoca with areas of
invasion
and ulceration. H.pylori stain was negative. EGD was
complicated by duodenal perforation (anterior D3 wall thickened
with air, retroperitoneal air), which was managed conservatively
with NGT decompression, broad-spectrum antibiotics, TPN, and
serial CT scans. CAT scan obtained on [**2181-7-2**], two days
following the procedure, demonstrated extensive free gas within
the retroperitoneum, predominantly on the right. There was
diffuse thickening of duodenal wall and possible gas within
duodenal wall. The collection was of high-density contrast
which
per the report sounds like it was extraluminal. Patient
transferred to [**Hospital1 18**] on [**2181-7-6**].
Patient admitted to [**Hospital1 18**] on [**2181-7-6**] and continued on
Intravenous fluids/antibiotics and TPN started. Follow up CT
scan on [**2181-7-9**] showed a 7 x 8.2 cm mass arising from the
greater curvature and fundus of the stomach, which is abutting
and possibly invading the splenic flexure of the colon. Another
soft tissue lesion is noted adjacent to the lesser curvature of
the stomach and body of the pancreas measuring approximately 23
mm (series 2 image 19) which cannot be further evaluated.
There is diffuse intra- and extra-peritoneal free air. Small
fluid collection
with gas bubbles posterior to the second portion of the duodenum
measures 3.2
x 1.5 cm, best seen on series 2, image 32. No free extravasation
of the oral
contrast material. No definite extravasation of oral contrast.
Patient started on oral liquids.
Dr. [**Last Name (STitle) **] consulted regarding possible surgical options.
Extensive discussion with presentation of case to Oncology
rounds was done. Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] then came up with
multiple options to deal with large mass and presented these
options in detail to patient and family. Patient decided to have
surgery.
On [**2181-7-23**] patient went to the operating room and had a subtotal
gastrectomy, splenectomy, segmental colectomy, open CCY,
roux-n-y gastrojejunostomy, primary stapled colon anastomosis,
and J-tube placement. Patient developed worsening acidosis and
hypotension and was taken back to the operating room on [**2181-7-24**].
Postoperatively he was in the intensive care unit on pressors
and maximal support. He slowly improved and went back to the
operating room on [**2181-7-28**] for abdominal washout and exploration
and then again on [**7-31**] for washout and abdominal closure.
On [**2181-8-2**] patient was extubated. He was maintained on goal tube
feeds. Lasix was used for diuresis. On [**2181-8-6**] patient
transferred back to floor. Patient awake, denies pain,
tolerating goal tube feeds. CT scan obtained showing No
drainable fluid collection. Speech and Swallow consulted and on
[**8-8**] patient was started on soft solids as well as tube feeds.
Occupational therapy and physical therapy consulted to treat to
prehospital level. Rehabilitation screen done.
On [**8-9**] patient discharged to rehabilitation facility. He will
return on [**8-17**] for a follow up CT scan and visit with Dr.
[**Last Name (STitle) **].
Medications on Admission:
allopurinol 300', ASA 81', Norvasc 5', B12 in, iron 325'
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary Diagnosis: Gastric Adenocarcinoma
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**10-10**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2181-8-15**]
3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10921**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2181-8-15**] 3:00
Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **] [**Name (STitle) 2974**] [**8-17**] at 12:30 [**Hospital Ward Name 23**] [**Location (un) **].
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2181-8-17**] 10:00
[**Hospital Ward Name 516**], [**Hospital Ward Name 23**] [**Location (un) **], you must arrive by 9:00 am, you
must not drink or eat anything from 7 am until your Cat Scan is
completed.
Completed by:[**2181-8-9**]
|
[
"173.5",
"274.9",
"V10.52",
"197.5",
"038.9",
"997.4",
"537.83",
"518.5",
"276.50",
"276.2",
"998.2",
"E878.6",
"151.6",
"998.59",
"574.20",
"197.4",
"789.59",
"568.0",
"995.92",
"401.9",
"599.0",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.21",
"46.39",
"45.74",
"41.5",
"96.6",
"45.62",
"86.3",
"54.62",
"99.15",
"54.12",
"54.59",
"43.7",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
7383, 7455
|
3329, 6945
|
360, 365
|
7541, 7550
|
2333, 3306
|
8875, 9620
|
2051, 2055
|
7052, 7360
|
7476, 7476
|
6971, 7029
|
7575, 8506
|
2070, 2314
|
220, 322
|
8518, 8852
|
393, 1637
|
7495, 7520
|
1659, 1976
|
1992, 2035
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,170
| 122,085
|
159
|
Discharge summary
|
report
|
Admission Date: [**2141-11-7**] Discharge Date: [**2141-11-13**]
Date of Birth: [**2091-11-1**] Sex: M
Service: GU
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1232**]
Chief Complaint:
Sharp abdominal pain after cough, gross hematuria
Major Surgical or Invasive Procedure:
s/p right partial nephrectomy on [**2141-10-24**]
History of Present Illness:
Pt is a 50 year old male who underwent a right partial
nephrectomy on [**2141-10-24**] and was discharged and presented to the
ER on [**2141-10-30**] after an MVA with complaint of serosanguinous
discharge from old chest tube site. Chest xray and ultrasound at
the time were negative. The patient then returned to hospital on
[**2141-11-7**] with a complaint of severe abdominal pain and one
episode of gross hematuria after a cough. The patient presented
to an outside hospital with a hematocrit of 27 and a BP of
70/40. The patient was given IV fluids and 1 unit of PRBC's
(post-transfusion hematocrit was 29), was stabilized, and then
med flighted to [**Hospital1 18**].
Past Medical History:
IgA nephropathy
Hypertension
Gout
Psoriasis
Social History:
Patient has a significant alcohol history of [**7-11**] drinks/day
Family History:
Non-contributory
Physical Exam:
Gen: A+Ox3
CV: RRR
Lungs: Crackles at right base
Abd: Soft, distended, very mild tenderness to palpation
diffusely, incision clean/dry/intact
Ext: No cyanosis or edema
Pertinent Results:
[**2141-11-7**] 07:30PM BLOOD WBC-24.0*# RBC-3.22* Hgb-9.6* Hct-28.5*
MCV-89 MCH-29.8 MCHC-33.6 RDW-13.1 Plt Ct-404#
[**2141-11-8**] 04:20AM BLOOD WBC-18.0* RBC-2.84* Hgb-8.1* Hct-24.7*
MCV-87 MCH-28.6 MCHC-32.9 RDW-13.3 Plt Ct-345
[**2141-11-8**] 10:30AM BLOOD WBC-19.8* RBC-3.45* Hgb-10.0* Hct-29.4*
MCV-85 MCH-29.0 MCHC-34.0 RDW-14.0 Plt Ct-272
[**2141-11-8**] 01:56PM BLOOD WBC-15.7* RBC-3.25* Hgb-9.3* Hct-27.8*
MCV-85 MCH-28.6 MCHC-33.5 RDW-14.0 Plt Ct-259
[**2141-11-8**] 05:48PM BLOOD Hct-30.2*
[**2141-11-9**] 06:35AM BLOOD Hct-28.3*
[**2141-11-9**] 04:45PM BLOOD Hct-30.6*
[**2141-11-10**] 07:35AM BLOOD WBC-12.2* RBC-3.33* Hgb-9.6* Hct-28.7*
MCV-86 MCH-28.9 MCHC-33.4 RDW-13.9 Plt Ct-326
[**2141-11-7**] 07:30PM BLOOD Glucose-142* UreaN-44* Creat-2.5* Na-140
K-5.8* Cl-107 HCO3-21* AnGap-18
[**2141-11-8**] 04:20AM BLOOD Glucose-137* UreaN-47* Creat-2.9* Na-140
K-6.6* Cl-110* HCO3-21* AnGap-16
[**2141-11-8**] 10:30AM BLOOD Glucose-129* UreaN-42* Creat-2.5* Na-141
K-4.9 Cl-107 HCO3-20* AnGap-19
[**2141-11-8**] 01:56PM BLOOD Glucose-118* UreaN-38* Creat-2.3* Na-141
K-4.9 Cl-107 HCO3-22 AnGap-17
[**2141-11-8**] 05:48PM BLOOD Glucose-120* UreaN-35* Creat-2.2* Na-141
K-4.8 Cl-105 HCO3-22 AnGap-19
[**2141-11-9**] 06:35AM BLOOD Glucose-126* UreaN-25* Creat-1.8* Na-137
K-4.3 Cl-105 HCO3-23 AnGap-13
[**2141-11-8**] 10:30AM BLOOD Lipase-616*
[**2141-11-8**] 01:56PM BLOOD Lipase-390*
[**2141-11-9**] 06:35AM BLOOD Lipase-111*
[**2141-11-8**] 10:30AM BLOOD ALT-24 AST-21 LD(LDH)-296* AlkPhos-95
Amylase-436* TotBili-0.9
[**2141-11-9**] 06:35AM BLOOD ALT-16 AST-16 AlkPhos-87 Amylase-165*
TotBili-0.7
Brief Hospital Course:
The patient was admitted to the MICU and was transfused 2 units
of PRBS's. Post-transfusion hematocrit remained stable around
30. A CT scan was obtained on hospital day #2, which showed a
small-to-moderate amount of high density fluid which most likely
represented blood around the liver and the spleen and the right
kidney, with
adjacent perinephric fluid/hematoma. The origin of bleeding was
not definitively identified, but bleeding could potentially have
been arising in the kidney given the history of recent renal
surgery and history of hematuria. No active extravasation was
identified. The patient was hemodynamically stable throughout
his stay in the MICU, and was transferred to the floor on HD#2.
A repeat CT on hospital day #3 showed no active changes from the
previous scan. On HD#4, the patient appeared more distended,
though he continued to pass flatus. A KUB was obtained, which
showed no signs of obstruction. An MRI urogram was also
obtained, which showed stable blood around the right kidney,
extending into the peritoneum and a blood clot within the right
renal pelvis. The patient continued to remain stable with a
hematocrit holing steady around 30 and a creatinine holding
steady at 2.1. The patient was discharged on HD#7 in stable
condition.
Medications on Admission:
Atenolol 50 mg PO QDaily
Lisinopril 20 mg PO QDaily
Norvasc 5 mg PO QDaily
Lipitor 10 mg PO QDaily
Allopurinol 100 mg PO QDaily
Protonix 25 mg PO QDaily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): please take while taking pain medications. Stop
if loose bowel movements.
Disp:*30 Capsule(s)* Refills:*2*
2. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every
4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p right partial nephrectomy, readmitted for question of
postoperative bleed
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Name (NI) 1233**] office for follow up
Followup Instructions:
as above
|
[
"401.9",
"696.1",
"274.9",
"560.1",
"599.7",
"E878.6",
"998.12",
"V10.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
4947, 4953
|
3137, 4407
|
360, 411
|
5075, 5083
|
1503, 3114
|
5181, 5193
|
1282, 1300
|
4610, 4924
|
4974, 5054
|
4433, 4587
|
5107, 5158
|
1315, 1484
|
271, 322
|
439, 1114
|
1136, 1182
|
1198, 1266
|
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